VELEZ COLLEGE

COLLEGE OF NURSING
F. RAMOS ST. CEBU CITY PHILIPPINES

PERIOPERATIVE NURSING

A CASE STUDY ON PATIENT C.M. WITH A POST-OPERATIVE DIAGNOSIS OF INTRAMURAL LEIOMYOMA WITH SUBMUCOUS COMPONENTS,
ENDOMETRIAL POLYP IN DEGENERATION, STATUS POST FRACTIONAL CURETTAGE WITH CERVICAL PUNCH BIOPSY WITH
FROZEN SECTION TOTAL ABDOMINAL HYSTERECTOMY – BILATERAL SALPHINGO OOPHORECTOMY
AND PERITONEAL FLUID CYTOLOGY

CLINICAL INSTRUCTORS
Ms. Anne Caroline Mendez RN
Mr. Mark Anthony Longinos RN MAN

SUBMITTED ON:
November 25, 2009

SUBMITTED BY:
Grant Rainiere Young Alisteir Montecillo
Redentor Durano II Jabe Gica
Kier Escario Michelle Anne Sabellano
Jeff Benjamin Go

INTRODUCTION
LEIOMYOMA
A leiomyoma (plural is 'leiomyomata') is a benign smooth muscle neoplasm that is not premalignant. They can occur in any organ, but the most common forms occur
in the uterus, small bowel and the esophagus. Uterine fibroids are leiomyomata of the uterine smooth muscle. As other leiomyomata, they are benign, but may lead to
excessive menstrual bleeding (menorrhagia), often cause anemia and may lead to infertility. Uterine leiomyomas originate in the myometrium and are classified by location:
 Submucosal - lie just beneath the endometrium.
 Intramural - lie within the uterine wall.
 Subserosal - lie at the serosal surface of the uterus or may bulge out from the myometrium and can become pedunculated.
Signs and Symptoms:
Fibroids may cause no symptoms, or they may produce abnormal vaginal bleeding. Other symptoms are due to pressure on the surrounding organs and include:
 Pain
 Backache
 Pressure
 Bloating
 Constipation
 Urinary problems
 Menorrhagia
 Metrorrhagia
Risk Factors:
 Race
 Age
 Sex
 History of Leiomyoma
Diagnostic Tests:
 Pelvic Examination
 Ultrasound
 Hysteroscopy
 Papanicolaou (Pap) Smear
 Endometrial Biopsy
 MRI and CT Scanning: These can be useful, showing, for example, whether the ureter is obstructed and ruling out bowel involvement
Management
 Surgical
• Myomectomy- removal of large tumors
• Hysterectomy- removal of the uterus
• Hysteroscopic resection of myomas- a laser is used through a hysteroscope passed through the cervix
• Laparoscopic myomectomy- a removal of fibroid through a laparoscope inserted through a small abdominal incision
• Laparoscopic myolisis- a laser or electrical needles are used to cauterize and shrink the fibroid
• Laparoscopic cryomyolysis- electric current is used to coagulate the fibroid
• Uterine artery embolization (UAE)
 Pharmacological
• GnRH analogs- induce a temporary meopause-like environment
• Antifobrotic agents
 • Birth Control Pill/Progestins: While these will not shrink fibroids, they may be effective enough in controlling the symptoms (particularly bleeding) that the patient
can make it through to menopause.

ENDOMETRIAL POLYP
Endometrial polyps are small, soft, growths in the lining of your uterus. Endometrial polyps grow very slowly. You may have 1 or many endometrial polyps. Sometimes
endometrial polyps protrude through the vagina, causing cramps. The cramps occur because when the endometrial polyps protrude through the vagina, they impinge on the
opening of the cervix. If the polyps become twisted and lose their blood supply, they can become infected. Polyps only rarely turn cancerous. However, some women with
endometrial polyps will have difficulty becoming pregnant.
Symptoms:
Sometimes, symptoms don’t occur. Often, symptoms do not occur when the polyps are small. When symptoms do occur, the most common symptoms are:
• spotting between menstrual periods
• pelvic cramps
• heavy or prolonged menstrual periods
• bleeding during hormonal therapy
Risk Factors:
• obesity
• high blood pressure
• history of cervical polyps
• intake of tamoxifen or hormone replacement therapy
Diagnostic Exams:
Diagnosing endometrial polyps involves looking inside the uterine cavity. A regular ultrasound (also called a sonogram) usually does not diagnose polyps, because the
pressure inside the uterus flattens the polyps, making them very hard to see. A special ultrasound, called a sonohysterogram (water ultrasound), allows doctors to see inside
the uterus after a few drops of sterile water is carefully infused into the uterus through the vagina. The water opens the uterine cavity, allowing the doctor to see if any polyps
are present. Another diagnostic test is a hysterosalpingogram (HSG), which uses dye under pressure to open the uterus and tubes. A quick X-ray is then taken to see if any
polyps are in the uterus. Finally, gynecologists are becoming more skilled at using the hysteroscope to look inside the uterus. This is a small, lighted tube that goes into the
vagina then the uterus, to look around inside the uterus. Hysteroscopy using small tubes can be performed in the office, but larger tubes (used to remove large polyps or
fibroids) usually require anesthesia in the hospital.
Complications:
Rarely, once the growths are removed, they may return -- this usually occurs years later, if at all. Most polyps grow very slowly. Rarely is major surgery needed for
polyps, unless they are found to be precancerous or cancerous. In some women, if the polyp(s) interfere with the egg and sperm, it may make it hard to get pregnant. It is
unknown at the time of writing how common this is. It is also possible that they may lead to a slightly higher chance of miscarriage, but this is also unknown. Most
gynecologists will remove polyps if they are found in women with a history of miscarriage. If a polyp is diagnosed one of the first questions is, "Could this be cancer?"
Although some polyps are thought to turn gradually into cancer, fortunately they rarely do. The risk does increase slightly as a patient passes age 50: polyps that appear
during menopause may put the woman at greater risk. Usually, postmenopausal bleeding caused by the polyps will warn women to seek care
Treatment:
The old-fashioned way was to perform a D&C (dilatation and curettage). This involves a gentle scraping of the uterine lining. Unfortunately, this may miss the polyp
completely, since this procedure is done solely by feel. As the scraping instrument goes by, it will likely just push the polyp out of the way without grabbing it. Hysteroscopes
now allow us to look right at the polyp as we grasp it or cut it away from the uterine lining. This ensures that the polyp (or, in some cases, multiple polyps) is removed.

TOTAL ABDOMINAL HYSTERECTOMY – BILATERAL SALPHINGO OOPHORECTOMY

This is the removal of the uterus including the cervix as well as the tubes and ovaries using an incision in the abdomen.
 Hysterectomy is the surgical removal of the uterus. Hysterectomy may be total, as removing the body and cervix of the uterus or partial, also called supracervical.
  Salphingo refers specifically to the fallopian tubes that connect the ovaries to the uterus.
 Oophorectomy is the surgical removal of an ovary or ovaries.
 Hysterectomy is also referred to as surgical menopause.
Operative Position:
Supine
Indications:
• Cancer
• Dysfunctional uterine bleeding
• Endometriosis
• Non- malignant growths
• Persistent pain to the Pelvis
• Previous injury to the uterus
• Postpartum obstetrical hemorrhage
Risk and Side Effects:
• Increased bladder function problems
• Greater risk of developing Cardiovascular problems such as atherosclerosis
• Risk for developing osteoporosis
Preoperative Management:
• The lower half of the abdomen and the pubic and perineal regions may be shaved.
• These area are cleaned with Povidine iodine.
• To prevent contamination and injury to the bladder or intestinal tract, the intestinal tract and the bladder need to be empty. An enema and antiseptic douche may be
prescribed the evening before the surgery.
• Preoperative meds may be administered before the surgery.
Postoperative Management:
• Monitor closely peripheral circulation
Rationale: To prevent thrombophlebitis and DVT ( noting varicosities, promoting circulation, using elastic compression stockings)
• Monitor Input and Output
Rationale: Voiding problems may occur due to the fact that the surgical site is close to the bladder
• Indwelling catheter may be inserted
Potential Complications:
• Hemorrhage
• Deep Vein Thrombosis and Pulmonary Embolism
• Bladder Dysfunction
Nursing Interventions:
• Relieving Anxiety
Rationale: Explanations are given about the physical preparations and procedures that are performed
• Improving Body Image
Rationale: Patient may have strong emotional reactions to having a hysterectomy and strong personal feelings related to the diagnosis. Nurse who exhibits interest,
concern, and willingness to listen to the patient’s fears will help the patient progress through the surgical experience
• Relieving Pain
Rationale: Assess intensity of pain and administer analgesia as prescribed
Health Teachings:
• Diaphragmatic Breathing Exercise
• Foot and leg exercise
• Incentive Spirometry
• Coughing
• Turning
• Tell patient to resume activity gradually
• Avoid straining and lifting
• Early ambulation
• General Liquid Diet post op
PERITONEAL FLUID CYTOLOGY
Peritoneal fluid analysis is a test to examine fluid accumulated in the peritoneal space (the abdominal space that houses the gastrointestinal organs). The sample is
obtained by an abdominal tap.
Procedure:
A sample of fluid is obtained by abdominal tap. The physicians will sterilize and numb a small area of your abdomen with a small needle. Next, a larger needle will be
inserted into the peritoneal space and the fluid will be withdrawn. Occasionally, vacuum bottles are used to draw off large amounts of fluid. The fluid is typically examined in
the laboratory for appearance, red and white blood cell counts, protein and albumin, bacteria and fungi. Occasionally, tests for glucose, amylase, ammonia, alkaline
phosphatase, LDH, cytology, and other substances are performed.
Preparation:
You must sign a consent form. Immediately before the abdominal tap, empty your bladder.
Purpose:
The test is performed to determine the cause of fluid in the abdomen, to detect whether trauma has caused internal bleeding, to detect a hole in the bladder, and to
detect peritonitis.
Interpretation:
Milk-colored peritoneal fluid may indicate disease such as carcinoma, lymphoma, tuberculosis or infection. Bloody fluid may indicate tumor or trauma. Bile-stained
fluid may indicate gallbladder problems. High white blood cell counts may indicate peritonitis or cirrhosis.
Other laboratory abnormalities may indicate problems in the intestines or abdominal organs. Large differences between the concentration of albumin in the peritoneal fluid
and in your blood serum may point to heart, liver, or kidney failure as the cause of the fluid collection. Small differences may point more towards cancer or infection.
Risks:
There is a slight chance of the needle puncturing the bowel, bladder, or a blood vessel in the abdomen. If a large quantity of fluid is removed, there is a slight risk of
low blood pressure and even shock. There is also a slight chance of infection.

FRACTIONAL DILATATION AND CURETTAGE

Description:
D and C, also called uterine scraping, may be performed in the hospital or in a clinic while you are under general or local anesthesia.The health care provider will
insert an instrument called a speculum into the vagina. This holds open the vaginal canal. Numbing medicine may be applied to the opening to the uterus (cervix).The cervical
canal is widened using a metal rod, and a curette (a metal loop on the end of a long, thin handle) is passed through the opening into the uterus cavity. The doctor gently
scrapes the inner layer of tissue, called the endometrium. The tissue is collected for examination.
Purpose
This procedure may be done to:
• Diagnose conditions such as uterine cancer
• Remove tissue after a miscarriage
 • Treat heavy menstrual bleeding or irregular periods (See: Bleeding between periods)
• Perform a therapeutic or elective abortion
• Investigate infertility
Your doctor may also recommend a D and C if you have:
• Endometrial polyps
• Thickening of the uterus
• An embedded intrauterine device (IUD)
• Bleeding after menopause
• Abnormal bleeding while on hormone replacement therapy
This list may not be all-inclusive.
Risks:
Risks related to D and C include:
• Puncture of the uterus
• Tear of the cervix
• Scarring of the uterine lining
Risks due to anesthesia include:
• Reactions to medications
• Problems breathing
After the Procedure:
D and C has relatively few risks, can provide relief from bleeding, and can help diagnose infection, cancer, infertility, and other diseases.
Prognosis:
You may return to normal activities as soon as you feel better, possibly even the same day. There may be vaginal bleeding, as well as pelvic cramps and back pain for
a few days after the procedure. Pain can usually be managed well with medications. Tampon use is not recommended for a few weeks, and sexual intercourse is not
recommended for a few days.

CERVICAL PUNCH BIOPSY

A cervical biopsy is a test in which tissue samples are taken from the cervix and examined for disease or other problems.
Procedure:
You will lie on your back with your feet in stirrups. As in a regular pelvic examination, an instrument (speculum) will hold the vaginal canal open for the doctor to look
inside. It will be inserted into the vagina and opened slightly so that the cervix is visible.The health care provider will place a small low-power microscope (colposcope) at the
opening of the vagina and cervix to examine the area. The colposcope magnifies the surface of the vagina and cervix. The cervix is swabbed with a vinegar solution (acetic
acid), which removes the mucus to help highlight abnormal areas. Photographs may be taken.Another method is the Schiller's test, which uses an iodine solution to stain the
cervix. The stain is inserted through the speculum. The iodine solution stains the normal portions of the cervix, but does not stain abnormal tissues.If the health care provider
finds abnormal tissue, a sample (biopsy) may be taken using a small biopsy forceps or large needle. More than one sample may be taken.Cells from the cervical canal may be
used as samples as well. This is called an endocervical curettage or biopsy (ECC), and it may further help find abnormal cervical cells. When the procedure is done, the health
care provider will remove all of the instruments.
Preparation:
There is no special preparation. Before the procedure, you should empty your bladder and bowel for your comfort. Do not douche or have sexual intercourse for 24
hours before the exam.
Purpose:
A cervical biopsy is usually done when the health care provider sees an abnormal area on the cervix during a routine pelvic examination. The biopsy can be done if
the abnormal area is big enough for the health care provider to see. A colposcopy may be needed for small abnormal areas, or if a Pap smear is abnormal.
Normal Results:
A specialist called a pathologist will examine the tissue sample from the cervical biopsy and will report to your doctor whether the cells appear normal or abnormal.
Interpretation:
Abnormal biopsy results may indicate problems, such as:
• Abnormal tissue or cell growth in the cervix (cervical intraepithelial neoplasia)
• Cancer
Colposcopy may be used to keep track of precancerous cells and look for abnormalities that come back after treatment. Problems that may be biopsied or monitored include:
• Abnormal patterns in the blood vessels
• Areas that are swollen, worn away, or wasted away (atrophic)
• Whitish patches on the cervix
Other findings may be signs of cervical polyps.
Risks:
You may have some bleeding after the biopsy for up to 1 week. If bleeding is very heavy or lasts for longer than 2 weeks, or if you notice any signs of infection (fever,
foul odor, or discharge), call your health care provider.
Considerations:
If the examination or biopsy does not show why the Pap smear was abnormal, your health care provider may suggest that you have a more extensive biopsy.
To allow the cervix to heal, for 1 week after the biopsy avoid:
• Douching
• Sexual intercourse
• Using tampons
ANATOMY AND PHYSIOLOGY
THE FEMALE REPRODUCTIVE SYSTEM

The female reproductive system is designed to carry out several functions. It produces the female egg cells necessary for reproduction, called the ova or oocytes. The
system is designed to transport the ova to the site of fertilization. Conception, the fertilization of an egg by a sperm, normally occurs in the fallopian tubes. After conception,
the uterus offers a safe and favorable environment for a baby to develop before it is time for it to make its way into the outside world. If fertilization does not take place, the
system is designed to menstruate (the monthly shedding of the uterine lining). In addition, the female reproductive system produces female sex hormones that maintain the
reproductive cycle.
During menopause the female reproductive system gradually stops making the female hormones necessary for the reproductive cycle to work. When the body no
longer produces these hormones a woman is considered to be menopausal.
What parts make-up the female anatomy?
The female reproductive anatomy includes internal and external structures. The function of the external female reproductive structures (the genital) is twofold: To
enable sperm to enter the body and to protect the internal genital organs from infectious organisms. The main external structures of the female reproductive system include:
EXTERNAL FEMALE GENITALIA
The external organs of the female reproductive system include the mons pubis, labia majora, labia minora, vestibule, perineum, and the Bartholin's glands. As a
group, these structures that surround the openings of the urethra and vagina compose the vulva, from the Latin word meaning covering.
a. Mons Pubis. This is the fatty rounded area overlying the symphysis pubis and covered with thick coarse hair.
b. Labia Majora. The labia majora run posteriorly from the mons pubis. They are the 2 elongated hair covered skin folds. They enclose and protect other external
reproductive organs.
c. Labia Minora. The labia minora are 2 smaller folds enclosed by the labia majora. They protect the opening of the vagina and urethra.
d. Vestibule. The vestibule consists of the clitoris, urethral meatus, and the vaginal introitus.
The clitoris is a short erectile organ at the top of the vaginal vestibule whose function is sexual excitation.
The urethral meatus is the mouth or opening of the urethra. The urethra is a small tubular structure that drains urine from the bladder.
The vaginal introitus is the vaginal entrance.
e. Perineum. This is the skin covered muscular area between the vaginal opening (introitus) and the anus. It aids in constricting the urinary, vaginal, and anal opening. It also
helps support the pelvic contents.
f. Bartholin's Glands (Vulvovaginal or Vestibular Glands). The Bartholin's glands lie on either side of the vaginal opening. They produce a mucoid substance, which
provides lubrication for intercourse.
INTERNAL FEMALE ORGANS
The internal organs of the female consists of the uterus, vagina, fallopian tubes, and the ovaries
a. Uterus. The uterus is a hollow organ about the size and shape of a pear. It serves two important functions: it is the organ of menstruation and during pregnancy it receives
the fertilized ovum, retains and nourishes it until it expels the fetus during labor.
Location: The uterus is located between the urinary bladder and the rectum. It is suspended in the pelvis by broad ligaments.
Divisions of the uterus: The uterus consists of the body or corpus, fundus, cervix, and the isthmus. The major portion of the uterus is called the body or corpus. The fundus is
the superior, rounded region above the entrance of the fallopian tubes. The cervix is the narrow, inferior outlet that protrudes into the vagina. The isthmus is the slightly
constricted portion that joins the corpus to the cervix.
Walls of the uterus: The walls are thick and are composed of three layers: the endometrium, the myometrium, and the perimetrium. The endometrium is the inner layer or
mucosa. A fertilized egg burrows into the endometrium (implantation) and resides there for the rest of its development. When the female is not pregnant, the endometrial
lining sloughs off about every 28 days in response to changes in levels of hormones in the blood. This process is called menses. The myometrium is the smooth muscle
component of the wall. These smooth muscle fibers are arranged. In longitudinal, circular, and spiral patterns, and are interlaced with connective tissues. During the monthly
female cycles and during pregnancy, these layers undergo extensive changes. The perimetrium is a strong, serous membrane that coats the entire uterine corpus except the
lower one fourth and anterior surface where the bladder is attached.
b. Vagina.
Location: The vagina is the thin in walled muscular tube about 6 inches long leading from the uterus to the external genitalia. It is located between the bladder and the
rectum.
Function: The vagina provides the passageway for childbirth and menstrual flow; it receives the penis and semen during sexual intercourse.
c. Fallopian Tubes
Location: Each tube is about 4 inches long and extends medially from each ovary to empty into the superior region of the uterus.
Function: The fallopian tubes transport ovum from the ovaries to the uterus. There is no contact of fallopian tubes with the ovaries.
Description: The distal end of each fallopian tube is expanded and has finger-like projections called fimbriae, which partially surround each ovary. When an oocyte is expelled
from the ovary, fimbriae create fluid currents that act to carry the oocyte into the fallopian tube. Oocyte is carried toward the uterus by combination of tube peristalsis and
cilia, which propel the oocyte forward. The most desirable place for fertilization is the fallopian tube.
d. Ovaries
Functions: The ovaries are for oogenesis-the production of eggs (female sex cells) and for hormone production (estrogen and progesterone).

BLOOD SUPPLY
The blood supply is derived from the uterine and ovarian arteries that extend from the internal iliac arteries and the aorta. The increased demands of pregnancy necessitate a
rich supply of blood to the uterus. New, larger blood vessels develop to accommodate the need of the growing uterus. The venous circulation is accomplished via the internal
iliac and common iliac vein.

FACTS ABOUT THE MENSTRUAL CYCLE

Menstruation is the periodic discharge of blood, mucus, and epithelial cells from the uterus. It usually occurs at monthly intervals throughout the reproductive period, except
during pregnancy and lactation, when it is usually suppressed.
a. The menstrual cycle is controlled by the cyclic activity of follicle stimulating hormone (FSH) and LH from the anterior pituitary and progesterone and estrogen from the
ovaries. In other words, FSH acts upon the ovary to stimulate the maturation of a follicle, and during this development, the follicular cells secrete increasing amounts of
estrogen.
b. Hormonal interaction of the female cycle are as follows:
Days 1-5. This is known as the menses phase. A lack of signal from a fertilized egg influences the drop in estrogen and progesterone production. A drop in progesterone
results in the sloughing off of the thick endometrial lining which is the menstrual flow. This occurs for 3 to 5 days.
Days 6-14. This is known as the proliferative phase. A drop in progesterone and estrogen stimulates the release of FSH from the anterior pituitary. FSH stimulates the
maturation of an ovum with graafian follicle. Near the end of this phase, the release of LH increases causing a sudden burst like release of the ovum, which is known as
ovulation.
Days 15-28. This is known as the secretory phase. High levels of LH cause the empty graafian follicle to develop into the corpus luteum. The corpus luteum releases
progesterone, which increases the endometrial blood supply. Endometrial arrival of the fertilized egg. If the egg is fertilized, the embryo produces human chorionic
gonadotropin (HCG). Thehuman chorionic gonadotropin signals the corpus luteum to continue to supply progesterone to maintain the uterine lining. Continuous levels of
progesterone prevent the release of FSH and ovulation ceases.
OVULATION
Ovulation is the release of an egg cell from a mature ovarian follicle. Ovulation is stimulated by hormones from the anterior pituitary gland, which apparently causes
the mature follicle to swell rapidly and eventually rupture. When this happens, the follicular fluid, accompanied by the egg cell, oozes outward from the surface of the ovary
and enters the peritoneal cavity. After it is expelled from the ovary, the egg cell and one or two layers of follicular cells surrounding it are usually propelled to the opening of a
nearby uterine tube. If the cell is not fertilized by union of a sperm cell within a relatively short time, it will degenerate.

HORMONES
Estrogen
Estrogens are a group of steroid compounds functioning as the primary female sex hormone. Like all steroid hormones, estrogens readily diffuse across the cell
membrane. Once inside the cell, they bind to and activate estrogen receptors which in turn up-regulate the expression of many genes.
 The three major naturally occurring estrogens in women are estrone (E1), estradiol (E2), and estriol (E3). Estradiol (E2) is the predominate form in nonpregnant
females, estrone is produced during menopause, and estriol is the primary estrogen of pregnancy.
Estrogens are produced primarily by developing follicles (Graafian follicles) in the ovaries, the corpus luteum, and the placenta. Follicle-stimulating hormone (FSH) and
luteinizing hormone (LH) stimulate the production of estrogen in the ovaries. Some estrogens are also produced in smaller amounts by other tissues such as the liver, adrenal
glands, and the breasts. These secondary sources of estrogens are especially important in postmenopausal women.
While estrogens are present in both men and women, they are usually present at significantly higher levels in women of reproductive age. They promote the
development of female secondary sexual characteristics, such as breasts, and are also involved in the thickening of the endometrium and other aspects of regulating the
menstrual cycle.
• Structural
 promote formation of female secondary sex characteristics
 decelerate height growth
 accelerate metabolism (burn fat)
 reduce muscle mass
 stimulate endometrial growth
 increase uterine growth
 increase vaginal lubrication
 thicken the vaginal wall
 maintenance of vessel and skin
 reduce bone resorption, increase bone formation
 morphic change (endomorphic -> mesomorphic -> ectomorphic)
• protein synthesis
 increase hepatic production of binding proteins
• coagulation
 increase circulating level of factors 2, 7, 9, 10, plasminogen
 decrease antithrombin III
 increase platelet adhesiveness
• Lipid
 increase HDL, triglyceride
 decrease LDL, fat deposition
• Fluid balance
 salt (sodium) and water retention
• Hormones
 increase cortisol, SHBG
• Gastrointestinal tract
 reduce bowel motility
 increase cholesterol in bile
• Cancer
 support hormone-sensitive breast cancers
 • Lung function
 promotes lung function by supporting alveoli (in rodents but probably in humans).
Progesterone
Progesterone acts with estrogen to bring about the menstrual cycle. During pregnancy, it quiets the muscles of the uterus so that an implanted embryo will not be
aborted and helps prepare breast tissue for lactation. Progesterone is produced by another glandular structure in the ovaries, the corpus luteum. The corpus luteum produces
both estrogen and progesterone, but progesterone is secreted in larger amounts Ovaries are stimulated to release their estrogens and progesterone in a cyclic way by the
anterior pituitary gonadotropic hormones.
Progesterone is sometimes called the "hormone of pregnancy", and it has many roles relating to the development of the fetus:
• Progesterone converts the endometrium to its secretory stage to prepare the uterus for implantation. At the same time progesterone affects the vaginal epithelium
and cervical mucus, making it thick and impermeable to sperm. If pregnancy does not occur, progesterone levels will decrease, leading, in the human, to
menstruation. Normal menstrual bleeding is progesterone-withdrawal bleeding.
• During implantation and gestation, progesterone appears to decrease the maternal immune response to allow for the acceptance of the pregnancy.
• Progesterone decreases contractility of the uterine smooth muscle.
• In addition progesterone inhibits lactation during pregnancy. The fall in progesterone levels following delivery is one of the triggers for milk production.
• A drop in progesterone levels is possibly one step that facilitates the onset of labor.
• It raises epidermal growth factor-1 levels, a factor often used to induce proliferation, and used to sustain cultures, of stem cells.
• It increases core temperature (thermogenic function) during ovulation.
• It reduces spasm and relaxes smooth muscle. Bronchi are widened and mucus regulated. (Progesterone receptors are widely present in submucosal tissue.)
• It acts as an antiinflammatory agent and regulates the immune response.
• It reduces gall-bladder activity.
• It normalizes blood clotting and vascular tone, zinc and copper levels, cell oxygen levels, and use of fat stores for energy.
• It may affect gum health, increasing risk of gingivitis (gum inflammation) and tooth decay.
• It appears to prevent endometrial cancer (involving the uterine lining) by regulating the effects of estrogen.

PATHOPHYSIOLOGY
See Appendix D
 OUTCOME PRESENT STATE TEST MODEL

CLIENT IN CONTEXT PRESENT STATE TEST INTERVENTIONS OUTCOME

GORDON’S FUNCTIONAL HEALTH EMERGENCY ROOM BLOTTER
PATTERNS Date: November 12, 2009
C.M., is a 47 yr old female, Filipino, Time in: 10:25 AM
Roman Catholic, married, housewife from Time out: 11:40 AM
Tuba, Dalaguete, Cebu, born on November Vital Signs:
14, 1962 in Lumbang Dalaguete, Cebu, • BP = 130/70 mmHG
was admitted for the first time in Cebu • PR = 60 bpm
Velez General Hospital last November 12,
• T = 36.7 oC
2009 at 10:25 AM accompanied by her
• R = 20 cpm
sister and son, for complaints of vaginal
bleeding under Dr. Velez House (Dr. • Height = 5’2”
Belinda Panares) with a case number of • Weight = 115 lbs.
083841, to PPW 4th Floor room number • BMI = 21.21 (Normal)
408B. Admitted on November 12, 2009
Admitted at 11:20 AM
History of Present Illness
February of 2006 PTA, patient DOCTOR’S ORDER
started to feel that her right lower November 12, 2009
quadrant of her abdomen was hardening Please admit to OB-GYNE under the service
but there was no pain. Her menstrual cycle of Dr. Velez/House
was still regular and normal consuming 3-4
• TPR q 4H
napkins per day. No consultation was done.
May of 2006 PTA, patient had her • DAT
menstrual flow for 2 weeks, but with • Problem G3P3003 menometrorrhagia
inconsistent amounts of discharges that • Labs
sometimes she could consume 3 diapers  CBC
per day and lumps were not noted.  UA
Hardening of the RLQ of the abdomen was  Pregnancy Test
still noted and no pain was felt. She then  TUS at CUPSI
consulted Dr. Clarita Andrades of Argao
Cebu and an ultrasound was ordered. It PHYSICAL ASSESMENT
was found out that she had uterine DAY 1 (PRE-OPERATIVE PHASE)
myoma. No drugs were given. The doctor Date of Assessment: November 16, 2009
advised the patient to undergo surgery but
the patient refused to take the advice due • Height: 5’2”
to financial constraints but she still wants • Weight: 115 lbs.
to be cured. With her sister’s influence, • BMI: 21.21
they went to Tabunok Cebu City, to see a
faith healer. For a year, they went to see General appearance:
the faith healer for 5 times. The patient Examined sitting on bed, awake, conscious,
states that, what the faith healer did was responsive, coherent, afebrile and with an
to place a cigarette foil with unrecalled
herbs and plants on the site of the
hardening RLQ of the abdomen. Patient
claimed that she felt better verbalized
that”mura man kog naayo ato dong, day
kay ni au akong pamati dayun nihumok –
humok ang gahi nakong pus.on ug wala na
nibalik ang dugay na pag-agas sa akong
dugo.” Patient claimed that her menstrual
cycle became normal again. No other
interventions were done as claimed by the
patient.
2 months PTA, the patient had her
menstrual flow for the entire month but
with regular amounts consuming 3-4
napkins per day. Patient claims that it was
not accompanied with pain and no lumps
were noted. Patient claimed that there are
no alterations in her physiologic functions.
No interventions were done.
1 day PTA, on the 5th day of her
menstrual cycle, the patient experienced
severe vaginal bleeding with lumps noted
while taking a bath. She felt sudden
weakness and sister claimed that she
became very pale. She was rushed to the
nearest health care facility in Argao Cebu.
The sister of the patient claimed that the
amount of blood loss was about 1-2 liters.
IVTT was administered. The doctor
prescribed Hemostan capsule #15, 3x a
day for 5 days and Hemorin capsule #1, 2x
a day for 5 days but was taken for 1 day
only. The doctor referred the patient to
Cebu Velez General Hospital for further
recommendations and assessment.
Past Health History
Patient claimed that when she was
born there were no problems. Childhood
illnesses include chicken pox, measles,
fever and the common cough and colds.
She had no accidents or serious injuries.
Patient has no allergies. Previous
ease in respiration with an IVF of (5) D5LR at
10 gtt/min, infusing well at left arm with the
following vital signs:
• Blood Pressure = 130/70 mmHg
• Pulse Rate = 61 bpm
• Respiratory Rate = 19 cpm
• Temperature = 36.9oC/axilla
Skin:
Brown in color, skin is evenly distributed, no
discolorations and infestations, warm, moist
skin with the presence of IV line on left arm,
and no edema noted.
Nails:
Pinkish nailbeds, clean, trimmed nails, no
signs of clubbing and with a CRT < 2
seconds.
Head:
Symmetrical, round, normocephalic, located
at midline, no involuntary movements, no
swelling, tenderness or crepitations with
movement on the Temporo-mandibular joint.
Eyes:
Eyeballs are round, symmetrical, sclera is
white and moist, no unusual discharges
noted, brown iris, eyes are able to move
gaze at the 6 cardinal gazes, pupils are
equally round, react to light and
accommodation.
Ears:
Symmetrical with lateral canthus aligned
with pinna, external ear same color with
face, no lesions, presence of moist, yellow,
odorless cerumen on both ears, able to hear
whispered word “Hello” at a distance of 2
feet.
Nose and Sinuses:
Septum is midline; nostrils are patent, with
hospitalization was on 1973 in Cebu City no discharges noted and clear
Medical Center (CCMC) for the excision of transillumination.
cyst on her right breast. She stayed in the
hospital for 1 month due to bleeding in the Mouth and Throat:
incision. Unrecalled drugs were given and Symmetrical lips, uvula at midline, no
no consultations done after. nasopharyngeal congestion, no discharges
and lesions noted in the buccal mucosa.
Health Perception and Health
Management Pattern Neck:
The patient describes health as Trachea is at midline, no lesions and lymph
“ang kawal-on ug sakit”. She is currently nodes are non-palpable.
concerned with her condition is excited but
anxious about the surgery that she states Chest and Lungs:
“Nahadlok man ko dong, pero normal Equal chest expansion, clear breath sounds,
raman siguro na dong, pero ganahan nako no retractions, no rales, no wheezes and
ma-operahan para maayo nako”. Before deep inspiration noted.
hospitalization, she rates her health as 9, 1
as the lowest and 10 as the highest. Before Heart:
the surgery, she rates her health as 5 then Distinct S1 and S2 sounds, regular paced
rates it as 8 after the surgery and heartbeats, CRT < 2 seconds and with the
verbalized “Nalipay kaau ko na nahuman following pulse rates at the different sites:
na ang operation ug na tangtang ang • Brachial = 61 bpm
mayoma”. She does not smoke, drink
alcohol and has no history of drug abuse. • Radial = 62 bpm
She usually self medicates when she has • Apical = 61 bpm
cough and colds, fever and headache and • Temporal = 61 bpm
takes Neozep and Biogesic at an
unrecalled dose. She does not take any Abdomen:
maintenance medication. She usually Symmetric, umbilicus at midline, brown in
drinks 2 – 3 cups of “salabat’ when she has color, NABS 20 clicks per 5 minutes, no
cough. tenderness upon palpation, and uterus
She doesn’t have any yearly check- palpated with the enlargement noted to be
ups done. After her breast excision dominantly at the right side.
surgery, she has no correct knowledge in
performing breast self-examination and Genito-Urinary:
only palpates her breast once in a while. Grossly female, and claims of having no
She recalled that she had been immunized lesions and discharges upon assessment.
with BCG.
Her family lives in an old 2 storey Rectum:
house and there are 7 of them. It is made Patent and free of any lesions and
with mixed materials. There are 2 doors, 6 hemorrhoids as claimed by the patient upon
windows, 3 bedrooms and 1 bathroom. assessment.
There kitchen is outside their house. There
toilet is water sealed. They get there water Breast:
source from the faucet and the artesian
well and store it in a pail and pitcher for
drinking. They take care of animals in their
home. They have cats, dogs, pigs, cows
and goats. There house is 5 meters away
from their house. Nearest grocery,
drugstore and hospital is 30 minutes away.
Nutritional – Metabolic Pattern
Patient doesn’t weigh herself so
weight 3 months ago is unknown. But, she
states that there was no significant change
in her weight. She currently weighs 115
lbs. or 52.27 kg and is 5 feet 2 inches tall.
Her ideal body weight is 51.74 kg., and her
BMI is 21.21 and is categorized of having a
normal weight. She states that her weight
is appropriate for size and feels good about
it. She states that she does not lose or gain
weight easily. She has good appetite
before and during hospitalization. She was
ordered not to take any food and any liquid
(NPO) 11 hours before surgery. And after
the surgery and passing flatus, the patient
only took crackers and water as the doctor
ordered general liquid diet and crackers
with no carbonated drinks. She doesn’t
have any vitamin supplements taken.
Her 24 hour diet recall includes 1
pc longganisa, banana and 1 cup rice for
breakfast, egg soup, beef and 1 cup rice
for lunch and spaghetti, a single meatball
and 1 serving of vegetables and I cup of
rice for dinner. Her usual daily meals
include I cup coffee which is preferred
sweet in regards to her coffee by the
patient, egg, fish and rice for breakfast, 1
serving each of vegetables and fish for
lunch and dinner. She claims that she
drinks 8 glasses a day. They seldom eat
pork and beef at home, about 2 times a
week. She is also fond of drinking coke,
about 3 8oz bottles a week. She is not fond
of eating snacks. She has no specific likes
Breasts are saggy and no lumps palpated,
scar is present at the bottom part of the
right areola.
Extremities:
Pinkish nail beds, with a steady gait, no
edema noted, extremities are symmetrical.
NEUROLOGIC ASSESSMENT
Mental Status:
Awake, alert, conscious, follows direction
accurately, patient follows instructions
properly and performs tasks right away.
Instructions are told once and are
understood right away. Speech is somewhat
moderate in volume and can be heard easily,
moderately paced, oriented to person (able
to recognize the student nurse), place (able
to identify Cebu), time (able to recognize
that it’s afternoon), able to recall last day of
operation (remote memory) and date of
yesterday (current memory).
Motor-Cerebellar Function:
(+) rapid alternating movements, (+) finger-
thumb test, (+) finger-nose test, (+) button-
unbutton shirt and open-close zipper, (+)
Romberg’s test and was able to do the
tandem walk.
Sensory Function:
Able to feel light touch, able to differentiate
between sharp and dull object (The
difference between pressing with a finger
and with a ballpen), (+) stereognosis
(ballpen), (+) kinesthesia (able to recognize
movement and direction of finger) and (+)
graphesthesia (The number 7).
Cranial Nerve Testing:
 Olfactory - Able to identify the
scent of Bambini cologne.
 Optic – Is able to see clearly, read
and dislikes and religion does not affect
her diet. When she gets stressed, she
usually eats less. She and her sister are
the ones who shop for food, prepare them
and cook it. She verbalized that there
income is sufficient for a decent meal.
Elimination Pattern
Before hospitalization, she voids
around 3-5 times a day around 1-1.5 liters.
She claims that it is clear and yellowish in
color. During her hospitalization, she
voided around 1430ml but with normal
characteristics. After the surgery, she was
catheterized and she voided 1200ml. She
doesn’t drink any diuretics and drinks at
least 1 cup of coffee a day. She has not
experienced urinary incontinence and
dysuria.
Before hospitalization, she passes
stool once a day. She claims that it is
brown and formed stool. She usually voids
in the morning and usually doesn’t
postpone it. There was no change in her
bowel movement during hospitalization.
After surgery, the patient claimed that she
has yet to pass stool. She seldom
experiences diarrhea and constipation.
Activity – Exercise Pattern
Patient is a housewife but from
1990 to 2002 she worked as a ticket seller
in a movie house. Her typical day includes
cleaning her house, cooking, feed their
animals and watches over there sari - sari
store. She usually talks to her costumers
and watches TV as her leisure activity. She
doesn’t have any exercise but she states
that cleaning her house and doing the
laundry as her exercise. Before and during
hospitalization, she does not need
assistance in dressing, bathing, toileting
and eating. After the surgery, her sister is
the one who feeds her and perform
things from afar and at a close
distance in regards to the student’s
nameplate.
 Occulomotor – (+) PERRLA and
Cardinal gazes for both eyes.
 Trochlear – (+) PERRLA and
Cardinal gazes for both eyes.
 Trigeminal – (+) Corneal sensitivity
test and patient can clench teeth
and masseter and temporal muscle
contracted bilaterally upon biting
tongue depressor.
 Abducens – (+) PERRLA and
Cardinal gazes for both eyes.
 Facial – Able to smile, frown, show
teeth, raise eyebrows and close eyes
tightly. Able to identify the taste of
banana as sweet.
 Vestibulococchlear – Can hear
whispered word “Hello” at a distance
of 2 feet and has a sense of balance.
 Glossopharyngeal – (+) Gag reflex
 Vagus – (+) Gag reflex
 Spinal Accessory – Able to shrug
shoulders against resistance and
able to turn head side to side.
 Hypoglossal – Able to stick the
tongue out and move it side to side
and up and down.
Range of Motion:
• Elbows: full
• Wrist: full
• Shoulders and arms: left
arm slightly limited due to the
presence of an IV line
• Hips: full
• Knees, feet, ankles: full
No bony deformities, crepitus
and fasciculations noted.
hygienic procedures as she difficulty in
ambulating. She didn’t feel any pain in Muscle Strength:
doing her everyday activities back then.
Patient was observed to grimace, and R L
presented guarding behavior through
splinting of the wound. The patient was not 5/5 5/5
able to perform her daily activities such as
housekeeping or laundry since admission. 5/5 5/5

Cognitive – Perceptual Pattern

The patient’s highest educational
attainment was grade 6. Patient is oriented
to time, place and person. He has no eye
problem and can read a nameplate 2 feet
away. She has no ear examinations done.
She cleans her ears with cotton buds 2
times a week. She could hear watch tick
test 5 inches away. She does not have any
problem in the sense of taste, touch and
smell based on the result of the physical
examination. She doesn’t have recurring
problems like headache, vertigo and
dizziness. Postoperatively, the patient was
able to demonstrate the abilities she could
perform preoperatively.
Sleep – Rest Pattern
Before hospitalization, the patient
sleeps 10 hours a day. She sleeps mostly
around 8 pm and wakes up around 6 pm
and does not nap. During hospitalization,
patient claims that “Sige ko mata mata
dong kay sige ug sulod ang mga nurse sa
room”. She verbalized that before
hospitalization, she feels refreshed after
sleeping but now she feels that she didn’t
regain her energy as she verbalized “La-ay
man gihapon akong lawas”. After surgery,
the patient always stays in bed and wakes
up when she needs to eat and when the
nurse enters the room to get the vital
signs. She verbalized that she could sleep
with a small amount of noise and light. She
does not have any nighttime awakenings
SCALE FOR GRADING MUSCLE
STRENGTH
5 – Full ROM against gravity, full
resistance
4 – Full ROM against gravity, some
resistance
3 – Full ROM with gravity
2 – Full ROM with gravity eliminated
(passive motion)
1 – Slight Reaction
0 – No Reaction
Deep Tendon Reflexes:
LEFT: (+2) biceps reflex, (+2)
triceps reflex, (+2) brachioradialis
reflex, (+2) patellar reflex, (+2)
Achilles reflex
RIGHT: (+2) biceps reflex, (+2)
triceps reflex, (+2) brachioradialis
reflex, (+2) patellar reflex, (+2)
Achilles reflex
SCALE FOR GRADING REFLEX
RESPONSES:
0 – No Reflex Response
+1 – Minimal Activity
+2 – Normal Response
+3 – More Active than Normal
+4 – Maximal Activity (Hyperactive)
DAY 2 (INTRA-OPERATIVE PHASE)
Date of Assessment: November 17, 2009
• Height: 5’2”
and does not have any nightmares. Before
she retires, she washes up her face,
brushes her teeth and prays.
Postoperatively, the patient was not able
to perform her daily rituals.
At home, she sleeps in a medium
sized bed with her husband. She sleeps
with one pillow which is placed in her head
and a blanket. She usually sleeps in a
supine and side lying position.
Self Perception and Self Concept
Pattern
The patient views herself as a kind
and loving person. She also thinks
positively. Her sister describes her as a
caring person and very responsible. She
states that she is very happy with her life
today. She states that she thinks that there
is nothing wrong with her body and that
her illness didn’t change the way she
looked at her self. After the surgery, the
patient was asked about the essence of
her womanhood and replied “Okay raman
dong, tiguwang naman pud ko.” She
believes that her strength is her good
cooking skills and the way she keeps the
house clean and organized. She claims that
raising her 3 sons well is her greatest
achievement in life.
Role – Relationship Pattern
In her family, she takes the
maternal role as a full time mother to her
children and as the loving wife of her
husband. She states that it usually her
husband who makes the decision in the
home but she always trust her husband’s
decisions because it works out for the best.
She states that her sons are very
responsible that they usually brought no
problem to the family. She is the third
among all the 7 siblings. She verbalizes
that she has a good and loving relationship
• Weight: 115 lbs.
• BMI: 21.21
General appearance:
Examined lying on a stretcher, awake,
conscious, responsive, coherent, afebrile and
eupneic with an IVF of (5) D5LR infusing well
at 10 gtt/min at left arm with the following
vital signs:
• Blood Pressure = 130/70 mmHg
• Pulse Rate = 63 bpm
• Respiratory Rate = 19 cpm
• Temperature = 36.6oC/axilla
Skin:
Presence of IV line noted at the left arm.
Heart:
Distinct S1 and S2 sounds, heart rate of 63
bpm.
Abdomen:
Uterus palpated with the enlargement noted
to be dominantly at the right side.
NEUROLOGIC ASSESSMENT
Mental Status:
Patient was awake, alert, and conscious.
Responds to questions asked and speech is
understandable, moderately paced and
smiles. Oriented to person (able to recognize
the student nurse), place (able to identify
Cebu Velez General Hospital), and time (able
to recognize time: morning).
Sensory function:
Patient is able to see things at a distance
and at close proximity, able to hear and
understand speech, able to smell and feel
touch applied to skin.
DAY 3 (POSTOPERATIVE PHASE)
with her mother. She is closest to her
eldest sister and the sister next to her as
she verbalized “ maau jud kaau ni ako
igsoon kay iya jud ko gi ubanan”. Her
present status brought their family closer,
helping her financially and even sacrificed
their job in order to accompany her to the
hospital and always there to support her.
Patient verbalized “Gi-tumor man
sad sa matres akong duha ka mga iya-an.”
Patient claimed that her father has a
history of cardiovascular disease,
hypertension and diabetes mellitus and her
mother has hypertension.
Genogram
See Appendix B
Ecomap
See Appendix C
Sexuality – Reproductive Pattern
Patient has a female orientation.
She had her menarche when she was 15.
Her first sexual contact was with her
husband when she was 20 yrs old and was
her only sexual partner as well as her
partner. She states that she is still sexually
active. She claims that she doesn’t use any
contraceptives. She claims that before and
after the onset of illness, she had not
experienced pain, burning and discomfort
during intercourse and loss of libido. She
has no history of sexually transmitted
diseases. Patient is a G3P3003. She has 3
sons born through normal spontaneous
vaginal delivery and all assisted by a
doctor in a hospital in Angeles City in 1985,
19863, and 1987. She had her first baby
when she was 23 years old and claims that
each was delivered full term. She claims
that she was checked by a doctor during
her pregnancies but was not regular. She
claims that she had no illness during the
Date of Assessment: November 18, 2009
• Height: 5’2”
• Weight: 115 lbs.
• BMI: 21.21
General appearance:
Examined lying on bed, awake, conscious,
responsive, coherent, afebrile and with ease
in breathing with an IVF of (6) D5LR (1 L)
infusing well at 30 gtt/min at left arm with
the following vital signs:
• Blood Pressure = 1600/90 mmHg
• Pulse Rate = 61 bpm
• Respiratory Rate = 18 cpm
• Temperature = 36.7oC/axilla
Skin:
Presence of IV line on left arm.
Abdomen:
A presence of a binder covering a bandage
estimated to be 12 inches long, in turn this
bandage covers a horizontal incision
estimated to be 7 inches long located below
the umbilicus.
NEUROLOGIC ASSESSMENT
Mental Status:
Awake, lethargic, responsive and conscious,
follows direction accurately, patient follows
instructions properly and performs tasks
right away. Instructions are told once and
are understood right away. Speech is
somewhat moderate in volume and can be
heard easily, moderately paced, oriented to
person (able to recognize the student nurse),
place (able to identify Cebu), time (able to
recognize that it’s afternoon), able to recall
last opeeration (remote memory) and date
of yesterday (current memory).
Motor-Cerebellar Function:
entire course of all her pregnancies and no
complications during and after birth. She
states that every baby gave joy to her and
her husband’s lives. When asked whether
the operation will affect her womanhood,
she replied “ ok ra man dong, tigulang
naman sad ko, wala nakoy plano
manganak”. She states that she has not
undergone mammogram and Pap smear.
Coping – Stress Pattern
When asked about her stressors
and problems, patient states that “
pasalamat ko sa ginoo dong kay kani ra
jud ako sakit ang pinaka dako na problema
karon, maau ra man ang akong pamilya
bisan kulang usahay ang kita sa ako
bana”. But sometimes, she has small fights
with her neighbors and sometimes with her
husband in which she says is normal. It
doesn’t really affect her life in a way that it
alters her daily activities and well being.
When she has problems, she always goes
to her sister and her husband but when
she thinks it is irrelevant, she usually
keeps it to herself. She believes that her
hospitalization is not a huge stressor
because it is for her own welfare.
Value – Belief Pattern
The patient is a Roman Catholic.
She values her family and she always
keeps the family together. Before and
during the onset of illness, patient
fervently prays everyday, goes to church
every Sunday, prays the rosary, attends
procession and joins prayer meetings. She
states that her illness is not a punishment
of God. She states that because of her
strong belief in God, the operation will be
successful and after the surgery she
verbalized, “Nagpasalamat jud ko sa Ginoo
na maau ra an gang akong operasyon”.
She doesn’t believe in superstitions.
(+) rapid alternating movements, (+) finger-
thumb test, (+) finger-nose test, (+) button-
unbutton shirt, Romberg’s test and tandem
walk not done as it might endanger the
patient.
Sensory Function:
Able to feel light touch, able to differentiate
between sharp and dull object (The
difference between pressing with a finger
and with a ballpen), (+) stereognosis
(ballpen), (+) kinesthesia (able to recognize
movement and direction of finger) and (+)
graphesthesia (The number 6).
Cranial Nerve Testing:
 Olfactory - Able to smell the
Bambini cologne with eyes closed
 Optic – Is able to see clearly, read
the nameplate of the student nurse
 Occulomotor – (+) PERRLA and
Cardinal gazes for both eyes
 Trochlear – (+) PERRLA and
Cardinal gazes for both eyes
 Trigeminal – (+) Corneal sensitivity
test and patient can clench teeth
and masseter and temporal muscle
contracted bilaterally upon biting
INDEPENDENT INTERVENTIONS: DESRIED OUTCOME:
tongue depressor.
1.Continually assessed patient’s Within 8 hours of nursing
 Abducens – (+) PERRLA and perception of cause of sleep difficulty and intervention, client will be able to
Cardinal gazes for both eyes. possible relief measures achieve optimal amount of sleep as
 Facial – Able to smile, frown, show R: To facilitate treatment and to improve evidenced by a rested appearance
teeth, raise eyebrows and close eyes sleep with the identification of relief and verbalization of feeling rested
tightly measures and to recognize the importance of
 Vestibulococchlear – Can hear bedtime routines and practices as
whispered word “Hello” at a distance 2.Determined usual sleep habits and evidenced by using these measures
of 2 feet. changes that are occurring in order to promote sleep
R: Assess need for and identifies
 Glossopharyngeal – (+) Gag reflex appropriate interventions ACTUAL OUTCOME:
 Vagus – (+) Gag reflex After a day of nursing intervention,
 Spinal Accessory – Able to turn 3.Organized plan of care client appeared rested and with the
head side to side. R:To promote minimal interruption in verbalization of “maka tarong-tarong
  Hypoglossal – Able to stick the sleep/rest nkog tulog day ky wala naman kaau
tongue out and move it side to side manulod nga mukuha ug tests.”
and up and down. 4.Promoted relaxation by providing a
darkened, quiet environment, ensuring
Range of Motion: adequate room ventilation, following
bedtime routines, and avoid banging doors
• Elbows: full R: Hospital environment can interfere with
• Wrist: full relaxation and sleep. Using established
• Shoulders and arms: left bedtime rituals increases relaxation
arm slightly limited due to
the presence of an IV line 7.Instructed client measures to promote
No bony deformities, sleep such as DBE
crepitus and fasciculations R: Sleep is difficult unless client is relaxed
noted.
8.Assisted in elevating head in a reclining
Muscle Strength: bed
R: To reduce shortness of breath and
R L increased rest

4/5 4/5 9. Asked to verbalize needs before going

to sleep
4/5 4/5 R: Promotes bedtime routines and attends
to client’s need

SCALE FOR GRADING MUSCLE 11.Instructed in relaxation measures like

STRENGTH reading magazines
5 – Full ROM against gravity, full R: Helps induce sleep
resistance
4 – Full ROM against gravity, some 12. Encouraged comfortable position and
resistance assisted in turning
3 – Full ROM with gravity R: Repositioning alters areas of pressures DESIRED OUTCOME:
2 – Full ROM with gravity eliminated and promotes rest Within 3 hours of nursing
(passive motion) intervention, patient will appear
1 – Slight Reaction relaxed and verbalize reduction of
0 – No Reaction INDEPENDENT INTERVENTIONS: anxiety to manageable level.
1. Acknowledged awareness of patient’s
LABORATORY FINDINGS anxiety. ACTUAL OUTCOME:
R: communicated acceptance of the After 3 hours of nursing intervention,
See Appendix A feeling. patient still showed anxiousness by
verbalization of “Mahadlok gihapon
2. Conversed with patient ko gamay day sa akong operasyon
R: to promote relaxation and encourage maong d au ko maka tog sa sigeg
expression of feelings. huna-huna”.
KEY ISSUES
DAY 1 (Pre-operative Phase) (November 3. Stayed by patient’s side.
16, 2009) R: to assure patient of security and safety.

1. SLEEP DEPRIVATION related to 4. Encouraged deep-breathing exercises.

discomfort and unfamiliar environment as
manifested by daytime drowsiness, lack of
energy and patient’s verbalization “Sige ko
og mata-mata dong, kay sulod ang mga
nurse sa room” and when asked about what
she felt when she wakes up she answered
“Lain man gihapon ako lawas.”
SCIENTIFIC BASIS:
Hospitalization affects the quality of
nocturnal and other sleep time especially for
older adults. The hospital environment often
lacks light and dark cues. Confinement
curtails activity or exercise that normally
causes fatigue. In addition, unfamiliar sights
and sounds and frequent awakenings for the
assessment for vital sing and other
interventions can disturb sleep.
SOURCE: Black, Joyce and Jane Hokanson
Hawks. Medical-Surgical Nursing & 7th edition
vol. 1, p. 439
Clients with sleeping problems have
difficulty falling asleep or difficulty staying
asleep. Various factors may be involved. This
includes frequent changes in sleep time,
changes in sleep environment or bedtime
rituals. SOURCE: Fundamentals of Nursing,
7th edition by Barbara Kozier, page 1122)
R: to promote relaxation.
5. Provided a quiet and peaceful
environment.
R: feelings of anxiety decrease in a calm
atmosphere.
6. Conducted a preoperative teaching
about his condition and the surgery she DESIRED OUTCOME:
would undergo Within 30 minutes of nursing
R: to reduce the level of anxiety, client has intervention, patient will verbalize
the right to receive necessary information understanding of procedures.
regarding his diagnosis and treatment
ACTUAL OUTCOME:
After 30 minutes of nursing
INDEPENDENT INTERVENTIONS: intervention, patient verbalized “ah,
1. Determined client’s ability to learn mao diay na akong angay buhaton…
R: to assess readiness to learn and salamat day”.
individual learning needs
2. Provided pre-operative health teachings
including hygiene, NPO after midnight,
emptying bladder and bowel, changing
into OR gown and taking off of jewelry.
R: to orient patient to surgical procedures.
3. Maintained an atmosphere of openness.
R: to encourage patient to express
opinions about his situation and to voice
out areas of doubt.

4. Provided positive reinforcement

R: encourages continuation of efforts
5. Provided an environment that
conducive to learning
R: To facilitate learning
INDEPENDENT INTERVENTIONS:
DESIRED OUTCOME:
Within 3 days of nursing intervention,
is the client will be able to:
• report improved sense of
energy
• perform ADLs and participate
in desired activities at level of
ability

2. MILD ANXIETY related to the perceived
possible complications during and after the
surgery as manifested by verbalization of
“hadlok ko gamay sa operasyon kay
mahadlok ko ma-ingato sauna” and
presence of poor eye contact with the nurse
and a worried face.
SCIENTIFIC BASIS:
Anxiety disorders are very common among
primary care patients. However, similar to
depression, anxiety is poorly recognized by
the patient and requires a high degree of
suspicion for diagnosis. Patients with anxiety
may present with a complaint of excessive
worrying but they are more likely to report
various somatic complaints, such as
palpitations, insomnia or exhaustion, or
gastrointestinal disturbances.
SOURCE: www.sh.lsuhsc.edu
3. PARTIAL KNOWLEDGE DEFICIT related
to the unfamiliarity of the operation to be
done as manifested by client’s verbalization
“unsa diay mahitabo ana day? Aron ma
kahibaw pd ko.”
SCIENTIFIC BASIS:
The preoperative client may not be
completely knowledgeable about surgical
procedures.
1. Determined the ability to participate in
activities. ACTUAL OUTCOME:
R: Fatigue can limit the person’s level of After 3 days of nursing intervention,
mobility. the client was able to:
• report that her energy was
2. Lessened environmental stimuli. restored but not fully
R: Over stimulation increases fatigue. • perform some ADLs with
assistance such as walking
3. Assess vital signs and going to the bathroom
R: to evaluate cardiopulmonary response without feeling tired
to activity
4. Obtain client’s description of fatigue
R: to assist in evaluating impact on client’s
life
5. Scheduled activities with frequent rest
periods in between.
R: To conserve energy.
6. Instruct in methods to conserve energy
such as delegating task and sitting instead
of standing in doing daily care/ other
activities
R: to conserve energy and to assist client
to cope with fatigue
7. Assist with self-care needs and
ambulation as indicated
R: to client cope with fatigue
8. Promote overall health measures such DESIRED OUTCOME:
as adequate nutrition and fluid intake Within the duration of the operation,
R: to promote wellness the client will experience no
aspiration.
9. Advised patient to get enough rest and
sleep ACTUAL OUTCOME:
R: to restore energy level Within the duration of the operation,
the client was not able to experience
aspiration.
INDEPENDENT INTERVENTIONS:
1. Reviewed client’s history, noting age,
weight and height, physical limitations,
SOURCE: p.1309, Medical-Surgical Nursing
by Black and Hawk)
4. FATIGUE related to altered blood
chemistry as manifested by lab results as of
Nov.16,2009 (HGB = 11.5 and HCT = 34.6)
and verbalation “gikan ko matulog kapoy
ghapon akong lawas”.
SCIENTIFIC BASIS: Fatigue may be the
result of one or more environmental causes
such as inadequate rest, improper diet, work
and home stressors, or poor physical
conditioning, or one symptom of a chronic
medical condition or disease process in the
body.
SOURCE: www.healthatoz.com
preexisting conditions
R: Affects choice of perioperative
positioning and affects skin/tissue integrity
during surgery.
2. Noted anticipated length of procedure
and customary position
R: to increase awareness of potential DESIRED OUTCOME:
postoperative complications. Within the duration of the operation,
the client will be free of injury related
3. Assessed individual’s response to to perioperative disorientation.
operative sedation/medication, noting
level of sedation and/or adverse effects
and report to surgeon as indicated. ACTUAL OUTCOME:
R: Each person has different responses to Within the duration of the operation,
different kinds of anesthesia. the client remained unharmed and
free from injury.
INDEPENDENT INTERVENTIONS:
1. Locked patient in place; support client’s
body and limbs; use adequate numbers of
personnel during transfers
R: to prevent shear and friction injuries.
2.Determined specific position reflecting
procedure guidelines
R: to avoid having injury to the patient.
3.Maintained body alignment as much as
possible using pillows/padding/safety
straps DESIRED OUTCOME:
R: to reduce potential for neurovascular Within the duration of the operation,
complications associated with the client will not manifest any signs
compression, overstretching or ischemia of and symptoms of infection or
nerve/s. excessive blood loss.
ACTUAL OUTCOME:
Within the duration of the operation,
the client did not manifest any signs
and symptoms of infection or
excessive blood loss.
INDEPENDENT INTERVENTIONS:
1. Noted skin color, texture and turgor.
 R: to asses extent of involvement and
injury

2. Maintained sterility of the field.

R: to prevent contamination

3. Made sure that the instruments that are

soiled are not mixed with the sterile
instruments.
R: to prevent contamination and infection
DAY 2 (Intra-operative Phase)
(November 17, 2009) 4. Ensured complete sponge count as done
by the scrub nurse and participated by the
1. RISK FOR ASPIRATION related to student nurse.
administration of anesthesia R: to ensure that no instruments are left
Cues: Use of Anesthesia (Tetracaine) inside the operative site.
Adverse Effects of Tetracaine:
Respiratory arrest 5. Noted poor hygiene/health practices
R: Hygiene may have a big impact on
SCIENTIFIC BASIS: One of the general tissue health
adverse effects of local anesthetics, esters
and specifically tetracaine is respiratory 6. Assessed blood supply and sensation
arrest. (nerve damage) of affected area. Evaluate
SOURCE: p.248, Pharmacology for Nurses pulses/calculate ankle/brachial index
by Michael Patrick Adams et. al. R: to evaluate actual/potential for DESIRED OUTCOME:
impairment of circulation of lower Within the duration of the operation,
extremeties. the client will not manifest any signs
and symptoms of infection or
7. Determined and Noted degree/depth of excessive blood loss.
injury/damage to integumentary system,
extent of tunneling/undermining, if ACTUAL OUTCOME:
present. Within the duration of the operation,
2. RISK FOR PERIOPERATIVE R: to note how deep and how the extent of the client did not manifest any signs
POSITIONING INJURY related to position impairment is and symptoms of infection or
requirements and loss of consciousness excessive blood loss.
secondary to administration of Tetracaine 8. Maintained sterility in the area of
Cues: decreased level of consciousness operation.
caused by induction of Tetracaine R: to prevent transmission of
microorganisms to enter the incision site.
SCIENTIFIC BASIS: As the patient breathes
in the anesthesia mixture, warmth, dizziness,
and a feeling of detachment may be INDEPENDENT INTERVENTIONS:
experienced. 1. Stressed proper hand washing
SOURCE: Brunner and Suddarth’s Medical- techniques by all caregiver between
Surgical Nursing. “General Anesthesia, Stage therapies and client.
I: beginning anesthesia”. 11th ed, Vol1, R: a first-line defense against nosocomial
p.509. infections or cross contamination.

2. Observe for localized signs of infection

at surgical incision and wound such as
swelling, inflammation and unusual
discharges
R: to assess contributing factors.

3. Instructed client and SO in techniques

such as strict hand washing before
3. IMPAIRED SKIN AND TISSUE touching DESIRED OUTCOME:
INTEGRITY related to mechanical trauma R: to promote wellness and prevent cross Within 1 hour of nursing intervention,
secondary to total abdominal hysterectomy contamination. patient will be able to maintain a
with bilateral salphingo-ooparectomy as body temperature ranging from 36.5
manifested by to midline abdominal surgical 4. Instructed patient not to touch site °C to 37.5 °C.
incision frequently
R: reduce risk of infection ACTUAL OUTCOME:
SCIENTIFIC BASIS: After 1 hour of nursing intervention,
A wound can be infected by microorganisms 5. Instructed to keep site clean and dry patient’s temperature was 36 °C.
at the time of injury, during surgey and post R: to reduce risk of infection and promote
operatively. healing
SOURCE: Kozier Fundamentsls of Nursing
6. Discussed importance of not using other
persons prescribed drugs and avoid self
medication.
R: inappropriate use can lead to
development of drug-resistant strains.

INDEPENDENT INTERVENTIONS:
1.Monitored vital signs especially
temperature
R: to prevent occurrence of temperature
deviations DESIRED OUTCOME:
Within 3 days of nursing intervention,
2. Provided adequate covering. the client will be able to:
R: to promote warmth and prevent • report pain is relieved,
unnecessary heat loss. controlled or decreased

3. Adjusted air-cooling device. • follow prescribed


4. RISK FOR INFECTION related to
possible intrusion of pathogens secondary to
invasive procedure (total abdominal
hysterectomy with bilateral salphingo-
ooparectomy)
Cues: presence of midline abdominal
incision
SCIENTIFIC BASIS: the nature, number
and duration of physical and emotional
stressors can influence susceptibility to
infection. Stressors elevate the blood
cortisone. Prolonged elevation of blood
cortisone decreases anti-inflammatory
responses, depletes energy stores, leads to a
state of exhaustion, and decreases
resistance to infection. For example, a
person recovering from a major operation or
injury is more likely to develop an infection
than a healthy person.
SOURCE: Kozier and Erb’s Fundamental’s of
Nursing. “Factors increasing susceptibility to
infection”, 8th ed, p. 675
SCIENTIFIC BASIS: A wound can be
infected with microorganisms at the time of
injury, during surgery or postoperatively.
Surgery involving the intestines can also
result in infection from the microorganisms
inside the intestine. Surgical infection is
most likely to become apparent 2 to 11 days
postoperatively.
SOURCE: Kozier and Erb’s Fundamental’s of
Nursing. “Infection”, 8th ed, p. 912
5. RISK FOR IMBALANCED BODY
R: to prevent unnecessary heat loss by pharmacological regimen
convection. • verbalize nonpharmacologic
methods that provide relief
4. Maintained surgical asepsis at all times.
R: To prevent the spread of
ACTUAL OUTCOME:
microorganisms and prevent infection
After 3 days of nursing intervention,
the client was able to:
5. Assess for blood loss
R: to much blood loss can decrease the • report a decrease in pain
temp from 5 to 2 with 10 as the
highest and 1 as the lowest
6. Monitor I&O • follow prescribed
R: to note unusualities in the drains pharmacological regimen
• demonstrate deep breathing
exercise as a
nonpharmacological method
to relieve pain
INDEPENDENT INTERVENTIONS:
1. Assessed onset, location, duration,
characteristics, aggravating and relieving
factors, severity (1-10 scale) & frequency
of pain.
R: to determine quality of pain
2. Observe nonverbal cues/ pain behaviors
R: Observations may be the only indicator
present when client is unable to verbalize
3. Monitor vital signs
R: Vital signs is usually altered in acute
pain though not always
DESIRED OUTCOME:
4. Note when pain occurs
R: To medicate prophylactically, as Within 3 days of nursing intervention,
the client will be able to:
appropriate
• Maintain optimal nutrition/
5. Provide comfort measures physical well-being
R: To promote nonpaharmacological pain • Participate in methods to
management decrease the risk for infection
• Be infection-free
6. Instruct in/ encourage the use of
relaxation techniques like DBE ACTUAL OUTCOME:
R: to distract attention and reduce tension After 3 days of nursing intervention,
TEMPERATURE related to body’s exposure
to cold environment.
Cues:
Lack of clothing for the patient.
Air-conditioned operating room.
DAY 3 (Postoperative Phase)
1. ACUTE PAIN related to surgical incision
at the hypogastric region secondary to total
abdominal hysterectomy with bilateral
saplphingo-oophorectomy onset of
continuous sharp gnawing pain at incision
site noted hours after surgery at hypogastric
region aggravated by sudden movement
relieved by analgesics and rest with a pain
scale of 6 with 1 as the lowest and 10 as the
highest as manifested by facial grimacing
when moving and guarding behavior.
SCIENTIFIC BASIS: Nociceptive pain is
caused by an injury to the body tissues. The
injury may be a cut, a bruise, bone fracture,
crush injury, burn or anything that damages
tissues. This type of pain is typically aching,
the client was:
7. Encourage verbalization about the pain • Able to participate in methods
R: To slightly relieve pain using a non- to decrease the risk for
pharmacologic method to alleviate pain. infection such as hand
washing
8. Encourage adequate rest periods • Noted to have no post op
R: to prevent fatigue infection
COLLABORATIVE INTERVENTIONS:
1. Administered Nalbupine (C: opioid
analgesic; I: moderate to severe pain; A:
decrease pain)
INDEPENDENT INTERVENTIONS:
1. Determine depth of damage of the
integumentary system
R: to assess the extent of the injury
2. Assess blood supply and sensation
R: to evaluate actual/ potential for
impairment of circulation to lower
extremities
3. Performed hand washing before and
after contact with the client
R: to prevent contamination
4. Taught patient and SO proper way of
hand washing
R: hand washing is the most effective way
to prevent infection
5. Note presence of compromised vision,
hearing, or speech
R: Skin is a particularly important avenue
of communication for this population and,
when compromised, may affect responses.
DESIRED OUTCOME:
6. Note for signs of infection such as fever,
Within 3 days of nursing intervention,
chills, redness, swelling and purulent
the client will be able to:
drainage
• Identify individual areas of
R: these may indicate post op infection
sharp, or throbbing. Most pain is nociceptive
pain. Pain receptors for tissue injury
(nociceptors) are located mostly in the skin
or in the internal organs. The pain almost
universally experienced after surgery is
nociceptive pain.
SOURCE: The Merck Manual, p.404
IMPAIRED SKIN INTEGRITY related to
mechanical trauma secondary to total
abdominal hysterectomy with bilateral
salphingo-oophorectomy as manifested by
presence of surgical incision on the
hypogastric region.
SCIENTIFIC BASIS: Skin, the flexible tissue
enclosing the body of vertebrate animals. In
humans and other mammals, the skin
operates a complex organ of numerous
structures serving vital protective and
metabolic functions. Surgical incision is a
medical procedure involving an incision with
instruments; performed to repair damage or
arrest disease in a living body. Wound
healing is a complex sequence of events
initiated by injury to the tissues. The
weakness/ needs
7. Keep area clean/ dry • Perform self-care activities
R: to aid in the body’s natural process of within level of own ability
repair
ACTUAL OUTCOME:
After 3 days of nursing intervention,
8. Reposition every 2 hours
the client was able to:
R: to prevent ulcers
• Identify her weakness/ needs
such as her difficulty in
9. Encourage early ambulation
getting out from the bed
R: promotes circulation and reduces risk
associated with immobility • Perform some self-care
activities such as toileting
without assistance
10. Encouraged patient to eat a well
balanced and protein- rich diet once on full
diet
R: to provide a positive nitrogen balance to
aid in tissue healing and to maintain
general good health
11. Assist client to learned stressed
reduction activity and techniques
R: To control feelings of helplessness and
deal with situation.
INDEPENDENT INTERVENTION:
1. Evaluate current limitations of client in
doing usual activities
R: To obtain baseline data
2. Performed physical examination
R: To assess client’s motor functions
3. Perform/ assist with meeting client’s
needs when he or she is unable to meet
own needs
R : to assist in correcting or dealing with
situation
4. Practice and promote short-term goal
setting and acheivement
R : accepting ability to do one thing at a DESIRED OUTCOME:
time ; boost self-esteem Within 3 days of nursing intervention,
components are coagulation of bleeding,
inflammation, epithelization, fibroplasias and
collagen metabolism, collagen maturation,
scar remodeling and wound contraction
SOURCE:
http://www.answers.com/topic/skin
5. Provide privacy and equipment within
easy reach during personal care activities
R : to assist in correcting/ dealing with the
situation
6. Allow sufficient time for client to
accomplish tasks to the fullest extent of
ability
R : to assist in correcting/ dealing with the
situation
7. Advised patient to set time to rest,
especially after ADLs.
R: Increase patient’s strength and
tolerance for activity; to provide comfort
and relaxation.
8. Encouraged patient participation in
random activities (ambulating, daily
exercises).
R: Promotes independence, enhances self-
esteem
Independent interventions
the client will be able to:
• Identify interventions to
prevent/ reduce risk of
infection
• Understand the importance of
keeping the incision site
clean/ dry
ACTUAL OUTCOME:
After 3 days of nursing intervention,
the client was able to:
• Identify interventions to
prevent/ reduce risk of
infection like proper hand
washing
• Understand the importance of
keeping the incision site
clean/ dry by nodding

9. Encouraged client to increased exercise

levels gradually
R: To help client increased level of activity
of client

10. Encouraged client to participate in

recreational activities & hobbies
appropriate for the situation
R: To enhance sense of well-being

INDEPENDENT INTERVENTIONS:
1. Observe for localized signs of infection
at insertion sites of invasive lines, sutures,
surgical incisions/ wounds
R: to assess causative/ contributing factors

PARTIAL SELF CARE DEFICIT: BATHING, 2. Stress proper hand hygiene by all
DRESSING, & TOILETING; related to caregivers and SOs
postoperative pain at the hypogastric region R: a first line of defense against infections
as manifested by difficulty in performing
ADLs as manifested sister’s assistance in
performing ADLs.
SCIENTIFIC BASIS: Self care is personal
health maintenance. It is any activity of an
individual with the intention of improving or
restoring health, or treating or preventing
disease.
Self care includes all health decisions people
(as individuals or consumers) make for
themselves and their families to get and stay
physically and mentally fit. Self care is
exercising to maintain physical fitness and
good mental health. Self care is also taking
care of minor ailments, long term conditions,
or one’s own health after discharge from
secondary and tertiary health care. . To
enable people to do enhanced self care, they
can be supported in various ways and by
different health service providers.
SOURCE: http://en.wikipedia.org/wiki/Self-
care
3. Change surgical/ other wound dressings,
as indicated, using proper technique for
changing/ disposing of contaminated DESIRED OUTCOME:
materials Within 3 days of nursing intervention,
R: to reduce/ correct existing factors the client will be able to regain and
maintain usual pattern of elimination.
4. Cover perineal/ pelvic region dressings/
casts with plastic when using bedpan ACTUAL OUTCOME:
R: to prevent contamination After 3 days of nursing intervention,
the client still wasn’t able to pass
stool.
5. Encourage early ambulation, teach deep
breathing, coughing, position changes
R: for mobilization of respiratory secretions
and prevention of aspiration/ respiratory
infections
6. Maintain adequate hydration, stand/ sit
to void, and catheterize, if necessary
R: to avoid bladder distention/ urinary
stasis
7. Administer/ monitor medication regimen
and note client’s response
R: to determine effectiveness of therapy/
presence of side effects
8. Emphasize necessity of taking
antibiotics as directed (dosage and length
of therapy)
R: premature discontinuation of therapy
when client begins to feel well may result
in return of infection and potentiate drug
resistant strains
9. Include information about ways to
reduce potential for postoperative
infection (wound/ dressing care, avoidance
of others with infection)
R: to promote wellness

RISK FOR INFECTION related to
inadequate primary defenses and tissue
destruction secondary to total abdominal
hysterectomy with bilateral salphingo-
oophorectomy
Cues: surgical incision on hypogastric region
SCIENTIFIC BASIS: The location and extent
of the surgical site and incision put the
patient at risk for contamination of the site
and infection and sepsis. The patient is
monitored closely for local and systemic
signs and symptoms of infection: purulent
drainage, redness, increased pain, fever, and
an increased white blood count.
SOURCE: Medical Surgical Nursing, Brunner,
p. 1434
SCIENTIFIC BASIS: A wound can be
infected with microorganisms at the time of
injury, during surgery or postoperatively.
Surgical infection is most likely to become
apparent 2 to 11 days postoperatively.
SOURCE: Kozier and Erb’s Fundamental’s of
Nursing. “Infection”, 8th ed, p. 912
INDEPENDENT INTERVENTIONS:
1. Review medical/ surgical history
R: to identify conditions commonly
associated with constipation
2. Discuss usual elimination pattern and
use of laxatives
R: to obtain baseline data & identify
individual risk factors or needs
3. Ask the patient if he has "passed gas"
within 24 hours of return to the ward from
the recovery room.
R: this indicates the return of peristalsis
4. Ambulate patient as early as possible
R: ambulation assists in peristalsis
5. Discuss acceptable variations in
elimination
R: may help reduce anxiety about situation
6. Promote adequate fluid intake, including
water and high- fiber fruit juices or foods
rich in fiber such as cereals, beans, peas
and cabbage, grain products like whole
grain breads
R: promotes soft stool and stimulates
bowel activity
7. Encouraged client to increase
activity/exercise within limits of capability.
R: Stimulates contractions of the
intestines.
 RISK FOR CONSTIPATION related to
immobility secondary to s/p total abdominal
hysterectomy with bilateral salphingo-
oophorectomy
Cues:
Always staying on her bed
SCIENTIFIC BASIS: Anesthesia slows or
stops the peristaltic action of the intestine,
which results in constipation. Nausea and
vomiting may cause fluid imbalance.
Abdominal distention/flatus may also be
present.
SOURCE:
http://www.tpub.com/content/armymedical/
md0915/md09150067.htm

APPENDIX A
LABORATORY & DIAGNOSTIC FINDINGS

COMPLETE BLOOD COUNT

Performed on: August 25, 2009
Purpose:
A complete blood count serves a clinical purpose, through which it serves by diagnosing certain diseases and evaluates the stage of a particular disease. The cells that
generally circulate the body are divided into three and are counted, and thus gives a general health status about the client.
Component Patient’s Values Normal Values
11 – 16 – 2009 11 – 14 – 2009 11 – 12 – 2009
White Blood Cells 7.98 7.99 7.07 4.10 – 10.9 k/uL
Neutrophils 5.56 5.75 5.18 2.50 – 7.50
Lymphocytes 1.31 1.54 1.44 1.00 – 4.00
Monocytes 0.769 0.496 0.337 0.10 – 1.20
Eosinophils 0.262 0.178 0.081 0.0 – 0.5
Basophils 0.081 0.034 0.030 0.0 – 0.1

Red Blood Cells 4.77 4.21 3.15 4 – 5.20 m/uL

Hemoglobin 11.5 9.14 5.27 12 – 16 g/dL
Hematocrit 34.9 28.8 17.8 36 – 46%
Mean Corpuscular Volume 73.2 68.5 56.4 80 – 100 fL
Mean Corpuscular Hematocrit 24.1 21.7 16.7 26 – 34 pg
Mean Corpuscular Hemoglobin Concentration 32.9 31.8 29.7 31 – 36 g/dL
Red Blood Cell Distribution Width 29.1 38.1 23.4 11.6 – 18%

Platelets 289 327 455 140 – 440 k/uL

Mean Platelet Volume 8.33 8.25 7.78 0 – 100 fL

Implications:
The amount of hematocrit and hemoglobin are below the normal range which indicates anemia.

URINALYSIS
Performed on: November 12, 2009
Purpose:
Urinalysis are usually used to as a general health screening test to detect renal and metabolic diseases diagnosis of diseases or disorders of the kidneys or urinary tract
monitoring of patients with diabetes In addition, quantitative urinalysis tests may be performed to help diagnose many specific disorders, such as endocrine diseases, bladder
cancer, osteoporosis, and porphyrias (a group of disorders caused by chemical imbalance).
Macroscopic Microscopic
Color: Yellow RBC/hpf: 1 – 2
Appearance: Cloudy WBC/hpf: 1 – 3
pH: 7.0 Epithelial Cells: 5 – 8/hpf
Specific Gravity: 1.018 Phosphates: Abundant
Protein: Negative Bacteria: Abundant
Glucose: Negative Ketones: Negative
Reducing Substances: Negative Blood: Moderate
Heat and Acetic Acid Test: Negative
Implications:
There were no significant findings noted.

BLOOD CHEMISTRY
Performed on: November 12, 2009
Purpose:
In the body, the important ions of electrolytes are sodium, potassium, calcium, magnesium, chloride, hydrogen phosphate, and hydrogen carbonate. Humans must regulate
these electrolytes in order to optimally function. Such gradients affect and regulate the hydration of the body, blood pH, and are critical for nerve and muscle function.
Liver Function Tests – ALT/SGPT Creatinine
Patient’s value: 10 u/L Patient’s value: 0.8 mg/dL
Normal value: 0 – 39 Normal value: 0.6 – 1.5 mg/dL
Potassium Sodium
Patient’s value: 3.2 mmol/L Patient’s value: 139 mmol/L
Normal value: 4.0 – 5.6 mmol/L Normal value: 136 - 142 mmol/L
Implications: Low blood potassium levels can be caused by high levels of aldosterone (hyperaldosteronism) made by the adrenal glands.

CLOTTING & BLEEDING TIME

Performed on: November 12, 2009
Purpose:

Clotting Time- are used to determine the integrity of the coagulation pathways, and platelet function. In general, the common tests for the intrinsic or common pathways
are the activated partial thromboplastin time (APTT) and activated coagulation time (ACT). One-stage prothrombin time (OSPT) is usually used to evaluate the extrinsic or
common pathways, and platelet count, clot retraction, bleeding time and activated coagulation time reflect platelet numbers and function.
Bleeding Time- This test measures the time taken for blood vessel constriction and platelet plug formation to occur. No clot is allowed to form, so that the arrest of bleeding
depends exclusively on blood vessel constriction and platelet action.
Clotting Time Bleeding Time
Patient’s value: 3 minutes and 28 seconds Patient’s value: 1 minute and 50 seconds
Normal value: 2 – 6 minutes Normal value: 1 -3 minutes
Implications: No significant findings found.

PLATELET & PROTHROMBIN TIME

Performed on: November 12, 2009
Purpose: These tests will detect most coagulation protein problems. A relation between thrombocytopenia and time on bypass also was reported. The clinical picture,
bleeding time, prolonged partial thromboplastin time test, and plasma prothrombin time test lead to the diagnosis.
Platelet and Prothrombin Time
Patient’s value: 11.3
Control value: 12.3
Implications: No significant findings found.

PREGNANCY TEST
Performed on: November 12, 2009
Purpose: to determine whether or not a woman is pregnant.
Pregnancy Test β - HCG
Patient’s value: Positive
Implications: Increase HCG which is released by the trophoblastic cells of the fertilized ovum is a reliable marker of pregnancy.

CHEST PA
Performed on: November 12, 2009
Purpose: Chest X-rays can also reveal fluid in your lungs or in the spaces surrounding your lungs, enlargement of your heart, pneumonia, emphysema, cancer and many
other conditions. Some people have a series of chest X-rays done over time, to track whether a particular health problem is getting better or worse.
Findings: Examination reveals there is irregular calcific density noted in the right lowe lung. The cardiac silhouette is not enlarged, no bony abnormalities.
Conclusion: Benign calcification of the right lower lung

TUMOR MARKER TEST

Performed on: November 13, 2009
Purpose: The majority of tumor markers are used to monitor patients for recurrence of tumors following treatment. In addition, some markers are associated with a more
aggressive course and higher relapse rate and have value in staging and prognosis of the cancer. Most tumor markers are not useful for screening because levels found in
early malignancy overlap the range of levels found in healthy persons. The levels of most tumor markers are elevated in conditions other than malignancy, and are therefore
not useful in establishing a diagnosis.

β – HCG II Tumor Marker

Patient’s value: 49.41 mIU/ml
Control value: PreMP < 1, PostMP < 7

Implication: HCG is a glycoprotein consisting of subunits a e b, which are nonconvalently linked. The hormone is normally produced by the syncytiotrophoblastic cells of the
placenta and is elevated in pregnancy. It’s most important uses as a tumor marker are in gestational trophoblastic disease and germ cell tumors.

ULTRASOUND
Performed on: November 12, 2009
Purpose: Ultrasound is performed routinely during pregnancy. Early in the pregnancy (at about seven weeks), it might be used to determine the size of the uterus or the
fetus, to detect multiple or ectopic pregnancy, to confirm that the fetus is alive (or viable), or to confirm the due date.
 Uterus: 16.1 x 11.6 x 7.4 cm anteverted
Cervix: 4.2 x 3.8 x 3.1 cm without Nabothian cyst
Endometrium: 2.3 cm
Right ovary: not visualized
Left ovary: 4.1 x 2.8 x 2.8 cm lateral
Others: no free fluid from the cul – de – sac
Remarks:
• The uterus is anteverted with regular contour and inhomogenous myometrium.
• Well circumiscribed heterogenous structure noted within posterior myometrium measuring 7.0 x 7.2 x 5.5 cm suggestive of an intramural myoma with submucous
component.
• Cervix is closed and homogenous.
• Endometrium is thickened and heterogenous suggestive of blood clots.
Impression:
• Enlarged anterverted uterus with thickened endometrium
• Uterine myoma

Implications: Results of the ultrasound suggest that the patient has a myoma described to be intramular and at the same time with submucous components. By intramural,
it means that the myoma is located within the uterine wall, while having submucous components suggests that it lies just beneath the endometrium, the inner most layer of
the uterus.

ELECTROCARDIOGRAM
Performed on: November 12, 2009
Purpose:
Electrical impulses in the heart originate in the SA node and travel through the intrinsic conducting system to the heart muscle. The impulses stimulate the myocardial muscle
fibers to contract and thus induce systole. The electrical waves can be measured at selectively placed electrodes (electrical contacts) on the skin. Electrodes on different sides
of the heart measure the activity of different parts of the heart muscle. An ECG displays the voltage between pairs of these electrodes, and the muscle activity that they
measure, from different directions, also understood as vectors. This display indicates the overall rhythm of the heart and weaknesses in different parts of the heart muscle. It
is the best way to measure and diagnose abnormal rhythms of the heart, particularly abnormal rhythms caused by damage to the conductive tissue that carries electrical
signals, or abnormal rhythms caused by levels of dissolved salts (electrolytes), such as potassium, that are too high or low.
Rate:
Atrial: 89
Ventricular: 89
Rhythm: Sinus
Axis: +30o
PR Interval: 0.16 seconds
QRS: 0.08 seconds
QT Interval: 0.32 seconds
 P wave: upright
ORS: normal R wave progression
Transitional zone: V3 – V4
T Wave: upright
ST segment: isoelectric
Interpretation:
Sinus rhythm, within normal limits
Implications: There were no significant findings noted.

LIPID PANEL
Performed on: November 13, 2009
Purpose:
The lipid panel checks the lipid levels in blood, which can indicate a person's risk for heart disease or atherosclerosis which is the hardening, narrowing, or blockage of the
arteries.

Component Patient’s Values Flag Normal Values

Glucose 100 75 – 115 mg/dl

Implications: There were no significant findings noted.

APPENDIX B
GENOGRAM
 - Female

- Male

- Cardiovascular Disease, Hypertension and Diabetes Mellitus

- Uterine Myoma and History of Hysterectomy

- Hypertension

- Patient

APPENDIX C
ECOMAP
DRUG STUDY

1.) Benadryl (Diphenhydramine)

Class: Antihistamine, Anti-motion sickness agent, Sedative/hypnotic, Anti-parkinsonian agent, Cough suppressant
Action: Competitively blocks the effects of histamine at H1-receptor sites have atropine-like, antipruritic, and sedative effects.
Indications: Relief of symptoms associated with perennial and seasonal allergic rhinitis; vasomotor rhinitis; allergic conjunctivitis; mild, uncomplicated urticaria and
angioedema; amelioration of allergic reactions to blood or plasma; dermatographism; adjunctive therapy in anaphylactic reactions. Active and prophylactic treatment
of motion sickness; Nighttime sleep aid
Contraindications: Hypersensitivity to any anti-histamine; Third trimester of pregnancy; lactation.
Side Effects: Drowsiness, sedation, dizziness, disturbed coordination, fatigue, confusion, restlessness, excitation, nervousness, tremor, headache, blurred vision,
diplopia, Hypotension, palpitations, bradycardia, tachycardia, extrasystoles, Epigastric distress, anorexia, increased appetite and weight gain, nausea, vomiting,
diarrhea or constipation, Urinary frequency, dysuria, urinary retention, early menses, decreased libido, impotence, Hemolytic anemia, hypoplastic anemia,
thrombocytopenia, leukopenia, agranulocytosis, pancytopenia, Thickening of bronchial secretions, chest tightness, wheezing, nasal stuffiness, dry mouth, dry nose,
dry throat, sore throat, Urticaria, rash, anaphylactic shock, photosensitivity, excessive perspiration
Nursing Considerations:
• Advise patient to take drug with food to decrease GI upset
• Advise patient to take drug as prescribed by the doctor
• Inform patient about the drug she is receiving and its side effects
• Monitor client’s response
• Advise patient to avoid alcohol because serious sedation could occur
 • Instruct patient to report to health care provider if difficulty breathing, hallucinations, tremors, loss of coordination, unusual bleeding or bruising,
visual disturbances, irregular heartbeat occurs

2.) Atropine Sulfate

Classes: Anti-cholinergic, Anti-muscarinic, Parasympatholytic, Anti-parkinsonism drug, Antidote, Diagnostic agent (ophthalmic preparations), Belladonna alkaloid
Actions: Competitively blocks the effects of acetylcholine at muscarinic cholinergic receptors that mediate the effects of parasympathetic postganglionic impulses,
depressing salivary and bronchial secretions, dilating the bronchi, inhibiting vagal influences on the heart, relaxing the GI and GU tracts, inhibiting gastric acid
secretion (high doses), relaxing the pupil of the eye (mydriatic effect), and preventing accommodation for near vision (cycloplegic effect); also blocks the effects of
acetylcholine in the CNS.
Indications
• Antisialagogue for pre-anesthetic medication to prevent or reduce respiratory tract secretions
• Restoration of cardiac rate and arterial pressure during anesthesia when vagal stimulation produced by intra-abdominal traction causes a decrease in
pulse rate, lessening the degree of AV block when increased vagal tone is a factor (eg, some cases due to digitalis)
• Relief of bradycardia and syncope due to hyperactive carotid sinus reflex
• Relief of pylorospasm, hypertonicity of the small intestine, and hypermotility of the colon
• Relaxation of the spasm of biliary and ureteral colic and bronchospasm
• Relaxation of uterine hypertonicity
• Management of peptic ulcer
Contraindications: Hypersensitivity to anticholinergic drugs. Contraindicated with glaucoma, adhesions between iris and lens, stenosing peptic ulcer,
pyloroduodenal obstruction, paralytic ileus, intestinal atony, severe ulcerative colitis, toxic megacolon, symptomatic prostatic hypertrophy, bladder neck obstruction,
bronchial asthma, COPD, cardiac arrhythmias, tachycardia, myocardial ischemia, impaired metabolic, liver, or kidney function, myasthenia gravis. Use cautiously
hypertension, hyperthyroidism and lactation.
Side Effects: Blurred vision, mydriasis, cycloplegia, photophobia, increased intraocular pressure, headache, flushing, nervousness, weakness, dizziness, insomnia,
mental confusion or excitement (after even small doses in the elderly), nasal congestion, Palpitations, bradycardia (low doses), tachycardia (higher doses), Dry mouth,
altered taste perception, nausea, vomiting, dysphagia, heartburn, constipation, bloated feeling, paralytic ileus, gastroesophageal reflux, Urinary hesitancy and
retention; impotence, Decreased sweating and predisposition to heat prostration, suppression of lactation
Nursing considerations:
• Encourage oral fluids
• Provide therapeutic environment and room temperature control to prevent hyperpyrexia
• Encourage patient to take drug as prescribed.
• Inform patient about the drug and the side effects that may occur
• Advise patient to report to health care provider if rash; flushing; eye pain; difficulty breathing; tremors, loss of coordination; irregular heartbeat,
palpitations; headache; abdominal distention; hallucinations; severe or persistent dry mouth; difficulty swallowing; difficulty in urination; constipation;
sensitivity to light occurs

3.) Ranitidine Hydrochloride (Zantac)

Class: H2- antagonist
Actions: Competitively inhibits the action of histamine at the histamine2 (H2) receptors of the parietal cells of the stomach, inhibiting basal gastric acid secretion and
gastric acid secretion that is stimulated by food, insulin, histamine, cholinergic agonists, gastrin, and pentagastrin.
Indications:
• Short-term treatment of active duodenal ulcer
• Maintenance therapy for duodenal ulcer at reduced dosage
• Short-term treatment of active, benign gastric ulcer
 • Short-term treatment of gastroesophageal reflux disease
• Treatment of heartburn, acid indigestion, sour stomach
Contraindications: Hypersensitivity to Zantac. Use cautiously to patients with impaired renal or hepatic functions. Lactation
Side Effects: Headache, malaise, dizziness, somnolence, insomnia, vertigo, Tachycardia, bradycardia, Rash, alopecia, Constipation, diarrhea, nausea, vomiting,
abdominal pain, hepatitis, increased ALT levels, Gynecomastia, impotence or decreased libido, Leukopenia, granulocytopenia, thrombocytopenia, pancytopenia, Pain
at IM site, local burning or itching at IV site, Arthralgias
Nursing Considerations:
• Advise patient to take drug with meals to prevent GI upset
• Explain to the patient about the drug she is receiving and its side effects
• Encourage patient to take drug as prescribed by the doctor.
• Advise patient to report if sore throat, fever, unusual bruising or bleeding, tarry stools, confusion, hallucinations, dizziness, severe headache, muscle
or joint pain occurs.

4.) Metronidazole
Class: Antibiotic, Antibacterial, Amebicide, Antiprotozoal
Action: Bactericidal: inhibits DNA synthesis in specific (obligate) anaerobes, causing cell death; antiprotozoal-trichomonacidal, amebicidal: biochemical mechanism of
action is not known.
Indications:
• Acute infection with susceptible anaerobic bacteria
• Preoperative, intraoperative, postoperative prophylaxis for patients undergoing colorectal surgery
• Topical application in the treatment of inflammatory papules, pustules, and erythema of rosacea
• Unlabeled uses: prophylaxis for patients undergoing gynecologic, abdominal surgery; hepatic encephalopathy
Contraindications: Hypersensitivity to metronidazole; pregnancy. Use cautiously with CNS diseases, hepatic disease, candidiasis (moniliasis), blood dyscrasias,
lactation.
Side Effects: Headache, dizziness, ataxia, vertigo, incoordination, insomnia, seizures, peripheral neuropathy, fatigue, Unpleasant metallic taste, anorexia, nausea,
vomiting, diarrhea, GI upset, cramps, dysuria, incontinence, darkening of the urine, thrombophlebitis (IV); redness, burning, dryness, and skin irritation (topical),
severe, disulfiram-like interaction with alcohol,
Nursing considerations:
• Advise patient to take drug with food to avoid GI upset
• Inform the patient about the drug she is receiving and its side effects.
• Advise patient not to drink alcohol (beverages or preparations containing alcohol, cough syrups); severe reactions may occur.
• Explain to the patient that their urine may appear dark; this is expected.
• Advise patient to report severe GI upset, dizziness, unusual fatigue or weakness, fever, chills

5.) Nalbuphine HCl

Class: Narcotic Agonist- antagonist analgesia
Action: Acts as agonist at specific opioid receptors in the CNS to produce analgesia, sedation but also acts to cause hallucinations and is an antagonist at mu
receptors
Indication: Relief of moderate to severe pain. Preoperative analgesia, as a supplement to surgical anesthesia.
Contraindication: Hypersensitivity to Nalbuphine, Sulfites; lactation
Side Effects: Sedation, Clamminess, Sweating, Headache, Nervousness, Restlessness, Depression, Confusion, Faintness, Hostility, Unusual Dreams, Hallucinations,
Euphoria, Nausea, Vomiting, Cramps, Dry mouth, Respiratory depression, Dyspnea, Hypertension, Hypotension, Bradycardia, Tachycardia
Nursing Considerations:
 • Monitor patient's vital signs
• Advise patient to follow doctor's prescription
• Give oral drug with food to decrease GI upset and enhance absorption
• Inform patient on the side effects that may occur
• Discontinue if hypersensitivity occurs
• Provide narcotic antagonist or facilities for controlled respiration in case of respiratory depression

6.) Kalium Durule

Class: Electrolyte (potassium supplement)
Action:
• Maintains acid- base balance, isotonicity, and electrophysiologic balance of the cell
• Activator in many enzymatic reactions; essential to transmission of nerve impulses; contraction of cardiac, skeletal, and smooth muscle; gastric
secretion; renal function; tissue synthesis and carbohydrate metabolism
Indication: PO,IV: Treatment or prevention of potassium depletion
IV: treatment of certain arrhythmias due to cardiac glycoside toxicity
Contraindication: Hyperkalemia, severe tissue trauma, severe renal impairment
Side Effects: restlessness, confusion, weakness, arrhythmias,nausea, vomiting, diarrhea, abdominal pain, GI ulceration
Nursing Considerations:
• Asses patient for signs and symptoms of hypokalemia such as weakness, fatigue, arrhythmias, polyuria, polydypsia
• Monitor pulse, blood pressure and ECG periodically throughout intravenous therapy
• Treatment includes discontinuation of potassium, administration of sodium bicarbonate to correct acidosis, dextrose, and insulin to facilitate passage
of potassium into cells, calcium salts to reduce ECG effects
• Infuse slowly, at a rate up to 20 mEq/hr
• Explain to patient the purpose of the medication and the need to take as directed, especially when concurrent cardiac glycosides or diuretics taken
• Advise patient regarding sources of dietary potassium

7.) Traxenamic Acid

Class: Hemostatic agent (plasminogen inactivator), Anti fibrinolytic agent
Action: Inhibits activation of plasminogen, thereby preventing the conversion of plasminogen to plasmin
Indication: Prevention of hemorrhage following surgery in hemophiliacs
Contraindication: Hypersensitivity to drug, active intravascular clotting
Side Effects: dizziness, visual abnormalities, hypotension, thrombosis, thromboembolism, nausea, vomiting
Nursing Considerations:
• Observe site of surgery for excessive bleeding
• Patients taking tranexamic acid for more than several days should have ophthalmological examinations to detect visual abnormalities prior to
and at regular intervals during and after therapy
• Check signs for thromboembolism such as tenderness, reddish and warm spots
• Check V/S regularly to monitor any unusualities
• Instruct patient to complete drug therapy as indicated

8.) Bupivacaine Hydrochloride (Sensorcaine) 5-10 cc q 4H (epidural analgesia)

Classification: local anesthesia
 Action: inhibits initiation and conduction of sensory nerve impulses by altering the influx of sodium ions and efflux of potassium ions in neurons
Indication: may be combined with epidural opioids or clonidine in the management of severe acute or chronic pain
Contraindications: children under 12 years of age, for spinal or topical anesthesia or paracervical block, and in patients with known history of
hypersensitivity reactions to local anesthetics of the amide type
Adverse Reactions: headache, seizures, irritability, arrhythmias, cardiovascular collapse, bradycardia
Nursing Interventions:
- Assess for sensory and motor deficit
- Monitor BP regularly
- Check solutions for particles
- Discard partially used vials
- Should not be used for IV regional anesthesia
- Use solutions with epinephrine cautiously in patients with CV disorders and in body areas with limited blood supply
- Protect solutions containing epinephrine from light
- Use cautiously in debilitated, elderly and in patients with severe hepatic diseased or drug allergies

9.) Cefazolin
Classification: First generation cephalosporin
Action: Binds to bacterial cell wall membrane causing cell death
Indication:
• Maybe used as perioperative prophylactic anit-infective
• Treatment of : Skin and skin structure infections, pneumonia, urinary tract infections, bone and joint infection and septicemia
Contraindications:
• Hypersensitivity to cephalosporins
• Severe hypersensitivity to penicillins
Adverse Reactions: seizures, nausea and vomiting, nephrotoxicity, rashes, phlebitis at IV site, pain at IM site, superinfections
Nursing Considerations:
• Asses patients for infection (Vital signs; incision or wound, urine,sputum,stool;WBC) at beginning and throughout course of therapy
• Obtain culture and sensitivity
• Assess for hypersensitivity through skin test
• Assess for superinfection (Fever, Diarrhea, Foul discharges, Oral thrush, Black Furry tongue)

10.) Tetracaine
Class: Local Anesthetic, CNS agent
Action: Interfere with transmission of nerve impulses by interacting with membranous sheath that covers nerve fibers by physical and biochemical mechanisms, stop
propagation of nerve impulses, eventually blocking conduction
Indication: Topical anesthesia on accessible mucous membranes such as oropharynx, used primarily for spina;l anesthesia
Contraindication: Hypersensitivity to tetracaine or any component of formulation; ophthalmic secondary to bacterial infection; liver disease, CNS disease,
meningitis if used for epidural or spinal anesthesia, myasthenia gravis
Adverse Reactions: cardiac arrest, hypotension, chills, convulsions, dizziness, drowsiness, nervousness, unconsciousness, nausea, vomiting, tremors, respiratory
arrest
Nursing Consideration:
• Monitor vital signs especially BP because it may causes hypotension
• Monitor skin condition
 • Clean administration site well before administering
• Don’t use if rash occurs
• Explain procedure prior to administration

DISCHARGE PLAN

Health Teachings:
- advised to have adequate rest and sleep
- instructed to do deep breathing exercise when she feels pain and anxious.
- encouraged patient to ambulate
- instructed not to do strenuous activities
- encouraged eating the proper diet as advised by the doctor.
- advised to keep incision site clean and dry
- advised to have diversional activities
- instructed to take the medications at the right route, route dose and right time.
- encouraged verbalizing when in pain

Anticipatory guidance:
- encouraged taking note of any signs of infection at the incision site
- advised to have wound dressing every day and as necessary
- instructed to have a regular check up with the physician
- advised to take medications as prescribed
- instructed not to stop medication if not prescribe by the doctor
- instructed to check on incision site once in a while

Spirituality, security and safety:

- encouraged praying every day
- encouraged hearing mass every Sunday
- advised to continue with the prayer group
- advised to keep all sharp object away from the incision site
- advised to have confession at least once in every 3 months
- instructed to put pillows at the side of the bed when lying

Medications:
- advised to take medications at the right route, dose and time
- advised to take medications as prescribed
- instructed not to stop medication if not prescribed by the doctor

Incision care:
- advised to do hand washing before and after wound care
- instructed to take note of any signs of infection such as warmth, redness and swelling
- encouraged to have wound dressing every day or as needed.

Nutrition:
- encouraged oral fluids
- advised to follow the proper diet recommended
- instructed to avoid eating foods high in fats and cholesterol

Environment:
- instructed to provide a clean environment
- advised to have things accessible for the client
- instructed to have a clean and quiet home conducive for resting
- advised to listen to light music for relaxation
- advised to have a safe home and free from any health hazards
SUMMARY OF SIGNIFICANT FINDINGS

GORDON’S FUNCTIONAL HEALTH PATTERNS

• Previous hospitalization was on 1973 in Cebu City Medical Center (CCMC) for the excision of cyst on her right breast.
• “ang kawal-on ug sakit”. She is currently concerned with her condition is excited but anxious about the surgery that she states “Nahadlok man ko dong, pero normal
raman siguro na dong, pero ganahan nako ma-operahan para maayo nako”.
• “Nalipay kaau ko na nahuman na ang operation ug na tangtang ang mayoma”.
• After her breast excision surgery, she has no correct knowledge in performing breast self-examination and only palpates her breast once in a while.
• Patient doesn’t weigh herself so weight 3 months ago is unknown. But, she states that there was no significant change in her weight. She currently weighs 115 lbs. or
52.27 kg and is 5 feet 2 inches tall. Her ideal body weight is 51.74 kg., and her BMI is 21.21 and is categorized of having a normal weight.
• She was ordered not to take any food and any liquid (NPO) 11 hours before surgery. And after the surgery and passing flatus, the patient only took crackers and water
as the doctor ordered general liquid diet and crackers with no carbonated drinks.
• There was no change in her bowel movement during hospitalization.
• She didn’t feel any pain in doing her everyday activities back then. Patient was observed to grimace, and presented guarding behavior through splinting of the wound.
The patient was not able to perform her daily activities such as housekeeping or laundry since admission.
 • During hospitalization, patient claims that “Sige ko mata mata dong kay sige ug sulod ang mga nurse sa room”. She verbalized that before hospitalization, she feels
refreshed after sleeping but now she feels that she didn’t regain her energy as she verbalized “La-ay man gihapon akong lawas”. After surgery, the patient always
stays in bed and wakes up when she needs to eat and when the nurse enters the room to get the vital signs.
• The patient views herself as a kind and loving person. She also thinks positively. Her sister describes her as a caring person and very responsible. She states that she
is very happy with her life today.
• After the surgery, the patient was asked about the essence of her womanhood and replied “Okay raman dong, tiguwang naman pud ko.”
• “Gi-tumor man sad sa matres akong duha ka mga iya-an.”
• When asked whether the operation will affect her womanhood, she replied “ ok ra man dong, tigulang naman sad ko, wala nakoy plano manganak”.
• When asked about her stressors and problems, patient states that “ pasalamat ko sa ginoo dong kay kani ra jud ako sakit ang pinaka dako na problema karon, maau
ra man ang akong pamilya bisan kulang usahay ang kita sa ako bana”.

PHYSICAL EXAMINATION
PRE-OPERATIVE
• presence of IV line on left arm
• uterus palpated with the enlargement noted to be dominantly at the right side.
• scar is present at the bottom part of the right areola.
INTRA-OPERATIVE
• Presence of IV line noted at the left arm.
• Uterus palpated with the enlargement noted to be dominantly at the right side.
POST-OPERATIVE
• Presence of IV line on left arm.
• A presence of a binder covering a bandage estimated to be 12 inches long, in turn this bandage covers a horizontal incision estimated to be 7 inches long
located below the umbilicus.
• Romberg’s test and tandem walk not done as it might endanger the patient.