PERPETUAL HELP COLLEGE OF MANILA

1240 V. Concepcion St., Sampaloc, Manila

Submitted to:
Mrs. Josephine Dela Cruz, RN Clinical Instructor

Submitted by:
Abordo, Nena Bell Jill Alpecho, Kathreen Mae Alunday, Radigundee Awat, Cassandra Von Barzaga, Cristine Cabarrubias, Alvin Ray D. Canlas, Veronica Changco, Mariaelis Commendador, Maritonee Corpuz, Nichael Bonn - Physical Assessment & Nursing Care Plan - Drug Study - Medical and Surgical Management - Etiology or Risk Factors - Diagnostic Procedure -Gordons Health Pattern, Pathophysiology, Statement of Nursing Diagnosis & Nursing Care Plan - General Objectives, Nursing Care Plan & Discharge Plan - Anatomy & Physiology - Clients Data & Health History - Introduction

PERPETUAL HELP COLLEGE OF MANILA

Format for Case Presentation

I. II. Clients Data Health History Family Health History i. ii. Maternal Health History Paternal Health History

History of Past and Present Illness Risk Factors Associated with Disease i. ii. Non- modifiable Factors Modifiable Factors

III.

Physical Assessment Subjective- Gordons Health Pattern Objective- Koziers reference

IV. V. VI. VII. VIII. IX. X. XI.

Definition of Disease/Introduction Pathophysiology of the Disease Anatomy and Physiology Diagnostic Procedures done to Client Medical/Surgical Management done Drug Study Statement of nursing problems/nursing diagnosis based on grouped data(Gordons) Priority Nursing Problem/Nursing Care Plan Actual Potential

XII.

Discharge Plan

PERPETUAL HELP COLLEGE OF MANILA

Table of Contents
I. II. Clients Data... 1 Health History 2 Family Health History 2 iii. iv. Maternal Health History.. 2 Paternal Health History 2

History of Past and Present Illness..... 2 Risk Factors Associated with Disease 3 iii. iv. Non- modifiable Factors 3 Modifiable Factors.. 3

III. IV. V. VI. VII. VIII. IX. X.

Physical Assessment. 5 Subjective- Gordons Health Pattern.. 5 Objective- Koziers reference... 9 Definition of Disease/Introduction.. 32 Pathophysiology of the Disease 33 Anatomy and Physiology.. 34 Diagnostic Procedures done to Client.. 41 Medical/Surgical Management done.. 46 Drug Study.. 50 Statement of nursing problems/nursing diagnosis based on grouped data(Gordons).... 62 Priority Nursing Problem/Nursing Care Plan...... 63 Actual Potential Discharge Plan 64

XI.

XII.

General Objectives:
y This study on myoma aims to look into the indispensible information regarding the disease, its pathophysiology resulting to the theoretical signs and symptoms and correlate them with those manifested by the patient y It is also aims to develop our skills, knowledge and attitude in providing proper nursing care needed to have an effective nursing management and list the criteria used for diagnosing myoma y Develop good Nurse-Patient relationship

Specific Objectives:
In order to meet the general objective of the study, the ff intended to be done: y y To be able to acquire knowledge regarding myoma through research To be able to develop a better understanding on the use of medications and its implication on the treatment of myoma

y To be able to implement the appropriate plan of nursing management for

patients with myoma

I.

Clients Data Name- De Luna, Rima Mejica Age 32 Chief complaint: VAGINAL BLEEDING Diagnosis -AUB problem sec. to prolapsed submucosal myoma. G4P4 Time admitted 6:10 PM Ward- OB GYNE Address- 417 NBB Navotas B-day 11/19/78 Religion- Roman Catholic Father name- Loreto Dulay Mother name- Crisanda Mejica Husband name- Dante de Luna Admitting physician Dr. Macasadia

Pertinent physical findings: BP 100/80 HR 89 RR 20 TEMP. 37

WT 44.5 kgs HT 1.43 BMI 21.76 kg/m2 Slightly pink palpebral conjunctivas SCF clear BS. A dynamic pericardium WRRR (-) murmurs inspection + fleshy mass at introiter + moderate bleeding submucus. IE 10x5x5 cm prolapsing mass with stalked abnormal Personal and social history: Alcohol- occasional B-GYNE history: Menarche 15year old interval 28-30 duration 3days

Cornstarches 19 year old OB score G1 2000 G2 2006 G3 2007 G4 2008 male female preterm female

symptom- dysmenorrheal

NSD NSD (7mos) NSD

del. Midwife (-) complication del. Midwife (-) complication

del. Midwife (-) complication

No. of sexual partner 1 partner Previous pap smear NONE Method of contraceptive (+) 2008 trust pills

II.

Health History Family Health History i. Maternal Health History (+) hypertension ii. Paternal Health History (+) hypertension, (+) diabetes mellitus History of Past and Present Illness 2 months PTA patient noted increase menstruation duration and amount for 5 days. No inter menstrual bleeding noted. 1 day PTA, patient while strains during defecations. (+) bleeding during defecation. She strained and noted prolapsed mass at urination and prompted consult.

Risk Factors Associated with Disease v. Non- modifiable Factors -Anovulatory bleeding -Midcycle bleeding associated with ovulation -High levels of unopposed estrogen vi. Modifiable Factors -Complications of an early, undiagnosed pregnancy -Breakthrough bleeding while they are taking oral contraceptives -Genetic abnormalities, race, and related to age of menarche, obesity, and parity
7

Classification of Myomas
1. Intramural. Found in the uterine wall, surrounded by myometrium. Clinical manifestations include increased uterine size, vaginal bleeding between menses and dysmennorrhea 2. Submucosal. Located directly under the endometrim, involving the endometrial cavity. May become pedunculated (grow on a stalk). Clinical manifestations include prolonged vaginal bleeding and cramps and the tumor may be seen protruding through the cervix. 3. Subserosal. Found on the outer surface (under the serosa) of the uterus. Tends to become pedunculated, to wander, and to be multiple and large. Clinical manifestations include backache, constipation and bladder problems. 4. Wandering or parasitic. A pedunculated leiomyoma that twists on its pedicle, breaks off, then attaches to other tissues, particularly the omenum. 5. Intraligamentary. Implants on the pelvic ligaments. May be displace the uterus or involve the ureters.

6. Cervical. Occur infrequently and may obstruct the cervical canal

III.

Physical Assessment Subjective- Gordons Health Pattern During Hospitalization

Health Patterns

Before Hospitalization

Analysis

1. Health perception Health management Pattern

- Pt had abnormal uterine bleeding for almost 4 days. - during her Pt is a non smoker and a hospitalization, occasional alcohol drinker. Pt shes was rushed have the family illness of to the emergency hypertension and diabetes. room & a vaginal Mrs. D doesnt have regular myomectomy was medical check-ups and only done. after that seeks medical attention when operation, she still the need arises. Whenever feels weak she had headaches, she rest probably because for a while and take of losing too much paracetamol when needed. blood. Shes Pt. perceived her menstrual anxious if the cycle was regular until the mass that was fourth day of excessive taken is bleeding and presence of cancerous or not. mass when she urinated.

- She only seeks medical help whenever needed. The patient is anxious if the fibroid is cancerous or not.

2. Nutritional Metabolic Pattern

- According to Mrs. D., she eats three times a day. He usually eats vegetables, fish and meat whenever they have extra money. The patient verbalized that she seldom eat fruits. In terms of fluid intake, the client stated that he consumes at an average of 5-6 glasses of water per day, distributed at around 2 glasses in the morning, 3 at noon and 1 glass at evening before hospitalization. She is

- Normal eating pattern is at on the minimum of 3 times per - during her day, depending hospitalization, the upon metabolic doctor ordered need and NPO until the third demands. Fluid day wherein she intake is on the was on soft diet. average of 8 to 10 glasses per day. - She have to increase her fluid intake. In
9

the one who always prepare their food.

Patients WT 44.5 kgs HT 1.43 BMI 21.76 kg/m2

terms of her food intake and frequency, There are no remarkable deviations

Normal BMI range: <18.5...underweight 18.5-24.9..healthy 25.0-29.9overweight 30obesity

3. Elimination Pattern

- Bowel Habits: Mrs. D defecates once a day with a brownish stool. Bladder Habits: She voids 35 times a day with amber colored urine in small amount. Pt urinates not more than 1000ml per void.

- During hospitalization, since the patient was on NPO, there were changes on her bowel and bladder habits. She was on indwelling foley catheter.

- Normal bowel movement is 1 to 3 times a day and voiding at 1200 to 1500ml/day. - Mrs. Ds bowel and bladder habits has changed during hospitalization.

4. Activity Exercise Pattern

- Mrs. D usually does walking when she gets bored before her hospitalization. Pt is a housewife. She usually do household choirs and shes proud to say that its a good form of exercising.

- She stop taking walks during her hospitalization because it is contraindicated in operation performed. So, she only do bed rest and tries to turn on each side because she always wake up.

- Well described bout her activities in daily living like exercising. She is well informed that doing household choirs is a simple way of exercise.

5. Sleep Rest Pattern

- before the Pt was hospitalized, she mostly

- during her hospitalization,

- Based from Kozier

10

sleep 7pm or 8pm at night and wakes up at 8 in the morning. When she dont have anything to do after lunch, he usually have a nap.

The pt had stated that he experienced sleep difficulties. She always wake up in different intervals. Before going to sleep she always think about the mass that was taken out of her if its benign or malignant.

Fundamentals of Nursing, 810 hours of sleep is needed to have an adequate rest and an environment that is conducive to health is necessary to provide comfort to an individual. - The client has an abnormal state of sleep and rest. Frequent thinking about her situation is the primary cause of sleep deprivation.

6. Cognitiveperceptual pattern

- Patient does not have any hearing problems. She is oriented to time and place and can recall past events. Patient is a high school graduate. Mrs. D is able to understand, and communicate with others and make decisions on her own. She is able to see, feel, hear, smell, taste by testing him like pinching, giving some sentence to read and saying words that she have to repeat it after we said it.

- during her hospitalization, there is no significant change in the status and perception of his five senses.

- There is no symptoms of pain while we are doing an interview.

7. Selfperception and self

- Patient described herself as a hardworking person. She claimed her happiness and

- during in her hospitalization, she never think

- pt is being a positive thinker despite of what

11

concept pattern

contentment will be more felt if only his illnesses were absent. Pt is contented to have provided her family with good life.

negative things that will make her down while recovering with her illness.

happened to her health

8. Role Relationship pattern

- Patient described himself as - during her - pt is still being a loyal wife to her husband hospitalization, a good mother as well a responsible mother her husband is to her kids to her kids. Her husband aware of her despite of her comes home every weekend current situation. current health from work as a contractual She is worried status. carpenter. She takes care of about her kids if her kids and do the cooking theyre doing well and laundry form them. She without her. She is send them to school also concerned if everyday. theyre eating well. - Patient had her 1st menstruation at the age of 15. She used to use pills Patient claims to have no history of STD or UTI. She doesnt have any problem with her sexual intercourse.

9. Sexuality Reproductive pattern

- during her hospitalization, she clearly describe the patterns of satisfaction and dissatisfaction with sexuality.

- The Pt. analyzed clearly about it and able to understand the physical and psychological effects of his current health status on her sexual expression.

10.Coping and Stress Tolerance

- Defines stress as something - during her - Able to that can make someone tired. hospitalization, describe Currently stressed because she doesnt general coping of current physical condition. change her pattern and Long term stressor include perception toward effectiveness of financial problems, and short her situation. the pattern in term stressor include the Shes aware that terms of stress problems in the community being hospitalized tolerance. and family. Goes to is a stressful neighbors and friends to situation. She tries relieve stress and she shares to get well her problem them. because she Sometimes she brings her misses her kids.
12

kids to shopping malls to stroll and in that way her stress is relieved.

11.Value Belief Pattern

- Patient is a Roman Catholic - during her - able to and goes to church on hospitalization, determine the Sundays with her kids and there is no change patterns of claims to pray everyday. She with her religious values and values health life. She believes beliefs(spiritual) and sees it as a wealth. God will help her or goals that Patient does not have any recover faster guides his superstitious beliefs. choices and decisions. .

Objective- Koziers Reference

Vital signs
Normal Vital signs Actual Findings On the disease Blood pressure 120/80 160/90 process, any condition that may affect the cardiac output, blood Cardiac output will often affect the delivery of oxygen to the cells of the body and Analysis Interpretation

volume, blood viscosity when the system or tissues has direct effect on the blood pressure. The patient was in distress during the assessment. does not get the required oxygen for the metabolic process cellular function will be altered.

(Kozier, B. (2004).

13

Fundamentals of Nursing p. 510). Inflammation is a local, nonspecific defensive Temperature 36.537.5 39.4 response of the tissues to an injurious or infectious agent. It is an adaptive mechanism that destroys or dilutes the injurious agent, prevents further spread of the injury, and promotes the repair of damaged tissue. The rate of loss depends primarily on the surface temperature of the skin which is intern a function of skin blood flow. The blood flow of the skin varies in response to changes in the body core temperature and to changes in temperature of the external environment. Patient has an increased WBC count of 12.3% (August 23, 2010) Febrile

(Kozier, B. (2004). Fundamentals of Nursing p. 634). Pulse wave represents the Normal Range Pulse rate 60-100 92 (Kozier, B. (2004). Fundamentals of Nursing p. 496). Several factors that Respiratory 16-20 24 increase respiratory stroke volume output or the output or the amount for blood that enters the arteries with each ventricular contraction. The effectiveness of respiration is important for
14

rate

rate include stress and increase environmental temperature.

the uptake of oxygen from the air into the blood and release carbon dioxide from the blood into expired air.

(Kozier, B. (2004). Fundamentals of Nursing p. 506).

Skin
PARTS METHOD NORMAL FINDINGS Skin color varies from Skin Inspection light to deep brown; from ruddy pink to light pink, from yellow overtimes to olive. Generally uniform except in areas Palpation exposed to sun; areas of lighter pigmentation (palms, lips Temperature is higher than normal No edema, abrasions, lesion. Pale in appearance. Fair complexion with dry and flaky skin. There is a decrease in hemoglobin because of blood loss The skin is dry and flaky because sebaceous and sweat glands are less active. Dry skin is more prominent over the extremities. Pallor is the result of inadequate circulating blood. Normal blood circulation relies on muscle activity. Immobility impedes circulation and diminishes the supply of nutrients to specific area. Pressure ulcers ACTUAL FINDINGS ANALYSIS INTERPRETATION

15

nail beds) in dark skin people.

range.

are due to localized ischemia, a deficiency in the blood supply to the tissue.

No edema, abrasions, lesion. Temperature is uniform and w/in normal range

Generalized edema is most often an indication of impaired venous circulation and in some cases reflects cardiac dysfunction and venous abnormalities. Increase temperature from the normal level maybe due to tissue destruction, pyrogenic substances, or dehydration on the hypothalamus.

( Fundamentals of Nursing by Kozier, pp.529, 535,540,576, 1071)

Nails

Inspection

Convex curvature; angle of nail plate about 160o - with smooth

Convex, smooth in texture, pallor,

Patients nail beds are pale may be due to decreased

Pallor may reflect poor arterial circulation due to diminished circulating blood volume.

capillary refill oxyhemoglobin is 4-5 level on the

16

texture - color is highly vascular& pink in light skinned clients; dark skinned clients may have brown or black pigmentation in longitudinal streaks with intact epidermis on tissue surroundings - blanch testprompt return of pink or usual color (gen. <3 sec)

seconds on the hands. Nail bed color is pale on both lower and upper extremities.

blood.

(Fundamentals of Nursing by Kozier, p542)

Head
NORMAL PARTS METHOD FINDINGS ACTUAL FINDINGS ANALYSIS Each hair INTERPRETATION

17

Hair

Inspection

Evenly distributed hair over the scalp with thickness, variable amount of

Hair is black, thin and evenly distributed over the scalp. No infection or infestation noted. It is dry and sticky.

grows from a single, live follicle has its own roots in the subcutaneous tissue of the skin. Oil glands next to hair follicle provides gloss and, to some

Poor hygiene due to impaired physical mobility. The injury limits her activities of daily living. No significant relative is there to help her manage her poor hygiene.

Palpation

body hair. No infection or infestation.

Scalp

Inspection

White, clean, free from masses, lumps

Dry scalp. Clean, free from masses, lumps scars, lice, nits, dandruff, and lesions no area of tenderness

degree water proofing of the hair.

Normal Findings

Palpation

scars, lice, nits, dandruff, and lesions no area of tenderness

(Kozier, B. (2004). Fundamentals of Nursing p. 541)

Skull

Inspection

Rounded(

Round

Normal findings

Normal findings

normocephalic) (normocephalic), Palpation & symmetrical, with frontal, parietal, occipital, prominences) smooth, smooth skull contour. Smooth, absence of nodules or masses.

(Fundamentals of Nursing by Kozier page 544.)

18

uniform, absence of modules or masses

Eyes
NORMAL PARTS METHOD FINDINGS ACTUAL FINDINGS ANALYSIS INTERPRETATION

Eyebrows

Inspection

Symmetrically aligned. Equally distributed, curled slightly outward

Symmetricall y aligned and equal movement. Hair evenly distributed.

Normal findings.

Normal findings (Kozier, B. (2004). Fundamentals of Nursing p. 732).

Eyelashes

Inspection

Equally distributed, Curled slightly outward

Eyelashes are equally distributed and curled slightly outward.

Normal findings.

(Kozier, B. (2004). Fundamentals of Nursing p. 1152)

Normal findings

Eyelids

Inspection

The skin is intact, no

Lids closes symmetricall

Normal findings

Normal findings

19

discharge and no discoloration. The lids close symmetrically blinks involuntary and with bilateral blinking.
Sclera & Conjunctiva

y, bilateral blinking and no visible sclera above corneas when lids are open (Kozier, B. (2004). Fundamentals of Nursing p. 548

Inspection

Shiny, smooth & pink or red in color

Pale conjunctiva, smooth and shiny.

Patient has decreased hemoglobin level of 10.2 g/dl. (September 6, 2010)

Pallor may reflect poor arterial circulation due to diminished circulating blood volume

(Kozier, B. (2004). Fundamentals of Nursing p. 554).

Cornea

Inspection transparent, shiny & smooth, details of the iris are visible

transparent, shiny & smooth, details of the iris are visible

Normal Findings

Normal Findings

Pupils and Iris

Inspection

Black in color, equal in size,

Iris black in color, equal

Normal findings.

Normal findings

20

normally 3-7 mm in diameter, soundsmooth border iris flat & sound. Pupils constrict when looking at near object and dilate when looking at far objects.

in size and round in shape. Iris is flat and round. Pupil diameter is 3mm. Pupils constrict when light is directed towards it, and dilate when light is removed. (Kozier, B. (2004). Fundamentals of Nursing p. 554).

Visual Acuity

Inspection

Able to read newsprint with 20/20 vision on snellen chart.

Able to read newsprint with 20/20 vision on snellen chart.

Normal Findings

Normal Findings

Ears
PARTS METHOD NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS INTERPRETATION

Auricles Inspection

The color is the same as

Auricles aligned at the

Normal Findings

Normal Findings

21

facial skin, symmetrical, the auricles aligned with outer canthus of the eye Palpation

outer canthus of the eyes, symmetrical and color is the same as the facial skin.

Mobile, firm and not tender, pinna recoils after it is folded.

Ear Canal

Inspection

Distal third contains hair follicles and glands. Dry cerumen, grayish-tan color or sticky, wet cerumen in various shades of brown.

Distal third contains hair follicles and glands. Dry cerumen.

Normal findings.

Normal findings.

(Kozier, B. (2004). Fundamentals of Nursing p. 556-557)

Hearing Acuity

Inspection

Normal voice tones audible. Sound is

Normal Voice tones audible.

Normal findings

Normal findings

22

heard in both ears or localized at the center of the head (Weber Negative). Air conducted hearing is greater than bone conducted hearing (positive Rinne) According to Kozier page 597.

Nose
PARTS METHOD NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS INTERPRETATION

Nose

Inspection

Symmetric and straight No discharge in flaring Uniform in color Not tender,

Symmetric and straight No discharge in flaring Uniform in color Not tender, no lesion

Normal Findings

Normal Findings

23

no lesion

Facial Sinuses

Palpation

No tenderness

No tenderness noted.

Normal findings

Normal findings.

(Kozier, B. (2004). Fundamental s of Nursing p. 561)

Septum

Inspection

Air moves freely as the client breathes through the nares. Nasal septum intact & in midline

Nasal septum intact and in midline.

Normal findings

Normal findings

Kozier page 560-561

Mouth
PARTS METHOD NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS INTERPRETATION

Lips

Inspection Palpation

Uniform pink color Soft, moist,

Pale, Dry

Paleness is due to decrease in

Blood loss decrease hemoglobin level and since the patient isnt

24

smooth texture Symmetry of contour Ability to purse lips

hemoglobin and dry because of dehydration

allowed to take any liquids

Buccal mucosa

Inspection

Uniform pink color Soft, moist, smooth texture

Presence of foul breath odor.

Immobility related to invasive procedure done

Foul breath odor is due to poor self hygiene and lack of motivation from others

Gums

Inspection

Pink gums, moist, firm texture to gums.

Pinkish gums, no retraction, moist and firm.

Normal findings.

Normal findings.

(Fundamental s of Nursing by Kozier, p603)

Tongue

Inspection Palpation

Central position Pink color, moist, slightly rough; then, whitish

Pink in color, moist, no lesions, tenderness and nodules. Tongue is on the middle.

Normal Findings

Normal Findings

(Fundamental s of Nursing
25

coating Smooth; lateral margins; no lesions Raised papillae Moves freely, no tenderness Smooth tongue base with prominent veins.

Client was able to move tongue from side to side and up and down.

by Kozier, p603)

Teeth

Inspection

32 adult teeth smooth, white, shiny tooth enamel pink gums moist.

Without dentures and incomplete teeth, yellowish in color with pink gums. 4 teeth on upper and 7 on lower.

Tooth loss occurs as a result of dental disease but is preventable with good dental hygiene.

Normal findings

(Fundamental s of Nursing by Kozier p566)

26

Uvula

Inspection

Soft, moist, smooth texture Pink and smooth.

Soft, moist, and pink

Normal findings.

Normal findings.

(Fundamental s of Nursing by Kozier p604)

Tonsils

Inspection

No discharge. Tonsils of normal size. Pink and smooth posterior wall.

No discharge. Pinkish in color. normal size

Normal findings.

Normal findings.

(Fundamental s of Nursing by Kozier p604)

Neck
PARTS METHOD NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS INTERPRETATION

Neck

Inspection

Proportional to size of the head, symmetrical and straight. Freely

Proportionate to the size of head and symmetrical. Unable to move.

Muscles in the neck like sternocleido mastoid and trapezius draw the

Normal Findings

27

movable Palpation without difficulty. There are no No palpable lumps or tenderness The trachea is in the Central placement in midline of neck, spaces are equal on both sides. palpable lymph nodes. Head cannot easily flex and rotate. Trachea is in the central placement and no indication of possible neck tumor or thyroid enlargement.

head to the side and elevate the chin and elevate the shoulders to shrug them. (Fundamental s of nursing by Kozier p5)

Thorax
PARTS METHOD NORMAL FINDINGS Chest size and shape Inspection Anteroposterior to transverse chest is symmetrical. Anteroposterior to transverse in ratio of 1:2, chest is symmetrical (Fundamentals of nursing by Kozier p549) Normal findings. Normal findings ACTUAL FINDINGS ANALYSIS INTERPRETATI ON

28

Breath sounds

Auscultation Bronchovesicular breathe sound.

Patient has a clear, bronchovesicular breath sound.

Normal Findings

Normal findings

(Fundamentals of Nursing by Kozier p549)

Posterior

Palpation

Full and symmetric chest expansion. Premitus tactile most clearly at the apex of the lungs Quiet, rhythmic and effortless respiration. Vesicular and bronchovesicular

Full and symmetric chest expansion. Quiet and rhythmic, and effortless breathing.

Normal findings

Normal findings

Resonant except on the scapula, there is lowest point of (Fundamentals of nursing by Kozier p549)

Percussion

breath sound.

Notes resonate, except over scapula, the lowest point of resonance is at the diaphragm.

resonance over scapula.

Anterior

Inspection

Quiet, rhythmic and effortless

Effortless Respiration.

Normal Findings

Normal findings

29

respiration.

Palpation

Full and symmetric chest expansion. Same as posterior vocal fremitus, fremitus is normally decreased over heart and breast tissue.

Full and symmetric chest expansion.

(Fundamentals of nursing by Kozier p549 box 295; p617)

Breast
PARTS METHOD NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS INTERPRETATIO N

Breast

Inspection Palpation

No masses and lumps

n/a.

The patient refused to be assessed

The patient refused to be assessed

Areola

Inspection Palpation

Dark in color in contrast to surrounding skin. No masses, lumps and lesions.

n/a

The patient refused to be assessed

The patient refused to be assessed

30

Nipples

Inspection Palpation

Size is proportional. No discharged or secretions.

n/a

The patient refused to be assessed

Abdomen
PARTS METHOD NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS INTERPREATTION

Skin integrity

Inspection

Unblemished skin, uniform in color.

Unblemished skin, uniform in color

Normal findings

Normal findings

According to Kozier page 592-598

Contour and Symmetry

Inspection

Flat, rounded. Symmetric contour.

Distended

Abdomen is distended due to uterine fibroids

Uterine fibroids creates pressure to the bladder and rectum

Movement

Inspection

Symmetric movements caused by respiration.

Symmetric movement caused by respiration, no visible

Normal findings

Normal findings

31

vascular pattern.

According to Kozier page 592-598

Bowel sounds

Auscultation

Audible bowel sounds. Normal bowel sounds = 535 per minute

Audible bowel sounds. hypoactive Bowel sounds= 4 per minute

Normal Findings

Normal Findings

Clean Umbilicus Inspection

Clean

Normal findings

Normal findings

According to Kozier page 592-598

Bladder

Palpation

Not palpable

Not palpable

Normal findings

Normal findings

According to Kozier page 592-598

Liver

Palpation

May not be

No

Normal

Normal findings
32

palpable. Border feels smooth

enlargement. Not palpable

findings

According to Kozier page 592-598

Urogenitalia System
METHOD NORMAL FINDINGS ACTUAL FINDINGS Inspection Pubic hair evenly distributed, pubic skin intact, no lesions Foley catheter intact. n/a The Patient The Patient refused refused to be assessed Foley catheter is due to patients inability to void by herself. Inspection Skin of vulva area is slightly darker than the rest of the body, labia round full and relatively symmetric Inspection Clitoris does not exceed 1cm in width and 2cm in length, no inflammation, swelling or discharge Palpation No enlargement and tenderness n/a The Patient refused to be The Patient refused n/a The Patient The Patient refused refused to be assessed to be assessed n/a The Patient The Patient refused refused to be assessed to be assessed to be assessed. ANALYSIS INTERPRETATION

33

assessed

to be assessed

Musculoskeletal System
PARTS METHOD NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS INTERPRETATION

Upper Extremities

Inspection

Equal in size on both sides.

Equal in size on both sides. Equal in strength, coordinated movement. Able to tolerate wide range of motion. No difficulty upon bending and stretching. No lesions, no scars and no deformity.

Normal Findings

Normal Findings

Palpation

Equal in strength, coordinated movement. Able to tolerate wide range of motion. No difficulty upon bending and stretching. No lesions, no scars and no deformity.

(Fundamentals of Nursing by Kozier p1068)

Lower Extremities

Inspection

Equal in size on

Equal in size on both

Normal Findings

Normal Findings

34

both sides.

sides.

(Fundamentals of Nursing by

Palpation Able to tolerate wide range of motion. No difficulty upon bending and stretching. No lesions, no scars and no deformity. Able to tolerate wide range of motion. No difficulty upon bending and stretching. No lesions, no scars and no deformity.

Kozier p1068)

Peripheral pulse

Palpation

Symmetric full pulsation

Weak pulse on right and left dorsalis pedis pulse

A weak pulse both feet indicates reduced capillary perfusion

Patient has edema and may be due to reduced blood circulation.

(Fundamentals of Nursing by Kozier, p496)

35

IV.

Definition of Disease/Introduction
Myomatous or fibroid tumors of the uterus are estimated to occur in 20% to 40% of women during their reproductive years. It is thought that women are genetically predisposed to develop this condition, which is almost always benign. Fibroids arise from the muscle tissue of the uterus and can be solitary or multiple, in the lining (intracavitary), muscle wall (intramural), and outside surface (serosal) of the uterus. They usually develop slowly in women between 25 and 40 years of age and may become quite large. A growth spurt with enlargement of the fibroid tumor may occur in the decade before menopause, possibly related to anovulatory cycles and high levels of unopposed estrogen. Fibroids are a common reason for hysterectomy because they often result in mennorrhagia, which can be difficult to control.

36

V.

Pathophysiology of the Disease

Benign Tumors of the Uterus Fibroids (leiomyomas, Fibromyomas, myoma)

Anovulatory Cycles

High levels of unopposed estrogen

Intermingled varying amounts of fibrous connective tissue

Resembling the muscles in the walls of the organ

Usually multiple and vary from pea-sized to masses

Located in the Lower uterus

Located lower down on the cervix

In the body of uterus

Close beneath its lining membrane

Pedunculated Intracavitary Myoma

Intramural myomas

Intramural myomas

Protruding Intracavitary myoma Pedunculated serosal myoma

Danger during Childbirth

press upon the bladder & rectum

Urinary problems Constipation Bloating

Mennorrhagia Metrorrhagia

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VI.

Anatomy and Physiology

Ovaries The paired ovaries (o-vah-rez) are pretty much the size and shape of almonds. An internal view of an ovary reveals many tiny saclike structures called ovarian follicles. As a developing egg within a follicle begins to ripen or mature, the follicles enlarges and develops a fluid-filled central region called an antrum. At this stage, the follicle , called a vesicular or Graafarian follicle, is a mature and the developing egg is ready to be ejected from the ovary, an even called ovulation. After ovulation, the ruptured follicle is transformed into a very different-looking structure called corpus luteum, which eventually degenerates. Ovulation generally occurs every 28 days, but can occur more or less frequently in some women. In older women, the surfaces

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of the ovaries are scarred and pitted, which attests to the fact that many eggs have been released. Duct System The uterine (fallopian) tubes, uterus, and vagina form the duct system of the female reproductive tract. Uterine (Fallopian) Tubes The uterine (uter-in), or fallopian (fal-lope-an) tubes form the initial part of the duct system. They receive the ovulated oocyte and provide a site where fertilization can occur. Each of the uterine tubes is about 10 cm (4 inches) long and extends medially from an ovary to empty into the superior region of the uterus. Like the ovaries, the uterine tubes are enclosed and supported by the broad ligament. Unlike in the male duct system of the testes there is little or no actual contact between the uterine tubes and the ovaries. The distal end of each uterine tube expands as the funnel-shaped infundibulum, which has fingerlike projections called fimbrae (fimbree) that partially surround the ovary. As an oocyte is expelled from an ovary during ovulation, the waving fimbrae create fluid currents that act to carry the oocyte into the uterine tube, where it begins its journey toward the uterus. (obviously, however many potential eggs are lost in the peritoneal cavity) The oocyte is carried toward the uterus by a combination of peristalsis and the rhythmic beating of cilia. Because the journey to the uterus takes 3 to 4 days and the oocyte is visible for up to 24 hours after ovulation, the usual site of fertilization is the uterine tube. To reach the oocyte, the sperm must swim upward through the vagina and uterus to reach the

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uterine tubes. This is a difficult journey. Because they must swim against the downward current created by the cilia, it is rather like swimming against the tide. Uterus The uterus (uter-us womb), located in the pelvis between the urinary bladder and rectum, is a hollow organ that functions to receive, retain and nourish a fertilized egg. In a woman who has never been pregnant, it is about the size and shape of a pear. (During pregnancy, the uterus increases tremendously in size to accommodate the growing fetus and can be felt well above the umbilicus during the latter part of pregnancy) The uterus is suspended in the pelvis by the broad ligament and anchored anteriority and posterior by the round and uterosacrial ligaments, respectively. The major portion of the uterus is referred to as the body. Its superior rounded region above the entrance of the uterine tubes is the fundus, and its narrow outlet, which protrudes into the vagina below, is the cervix. The wall of the uterus is thick and composed of three layers. The inner layer or mucosa is the endometrium (en-do-metre-um). If fertilization occurs, the fertilized egg (actually the young embryo the time it reaches the uterus) burrows into the endometrium of the uterus (this process is called implantation) and resides there for the rest of its development. When a woman is not pregnant, the endometrial lining sloughs off periodically, usually about every 28 days, in response to changes in the levels of ovarian hormones in the blood. This process is called menses.

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Vagina The vagina (vah-ji-nah) is a thin-walled tube 8 to 10 cm (3 to 4 inches) long. It lies between the bladder and rectum and extends from the cervix to the body exterior. Often called the birth canal, the vagina provides a passageway for the delivery of an infant and for the menstrual flow to leave the body. Since it receives the penis (and semen) during sexual intercourse, it is the female organ of copulation. The distal end of the vagina is partially closed by a thin fold of the mucosa called the hymen (hi-men). The hymen is very vascular and tends to bleed when it is ruptured during the first sexual intercourse. However, its durability varies. In some females, it is torn during a sports activity, tampon insertion, or pelvic examination. Occasionally, it is so tough that it must be ruptured surgically if intercourse is to occur. Menstrual cycle Although the uterus is the receptacle in which the young embryo implants and develops , it is receptive to implantation only for a very short period each month. Not surprisingly this brief interval coincides exactly with the time when a fertilized egg would begin to implant, approximately 7 days after ovulation. The events of the menstrual, or uterine cycle are the cyclic changes that the endometrium, or mucosa of the uterus, goes through month after month as it responds to changes in the levels of ovarian hormones in the blood. Since the cyclic production of estrogens and progesterone by the ovaries is, in turn, regulated by the anterior pituitary gonadropic hormones, FSH and LH, it is

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important to understand how these hormonal pieces fit together. Generally speaking, both female cycles are about 28 days long (a period commonly called a lunar month), with ovulation typically occurring midway in the cycles, on or about day 14. The three stages of menstrual cycle are described next. Days 1-5: Menses. During this interval, the functional layer of the thick endometrial lining of the uterus is sloughing off, or becoming detached from the uterine wall. This is accompanied by bleeding for 3 to 5 days. The detached tissues and blood pass through the vagina as the menstrual flow. The average blood loss during this period is 50 to 150 ml (or about to cup). By day 5, growing ovarian follicles are beginning to produce more estrogen. Days 6-14: Proliferative stage. Stimulated by rising estrogen levels produced by the growing follicles of the ovaries, the basal layer of the endometrium regenerates the functional layer, glands are formed in it, and the endometrial blood supply is increased. The endometrium once again becomes velvety, thick, and well vascularized. (ovulation occurs in the ovary at the end of this stage in response to the sudden surge of LH in the blood.) Days 15-28: Secretory stage. Rising levels of progesterone production by the corpus lutuem of the ovary act on the estrogen-primed endometrium and increase its blood supply even more. Progesterone also cause the endometrial glands to increase in size and to begin secreting nutrients into the uterine cavity. These nutrients will sustain a developing embryo (if one is present) until it has been implanted. If fertilization does occur, the embryo produces a hormone very similar to LH, which causes the corpus luteum to continue producing its hormones. If fertilization does not occur, the corpus

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luteum begins to degenerate towards the end of this period as LH blood levels decline. Lack of ovarian hormones in the blood causes blood vessels supplying the functional layer of the endometrium to go into spasm and kink. When deprived of oxygen and nutrients, those endometrial cells begin to die, which sets the stage for menses to begin again on day 28. Although this explanation assumes a classic 28-day cycle, the length of the menstrual cycle is quite variable it can be as short as 21 days or as long as 40 days. Only one interval is fairly constant in all females; the time from ovulation to the

beginning of menses is almost always 14 or 15 days.

Hormone production by the Ovaries As the ovaries become active at puberty and start to produce ova, production of ovarian hormones also begins. The follicle cells of the growing and mature follicles produce estrogen, which causes the appearance of the secondary sex characteristics in the young woman. Such changes includes: Development of the breasts Appearance of axillary and pubic hair Enlargement of the accessory organs of the female reproductive systems (uterine tubes, uterus, vagina, external genitalia) Increased deposit of fat beneath the skin in general, and particularly in the hips and breasts Widening and lightening of the pelvis onset of menses, or the menstrual cycle

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The second ovarian hormone, progesterone, is produced by a special glandular structure of the ovaries, the corpus luteum. As mentioned earlier, after ovulation occurs the ruptured follicle is converted to the corpus luteum which looks like and acts completely different from the growing mature follicle. Once formed, te corpus luteum produces progesterone (and some estrogen) as long as LH is still present in the blood. Generally speaking, the corpus luteum has stopped producing hormones by 10 to 14 days after ovulation. Except for working with estrogen to establish the menstrual cycle, progesterone does not contribute to the appearance of the secondary sex characteristics. Its other major effects are exerted during pregnancy, when it helps maintain the pregnancy and prepare the breasts for milk production. (however, the source of progesterone during pregnancy is the placenta, not the ovaries.)

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VIII. Medical/Surgical Management Book-based

Treatment of uterine fibroids may include medical or surgical intervention and depends to a large extent on the size, symptoms and location as well as the womans age and her reproductive plans. Fibroids usually shrink and disappear during menopause, when estrogen is no longer produced. Simple observation and follow-up may be all the management that is necessary. The patient with minor symptoms is closely monitored. If she plans to have children, treatment is as conservative as possible. As a rule, large tumors that produce pressure symptoms must be removed (myomectomy).

Medical Management Asymptomatic leiomyomas can be observed every 6 months a practitioner if (1) the client is not pregnant, (2) there is no excessive bleeding or pressure on the bladder, bowel, or uterus and (3) the tumor is not rapidly growing. Medications (e.g., leuprolide [lupron]) or other gonadotropin releasing hormone (GnRH) analogues, which induce a temporary menopause like environment, may be prescribed shrink the fibroid. This treatment consists of monthly injections, which may cause hot flashes and vaginal dryness. Treatment is usually short term9ie, before surgery) to shrink the fibroids, allowing easier surgery, and no alleviate anemia, which may occur as a result of heavy menstrual flow. This treatment is used on a temporary basis because it leads to vasomotor symptoms and loss of bone density.
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Antifibrotic agents are under in investigation for long term treatment of fibroids. Mifepristone, a progesterone antagonist, has also been prescribed; it appears to be effective.

Surgical Management Surgical treatment may involve cutting off the blood supply to the fibroid with uterine artery embolization, laser surgery or myomectomy (removal of a tumor without removal of the uterus).these procedures preserve the reproductive organs and reproductive capability. Large leiomyomas may require hysterectomy.

Hysterectomy Indications: three types of hysterectomy may be performed: 1. Total hysterectomy is a removal of the uterus and cervix, and can be performed either abdominally or vaginally. 2. Total hysterectomy with bilateral salpingooophorectomy (TAH-BSO) is the removal of uterus, cervix, fallopian tubes, and ovaries. Can be performed abdominally or vaginally. 3. Radical hysterectomy same as a TAH-BSO plus removal of the lymph nodes, upper third of the vagina, and parametrium. Usually performed if a malignant tumor is found. Contraindications: The only contraindication to hysterectomy is any heath condition that prevents surgery.
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Complications. Hemmorrhage and infection are the primary complications. Outcomes. It is expected that the client will return home in 2 to 4 days and resume regular activities within 4 to 6 weeks, depending on the type of hysterectomy performed. Pain, abdominal bleeding, and anemia, if present, will cease. For all procedures except myomectomy, menstruation ends. Several other alternatives to hysterectomy have been developed for treatment of excessive bleeding due of fibroids. These include the following: Hysteroscopic resection of myomas: a laser is used through a hysteroscope passed through the cervix; no incision or overnight stay is needed. y Laparoscopic myomectomy: removal of a fibroid through a laparoscope inserted through a small abdominal incision y Laparoscopic myolysis: a laser or electrical needles are used to coagulate the fibroid y y Laparoscopic cryomyolysis: electric current is used to coagulate the fibroid Uterine artery embolization (UAE): polyvinyl alcohol or gelatin particles are injected into blood vessels that supply the fibroid via the femoral artery, resulting in infarction and resulting shrinkages. This percutaneous image-guided therapy offers an alternative to hormone therapy or surgery.UAE may result in infrequent but serious complications such as pain, infection, amenorrhea, necrosis and bleeding. A although rare deaths and ovarian failure may occur. Women need to weigh the risk and benefits carefully, especially if they have not completed

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childbearing, this procedure has been found to cause fewer complications than hysterectomy, but women may need further treatment in future. y Magnetic resonance-guided focused ultrasound surgery (MRgFUS):

ultrasonic surgery is passed through the abdominal wall to target and destroy the fibroid. Although not yet widely used, this noninvasive procedure is approved by the U.S .food and drug administration for premenopausal women with bother some symptoms due to fibroids and who do not want more children .it is an outpatient treatment Surgical Management

Client-based

Vaginal myomectomy involves removing fibroids through the vagina; as with

hysteroscopic myomectomy, therefore, there are no external scars. This operation is done when the fibroids are moderate in size but too deep or numerous for hysteroscopic or laparoscopic myomectomy. It is easier in women who have children as there tends to be more space in the pelvis for this type of surgery. The procedure is easiest when the fibroid(s) are at the back of the uterus, and most difficult when they are mainly at the top; in that situation, laparoscopic myomectomy may be preferred. Because conventional instruments are used, Vaginal myomectomy generally takes less time than laparoscopic myomectomy and the repair of the uterus is stronger. Recovery in terms of hospitalisation and return to normal activities is similar, and faster than with laparotomy.

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X.

Statement of nursing problems/nursing diagnosis based on grouped data (Gordons) 1. Activity Intolerance related to bed rest 2. Acute pain related to injury agents as manifested by trauma to tissues 3. Acute pain related to surgical procedure 4. Anxiety related to change in role status 5. Constipation or Risk for constipation related to decreased activity 6. Disturbed sleep pattern related to pain, lack of sleep privacy 7. Disturbed body image related to treatments 8. Hygiene self care deficit related to pain 9. Hyperthermia related to trauma as manifested by increase in body temperature 10. Ineffective health maintenance related to lack of social support 11. Nausea related manipulation of GI tract, postsurgical anesthesia 12. Risk for infection related invasive procedure 13. Risk for loneliness related to affection deprivation 14. Self-care deficit related to weakness and tiredness 15. Urinary retention related to pain, fear

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XI.

Priority Nursing Problem/Nursing Care Plan Actual Nursing Dx Acute pain secondary to surgical procedure (hysterectomy) as evidence by reported pain with the pain scale of 8 (pain scale from 1 10), limited range of motion and sleep disturbance pattern Inference
Hysterectomy

Assessment Subjective: The patient verbalizes: I felt pain on my surgical incision Objective: - Reported pain with the pain scaleof 8 (pain scale from 1 10) - Facial Grimacing - Guarding behavior

Planning
After 8 hours of rendering nursing

Intervention
Independent: 1. Evaluate pain regularly noting characteristic, location intensity (0-10).

Rationale
1. Provide information about need for or effectiveness of intervention. 2. Prevents undue strain on operative site. 3. May relieve pain and enhance circulation 4. Relieves muscle and emotional

Evaluation
After 8 of rendering nursing care, the goalswas met partially asevidenced by: Decreased

Breaking in the continuity of the skin

intervention, the patient will be able to: - Decrease pain

2. Identify specific scale of 8 to 4 as activity limitations. evidence by 3. Reposition as stable vital signs. indicated. 4. Encourage of relaxation technique like deep

Imflamation process triggered

pain scale to the level of 5.

Nerve ending compression

breathing exercise. 5. Monitor vital signs tension. DEPENDENT: 5. Changes in vital signs may be used for rough estimate of pain. DEPENDENT: 1. To relieve mild or moderate pain.

Pain

1.Administer analgesic medication: Ketorolac IVTT x 4 doses q 8 hours as prescribe by the physician.

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Actual Nursing Dx Hyperthermia related to trauma as manifested by In body temperature of 39.4 oC Inference Planning Intervention 1. Render TSB Rationale
> To body heat evaporation has a cooling effect >To circulation of blood > To promote heat loss > To absorb heat in said areas. Thus, heat loss >to determine if the temp. is w/in normal range

Assessment Subjective kanina pa po siya nilalagnat as verbalized by the patients relative Objective > T 39.4% C > Chilling > Clammy Skin > Skin warm to touch

Evaluation After 30 min. of nursing intervention, the body of the patient is able to reach the normal range of body temperature. > the patient is able to verbalize understanding of techniques of proper TSB

Tumors of the After 30 min. of uterus nursing intervention, Located in the patient the body of manifest the uterus thermo regulating as Invasive evidenced by: procedure > Skin Removal of temperature in tumors expected range Damage of the tissues > Body temperature Trauma of w/in normal tissue limits Hyperthermia In body temperature

2. Fluid intake

3. Removal of excessive clotting 4. Put cold compress to forehead neck, axilla, and groin. 5. Every 5 minutes check for temperature if the temp. is w/in normal range

> describes to prevent or minimize inc. in 6. Teach the body temp relative proper > describe proper measures during TSB

>Long strokes
creates friction to the skin and it produces heat. 51

TSB techniques like avoiding long strokes and only patting the wet towel on the skin

 Assessment Subjective

Potential Nursing Dx Anxiety related to change in Health status as manifested by irritability Inference Changes in physiologic status Planning After continuous nursing intervention, the client will be able to: -Verbalize appropriate range of feeling. Intervention
-encourage verbalization of concerns -assist patient in expressing feelings by active listening -provide accurate and concrete information about what is being done -provide a calm and peaceful environment -encourage relaxation techniques -encourage to project a positive and realistic attitude

Rationale - this aids comfort by improving the patients attitude toward the situation.

Evaluation After continuous nursing intervention, the client was able to: -verbalized appropriate range of feelings.

hindi ako mapalagay kasi baka hindi ako gumaling agad.naaawa ako mga anak ko.As verbalized by the patient Objective >Irritability >poor eye contact >Expressed concerns due to change in life events >dry mouth

Worsening of case

Hospitalization

Anxiety due to thoughts of not able to recover

-relieves discomfort and pain.

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XII.

Discharge Plan

M- medication y y y Advise the client to comply with the prescribe treatment regimen. Explain in a manner that can be understand as to name, actions, side effects etc. Emphasize that strict compliance of treatment should be observed to prolong life.

E- exercise Deep Breathing exercises. y Keep emotional stress under control by using relaxation techniques such as muscle relaxation exercises.

T- treatment y y Provide Rest periods between activities. Provide adequate ventilation and a quiet calm environment.

H- health teaching y y y Instruct the client in energy saving activities. Instruct the patient to eat healty foods. Advise family to provide emotional support.

O- OPD y y Advise patient to comply with clinic follow up. Advise patient to comply with treatments.

D- diet y y Eat in small frequent meals of high nutritional value. Drink plenty of water at least 8 times a day.

S- spiritual y y Advise the significant others to guide and support the Patient by uplifting her spiritual being. Maintain positive outlook in life.

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Reference Books Brunner & Suddarth, 2010, Textbook of Medical and Surgical Nursing 12th Ed., Lippincott & Willliams Joyce M. Black, 2005, Mediccal-Surgical Nursing: Clinical Management for Positive Outcomes 7th Ed., Elsevier Inc. Marguerrete Kinney, 1988, AACNs Clinical Reference for CriticalCare Nursing 2nd Ed., Mosby Harold Shyrock, 1985, Modern Medical Guide McCane & Huether, 2008 Understanding Pathophysiology 4th Ed., Mosby Elaine M. Marieb, 2004, Essentials of Human Anatomy & Physiology 7th Ed., Pearson Education South Asia PTE LTD Judith M. Wilkinson, 2005, Prentice Hall Nursing Diagnosis Handbook with NIC interventions and NOC outcomes 7th Ed., Pearson Education South Asia Stanly Loeb,1992, Nursing 92 Drug handbook, Springhouse Corporation Clayton and Stock, 2001, Basic Pharmacology for Nurses 12th Ed., Mosby Images http://images.search.yahoo.com/images

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