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NURSING CASE STUDY ADMISSION/FINAL DIAGNOSIS I. HEALTH HISTORY A. DEMOGRAPHIC (BIOGRAPHICAL DATA) 1. Clients initials: J. L. B. 2. Gender: Female 3. Age: 44 years old Birthdate: April 24, 1969; Birthplace: San Mateo, Rizal 4. Marital (Civil) Status: Married 5. Nationality: Filipino 6. Religion: Roman Catholic 7. Address and Phone Number: 376 Lipahan, Pulong Bunga, Silang, Cavite 09209640936 8. Educational Background/Other Significant Framing: High School Graduate 9. Occupation (usual and present): Housewife 10. Usual Source of Medical Care: Hospital B. SOURCE AND RELIABILITY OF INFORMATION Data were obtained from the patient who seems reliable. The clients chart was also incorporated as a secondary source of information. C. REASONS FOR SEEKING CARE OR CHIEF COMPLAINTS (top 3) sobrang sumasakit ang puson ko sobrang lakas ng regla ko, nag umpisa sya ng ganito kalakas nung April netong taon lang..umpisa nun buwan buwan na ganito napapatagal yung buwanang dalaw ko D. HISTORY OF PRESENT ILLNESS/ OR PRESENT HEALTH Two months prior to admission, the client experienced abnormally heavy and prolonged menstruation and dysmenorrhea as well. She reported that from three feminine pads moderately soaked it increased to five pads fully-soaked per day, and from her regular three-day period, it increased to five days accompanied with menstrual pains (a scale of eight out of ten from the pain scale) but no consultation occurred. Two weeks prior to admission, there was persistence of the above symptoms and the client decided to consult a doctor and had an ultrasound (trans-v) which showed the back part of her uterus to have an abnormality and also showed that her left ovary has an overgrowth. After these discoveries, she was scheduled for an operation to remove her uterus, fallopian tubes and her ovaries. The client was admitted to the hospital two days before her scheduled operation. E. PAST MEDICAL HISTORY OR PAST HEALTH J.L.B. is a housewife who considers daily household chores to be her exercise. As a child, she did not experience any serious illnesses, just had simple cough and colds. She also did not experience any injuries or accidents in the past and this is her first hospitalization and operation. J.L.B. had her menarche at the age of twelve and her last menstrual period was June 10, 2013. She is G2P2; G1 - 1996, girl, 7 lbs, NSD; G2 - 1998, girl, 6.7 lbs, NSD. Had a history of UTI with her second pregnancy, unrecalled medications but treated completely. She undergone Total Abdominal Hysterectomy and Bilateral Salpingooophorectomy due to an overgrowth on part of her uterus and left ovary after a transvaginal ultrasound. She stated that she has complete immunization and there are no known food and medication allergies. She claimed that she takes over the counter medicines to treat simple colds and minor aches and pains like Alaxan. During her hospitalization, she was given Mefenamic acid as needed for pain and Cefuroxime every eight hours as an antibiotic.


Grandfather, unrecalled age and cause of death

Grandmother, old age

Grandfather, unrecalled age and cause of death

Grandmother, unrecalled age and cause of death

Father, 77 lung disease

Mother, 76, rheumatoid arthritis and HTN

Patricio, 52, rheumatoid arthritis

Zenaida, 51, had hysterectomy

Anna,48, had myoma;hyste -rectomy

Eduardo,46, healthy

Patient, 44, adenomyosis

Priscilla, 38, healthy

According to the family genogram, her grandparents, paternal side, are deceased and she does not know her grandfathers cause of death but her grandmother died due to old age. Patients grandparents on the maternal side are already deceased and the patient does not recall the causes of death. The patients father died due to a lung problem (patient does not know the exact lung illness). Her mother has rheumatoid arthritis and also has hypertension. The genogram also shows that two of her sisters also undergone hysterectomy before. The client is the fifth child of her parents. G. SOCIO-ECONOMIC The client is a plain housewife and currently living with her husband and two daughters and both of them are still students. The familys source of income is from her husband who is a supervisor in a resort. She claimed that her husbands income is enough for them. H. DEVELOPMENTAL HISTORY Middle Adulthood: 35 to 55 or 65 Ego Development Outcome: Generativity vs. Self absorption or Stagnation Basic Strengths: Production and Care Now work is most crucial. Erikson observed that middle-age is when we tend to be occupied with creative and meaningful work and with issues surrounding our family. Also, middle adulthood is when we can expect to "be in charge," the role we've longer envied. The significant task is to perpetuate culture and transmit values of the culture through the family (taming the kids) and working to establish a stable environment. Strength comes through care of others and production of something that contributes to the betterment of society, which Erikson calls generativity, so when we're in this stage we often fear inactivity and meaninglessness. As our children leave home, or our relationships or goals change, we may be faced with major life changes the mid-life crisis and struggle with finding new meanings and purposes. If we don't get through this stage successfully, we can become self-absorbed and stagnate. Significant relationships are within the workplace, the community and the family. J.L.B. is worried about her children and the things to do at home since she is the one who is in charge of them like household chores and taking care of her childrens needs. During the

interview, it showed that she gets her strength from her significant others especially her husband and her daughters. I. REVIEW OF SYSTEM AND PHYSICAL EXAMINATION 1. ROS AND PE System a. General /overall health status ROS ok naman na ako pero malaki ang ibinaba ng weight ko..medyo hirap pa dn sa paggalaw gawa ng tahi PE -awake, conscious and coherent -non ambulatory -IVF on left metacarpal vein @ level 150 cc infusing well -pt has IFC -afebrile with a Temp= 36.5C -PR= 80bpm -RR= 20 cpm, -BP=130/90 mmHg Wt=53 kg; significant weight changes from 63 to 53 kg Skin : - (-) hyperpigmentation, no pallor and generalized scaliness, nails without clubbing or cyanosis - incision site and dressing are clean and intact; wound is slightly moist with clear fluid -symmetrical, smooth, firm -(-)lesions on the scalp -normocephalic -tempomandibular joint felt bilaterally with full ROM -symmetrical blinking -bulbar conjunctiva clear with tiny vessels visible -nontender lacrimal apparatus -(-)discharges on external ear -(-)tenderness -(-)nasal discharges -pink and moist mucosa with no lesions -(-)nontender nasal sinuses -sinuses clear upon illumination -(-)hoarseness -dry lips -(+) gag reflex -tonsils not enlarged -left first molar tooth decay -(+) full ROM -smooth, firm and nontender thyroid -(-)cervical lymph nodes enlargements -(-)skin lesions, no dimpling; non-tender on palpation, no palpable masses or lumps. No discharge. -flat pale brown areola -inverted nipples -(-) axillary lymph nodes enlargment -resonant on percussion, vesicular breath sounds, no crackles, no wheezes, no

b. Integument

wala naman akong nagising sakit sa balat

c. Head

wala naman

d. Eyes

ayos naman

e. Ears

wala naman ok naman,bihira naman magkasipon

g. Mouth and Throat

wala naman akong problema sa lalamunan

h. Neck


i. Breast and Axillary

wala,nagb-BSE ako kaya lang nakakalimutan ko sya kung minsan kaya hindi din consecutive yung exams

j. Respiratory


k. Cardiovascular

wala naman

l. Urinary

yun lang, yung nagkaroon nga ako ng UTI nung pinagbubuntis ko ang bunso namin

m. Genitalia

n. Musculoskeletal

dose ako nung unang nagkaron ng mens..huling regla ko nung June 10 hindi pa ako nakakalakad, pabangon bangon lang,ganyan..uupo.. minsan sumasakit ang likod ko,sa bandang kaliwang taas wala naman

rhonchi. -(+) apical pulse felt at fifth ICS LMC line -identical apical and radial pulse @80 bpm -normal heart sounds -regular rate,normal rhythm -urine output of >30 cc/hr -urine color amber yellow (seen from the urine bag connected to the cath.) -(-) bladder distention -normal kidney punch test The patient refused to be examined on her genital part -patient wasnt able to ambulate due to catheter -full ROM of upper extremities -less lower extremity functioning due to incision site pain -responds to questions and statements appropriately -oriented to time,place, and person -CN I:able to smell odor correctly -CN II: Snellen chart result 20/20 -CN III,IV,VI: good EOM -CN V: (+)sensation to light touch and pain -CN VII: (-) drooping of the corner of the mouth while head -CN VIII: passed whisper and Romberg test -CN IX: (+) gag reflex, able to identify taste -CN X: (+) symmetrical elevation of the palate, uvula rises while swallowing -CN XI: able to shrug shoulders, able to move neck with ease -CN XII: (-) limitation of tongue movements -(-) bleeding -(-) bruising -no excessive sweating -heat and cold tolerance

o. Neurologic

p. Hematologic q. Endocrine

wala, di naman ako pasain wala

J.FUNCTIONAL ASSESSMENT A. Health-Perception-Health Management Pattern Patient still feels that her body is weak since she just had an operation. Her diet is more on vegetables and fish and the patient thinks that these things nurses or doctors would suggest. In the past, it has been also easy for her to find ways to follow things nurses or doctors suggest The patient does not know the exact cause of her illness and she consulted a doctor after having heavy, prolonged and painful period. That decision was important for her because if she did not decide to go to a doctor, she would not have known the cause of those symptoms. B. Self-esteem, Self-concept/Self-perception Pattern The patient would describe herself as a very patient person. Most of the time, she feels good about herself but since the illness started, the patient felt that her body became weak.

There is nothing that frequently makes her angry and annoyed. The only thing that makes her anxious and fearful is when she gets bad news about her mothers health. C. Activity-Exercise Pattern She has sufficient energy for completing required activities like the household chores but has no regular exercise; considers her everyday chores as her informal exercise. She watches television and sings on the karaoke whenever she has spare time. Below are the different activities and its corresponding functional level. Level 0=full self care; level 1=requires use of requirements or device;level 2=requires assistance or supervision from another person; level 3= requires assistance or supervision from another person or device; level 4= is independent and does not participate Perceived ability for Feeding level 0 Bathing level 4 Toileting level 4 Bed mobility level 2 Dressing level 2 D. Sleep-Rest Pattern The patient would have eight hours of sleep and feels good after waking up. She sleeps right away when she goes to bed and always have a good night sleep; goes to the bathroom once in a while then goes back to sleep. She does not take daytime naps and does not use sleeping aids. E. Nutritional/Elimination Typical daily food intake would be fish and vegetables for lunch and dinner. She prefers pinangat and eats a lot especially during lunch time. She claimed that she lose weight by ten kilograms: from 63-53 kg She has a good appetite, loves to eat and no food or diet discomforts, food allergies/intolerance. Over the last 24 hours shes been eating and taking crackers and water since her GI is not yet fully recovered. She also claims that she heals well and there are no skin problems other than her wound incision. She admits that she is afraid to go to the dentist before thats why she is experiencing tooth decay now on her left first molar. Her usual bowel elimination would be once a day and with no discomfort. Urinary elimination would be about six times a day, with a light yellow urine and no discomfort. F. Sexuality-Reproductive Pattern a-b. The patient requested to skip this part of the interview since she is not comfortable to talk about sexual relations with other people she is not very familiar with. Her first menstruation started when she was 12 years old. LMP June 10,2013 with dysmenorrheal and prolonged, painful period G. Interpersonal Relationships/Resources She considers her social role as raising kids with good morals and bright future ahead of them which will contribute to the societys well-being. When it comes to her role in the family, she is a good wife to her husband and a mother to her children. She is very close with her family and has a strong support system (especially her husband) which she would go for counseling when there is a personal problem H. Coping and Stress Management/Tolerance Pattern Kinds of stress in life about health and when there is a family emergency. Her current stress now would be her hospitalization since she is worried about her kids being at home without her. Methods to relieve stress would be just talking with her husband or with her friends, and she says that these have been very helpful. She is not tense most of the time. The only thing that makes her tense is whenever she gets bad news about her mothers health. Grooming level 2 Gen. Mobility level 3 Cooking level 4 Home Maintenance level 4 Shopping level 4

According to her, her husband is the most helpful when taking things over. Having a grandchild is the big change in her life in the last year. When there is a big problem in her life, she seeks her husbands help and they both think about the solutions to that problem. She says that sharing the burden really helps. Most of the time, this way is successful. I. Personal Habits The patient does not have personal habits J. Environmental Hazards The client said that their neighborhood is safe and have adequate utilities. They have access for transportation.

III. LABORATORY STUDIES AND DIAGNOSTICS Procedure/ Date Transvaginal UTZ May 18, 2013 Indications -To confirm enlargement of the uterus -To assess endometrial lining -To assess the ovaries Normal Values/Findings There should be no abnormal pelvic growths Actual Findings and Interpretation Right ovary measures 2.16x2.30x1.24 cm; Left ovary measures 7.51x5.91x5.30 cm *Abnormalities noted that the left ovary is cystic as measured. Its unilocular, thin-walled containing echogneic stippling and lines The uterus anterior wall=2.39cm; posterior wall=2.65 cm and demonstrate a coarse echopattern. *Posterior adenomyosis Nursing Responsibilities (pre,intra,post) Pre: -Explain the procedure to the patient what it is for and how it is done -Inform the patient who will perform the test and where and when it will be performed -Inform the patient that she needs to empty bladder before the procedure -Inform the patient that there will be minimal discomfort during the test. Intra: -Accompany patient to the ultrasound room -Provide privacy Post: -Inform the patient that a written report of the ultrasound results will be forwarded to the referring physician and the physician will discuss the test results Pre: -Explain what the procedure is all about-how it is taken and what it is for;includes smears Intra: -Provide privacy Post: - Inform the patient that the results of the cytology will be forwarded to the referring physician and the physician will discuss the test results

Gynaecologic Cytology May 29,2013

To know the microscopic appearance of reproductive cells that would further confirm the diagnosis of abnormalities and malignancies of the reproductive organs

There should be no abnormalities that reflect any lesions that may indicate malignancy

General Categorization: (-) for intraepithelial malignancy *The growth is benign Other non-neoplastic findings: Reactive cellular changes associated with inflammation. *There is cell differentiation and overgrowth.

Clinical Lab Hematology June 12,2013

To determine if the cells and their values are within normal range;if there are presence of infections;

Hgb=123-153G/L Hct=0.36-0.45 WBC=5-10x10^g/L

Hgb=109 Hct=0.33 WBC=9.2; *Results are in normal range

Pre: -Explain the procedure to the patient -Inform the patient that the test requires blood sample -Inform the patient who will perform the test and when it will be performed

-Inform the patient that there will be discomfort from needle puncture and pressure from the tourniquet Intra: -Instruct the patient to apply manual pressure and dressing or cotton ball over puncture site on removal upon removal Post: -Monitor the puncture site for oozing or hematoma formation

II. PROBLEM LIST A. ACTUAL or Active Problem No. 1 2 3 Problem Acute pain in the incision site Weight loss Upper back pain Date Identified June 26, 2013 June 26, 2013 June 26, 2013 Date Resolved/Remarks

B. HIGH RISK or Potential Problem No. 1 2 3 Problem Risk for deep vein thrombosis Risk for slow wound healing Risk for musculoskeletal weakness Date Identified June 26, 2013 June 26, 2013 June 26, 2013

III. NURSING CARE PLAN CUES S: masakit ang tahi ko pag gumagalaw O: -Received patient lying on bed, awake, conscious, coherent, oriented to time and person place with an IVF on LBV D5IMB x12 level of 4800 cc @ 3 pm infusing well; rate of 4142ugtts/min -Pain scale of 6/10; facial grimace upon moving -Impaired physical mobility NURSING DIAGNOSIS ND: Acute pain related to surgical incision BACKGROUND KNOWLEDGE TAHBSO= incision on her abdomen to remove the diseased organsimpaired skin/woundpain LONG TERM The patient will be able to move and do exercises and activities of daily living independently after six to eight weeks. SHORT TERM After nursing interventions within the shift, the client will manifest a decrease in pain scale from 6/10 to 2/10 or lower. INTERVENTION DIAGNOSTIC Assess the clients perception, level of understanding and needs. RATIONALE EXPECTED OUTCOME Short term:The patients pain scale will decrease from 6/10 to 2/10 or lower Long term: The patient will perform ADL independently after six to eight weeks

>To identify and assess the different nursing interventions to be done

THERAPEUTIC Obtain clients VS including the pain scale and help with administering analgesics as indicated

>To assess the effectiveness of nursing interventions and obtain baseline for future comparison; to alleviate pain.

Encourage deep breathing EDUCATIVE Encourage verbal report during and after each nursing intervention Teach client diversional activities

>To inhibit pain

>Because pain is highly subjective >To divert attention from pain

S: eto medyo mahina pa ang katawan O: -Impaired physical

ND: Poor physical condition secondary to

Surgical procedure body insist demands of nutrition and

The patient will perform activities of daily living independently and

After nursing intervention, the patient will demonstrate an

DIAGNOSTIC Evaluate the need for individual assistance and discuss lifestyle changes imposed by fatigue state

>To determine degree of fatigue

Short term: The patient will demonstrate an increase in energy output with presence of fatigue Long term: The patient will perform

mobility -Weakness -Limited ROM on lower extremities


oxygen post opfatigue

participate in desired activities at level of ability six to eight weeks post op

increase energy output with presence of fatigue within the shift THERAPEUTIC Establish realistic activity goals with client >Enhance commitment in promoting optimal outcomes >To indicate the need to alter activity level

activities of daily living independently and participate in desired activities at level of ability

EDUCATIVE Instruct client in ways to monitor responses to activity and significant signs and symptoms



Uterus The uterus is located inside the pelvis immediately dorsal (and usually somewhat rostral) to the urinary bladder and ventral to the rectum. The human uterus is pear-shaped and about 3 in. (7.6 cm) long. The uterus can be divided anatomically into four segments: The fundus, corpus, cervix and the internal os. The Uterus is the organ of pregnancy as this is where implantation and development of the fetus occurs. Fallopian tube The fallopian tubes stretch from the uterus to the ovaries and measure about 8 to 10 cm (4 to 6 inches) in length. The ends of the fallopian tubes lying next to the ovaries feather into ends called fimbria (Latin for "fringes" or "fingers"). Millions of tiny hair-like cilia line the fimbria and interior of the fallopian tubes. The cilia beat in waves hundreds of times a second catching the egg at ovulation and moving it through the tube to the uterine cavity. Other cells in the tube's inner lining or endothelium nourish the egg and lubricate it's path during its stay inside the fallopian tube. Once inside the fallopian tube, the egg and sperm meet and the egg is fertilized. Ovaries The ovary (for a given side) is located in the lateral wall of the pelvis in a region called the ovarian fossa. The fossa usually lies beneath the external iliac artery and in front of the ureter and the internal iliac artery. The ovaries are not attached to the fallopian tubes but to the outer layer of the uterus via the ovarian ligaments. Usually each ovary takes turns releasing eggs every month; however, if there was a case where one ovary was absent or dysfunctional then the other ovary would continue providing eggs to be released.

V. PATHOPHYSIOLOGY Endometrial glands and tissue present in endometrium

Agent Altered cell differentiation and growth Cyst in the ovary Prevents uterine contractions

Surrounding myometrium hypertrophy and hyperplasia

Bleeding arterioles wont stop

Ovarian enlargement Stomach compression

Loss of appetite Uterus enlargement dysmenor rhea menorrha gia Prolonged period

Significant weight loss

Pelvic pain

Transvaginal utz

Gynaecologic cytology


Posterior adenomyosis with dermoid cyst of left ovary

Cell differentiation and overgrowth


VI. MEDICAL-SURGICAL MANAGEMENT (Curative) 1. Procedure Procedure/Date Total Abdominal Hysterectomy Bilateral Salpingo Oophorectomy June 25, 2013 Indication/Analysis Adenomyosis with dermoid cyst of the left ovary Nursing Responsibilites (PRE, INTRA, POST) Pre: - Reduce the anxiety of the patient and their relatives by orientation of the environment. - Informed consent - Check results of lab - Monitor VS - Assess I and O - Examine level of anxiety - Teach relaxation techniques - Bowel preparation -Light dinner, NPO -Cleansing enema - Prophylactic antibiotics - IV fluids Intra: -Total Abdominal Hysterectomy Bilateral Salpingo Oophorectomy Post: -Vital signs monitoring q15 -IV fluids -NPO to clear to soft diet -Assess the scale of pain: characteristics, scale, location -Assess the state of the wound -Assess nutritional status -Auscultation of bowel sounds -Give wound care information and disease. -Analgesics -Health teachings to prevent complications Pneumonia (DBE) DVT (turning exercise) Bedsores (turning exercise)

2. Pharmacotherapeutics/Medicines GN (BN) CLASSIFICATION STOCK Cefuroxime (Ceftin) Second generation cephalosporin antibiotic 500 mg/tab Mefenamic acid (Ponstel) NSAID 500 mg/cap Indication (client-specific) Dosage and Frequency Prevents infections caused by bacteria 500 mg/tab; q8 x 7 days Nursing Responsibilities/Implication (PRE, INTRA, POST) Pre: -Read orders carefully -Correct procedure and route for administration -Give information about the drugs indication to the client Intra: -Introduce self and identify patient -Ask and assist patient to sit -Inform patient to notify health care providers if there are

Treats pain (since the client undergone surgery) 500 mg/cap; q6 as needed

allergic reactions to the medications Post: -Document after administration of medications and health teaching

VII. DISCHARGE HEALTH TEACHING PLANS Content 1. Compliance Medication Cefuroxime 500 mg/tab; q8 x 7 days Mefenamic acid 500 mg/cap; q6 as needed Strategy Give verbal and written instructions to the patient and family about adherence to the prescribed medications.


Importance of having a regular exercise

Give verbal and written instructions on how to do simple exercises and remind him to avoid lifting objects. Give verbal and written instructions on proper wound care and changing wound dressing Teaches the patient and family about the treatment plan including the need to avoid all alcohol intakes, take medications as prescribe and check with the physician before taking any new medications. Patient and family teaching addresses skin and wound care and to watch for and report signs and symptoms of complications.


Wound care and dressing

Health teaching

Treatment plan


Encourage patient on intake of fruits, vegetables and protein

Give pamphlet about foods that are rich in protein and other foods that help with wound healing. Give pamphlet with information on the benefits of healthy lifestyle. Encourage patient to deviate from the old habits that might hinder with the recovery and also change lifestyle if too sedentary Giver verbal instructions and also the schedule for the follow up checkup. Contact the patient prior to his appointment to remind him of his check up.

Activity/Lifestyle Changes

Explain to the client that his or her activity is limited temporarily; bad habits

2. Follow up/Check-up

Explain the significance of a follow check up in the full recovery and healing from the illness

VIII. SUMMARY OF CLIENTS STATUS OR CONDITION AS OF LAST DAY OF CONTACT (Narrative form) As of last day of contact, the condition of the patient is better. She can sit up with assistance but still cannot walk on her own since she just underwent surgery and still has a catheter. She is practicing deep breathing and turning exercise to prevent venous stasis and respiratory complications. She is still not able to pass flatus thats why she is just taking crackers and water to eat but she follows the doctors and the nurses advise to sit once in a while and also turn. Her incision wound and its dressing are clean and intact. The wound itself is slightly moist, with clear little discharge. She is looking forward to be discharged in the hospital and go home to be with her family and the newest addition to their brood.