Adamson University

College of Nursing

Ovarian Cancer with Total Abdominal Hysterectomy

Bilateral Salpingo-Oophorectomy

A Case Study Presented To

The Faculty of the College of Nursing,
Adamson University

In Partial Fulfillment of the Requirements for the

Degree of Bachelor of Science in Nursing

February 1, 2019
 Adamson University
College of Nursing

TABLE OF CONTENTS

Table of Contents 2-3

I. Objectives of the case study 3

II. Introduction 3

a. Definition of case 4-8

b. Etiology 9

c. Incidence 9

d. General Signs and Symptoms 10

III. Patient’s Data

a. Patient’s Data 10

b. Nursing History 10

i. Chief Complaint 10

ii. Present History 11

iii. Past Medical History 12

iv. Heredo- Familial Tendency 12

v. OB History 12

vi. Nutritional Status 12

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vii. Immunization History ( If Adult = last 5 to 10 12

years )
viii. Physical Examination History 12-14

c. Gordon’s Functional Pattern 15-16

d. Course in the ward 16-17

IV. Anatomy and Physiology 17

V. Pathophysiology 18-19
VI. Laboratory Examinations 20-26

VII. Drug Study 27-37

VIII. Nursing Care Plan 38-45

IX. Discharge Planning (METHODS) 46-48

X. Implications of the case study to the following 48

areas:
a. Nursing Research
b. Nursing Education
c. Nursing Practice
XI. Bibliography 49

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I. OBJECTIVES OF THE CASE STUDY

 To thoroughly assess the clinical manifestations of patient that with Ovarian Cancer
based on patient’s history.
 To formulate comprehensive nursing diagnosis for a before the patient had Ovarian
Cancer.
 To formulate a plan of care for patients underwent TAHBSO.
 To formulate appropriate nursing interventions that can be applied for a patient after
TAHBSO operation.
 To evaluate the plan of care and to provide health teachings for a patient
with Ovarian Cancer.

II. INTRODUCTION

a. DEFINITION OF THE CASE

Ovarian Cancer is an especially insidious killer because cellular changes in the ovaries often
are asymptomatic until the cancer is quite advanced. Risk factors are not definitely identified, but
some proposed factors include low infertility and number of children, late menopause, and a family
history of reproductive cancers. Use of hormonal contraception may help prevent this, because it
results in less ovulation during the woman’s lifetime.

STAGING OF OVARI AN C ANCER

According to AJCC (American Joint Committee on Cancer), they use 3 factors to stage
(classify) this cancer.
 The extent (size) of the tumor (T)
 The spread to nearby lymph nodes (N)
 The spread (metastasis) to distant sites (M)

Stage Stage grouping Stage description

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I T1 The cancer is only in the ovary

N0 (or ovaries) or fallopian tube(s)
M0 (T1).
It has not spread to nearby
lymph nodes (N0) or to distant
sites (M0).

IA T1a The cancer is in one ovary, and

N0 the tumor is confined to the
M0 inside of the ovary; or the
cancer is in in one fallopian
tube, and is only inside the
fallopian tube.
It has not spread to nearby
lymph nodes (N0) or to distant
sites (M0).

IB The cancer is in both ovaries or

T1b fallopian tubes but not on their
N0 outer surfaces.
M0 It has not spread to nearby
lymph nodes (N0) or to distant
sites (M0).

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IC T1c The cancer is in one or both

N0 ovaries or fallopian tubes and
M0 any of the following are present:
-The tissue (capsule)
surrounding the tumor broke
during surgery, which could
allow cancer cells to leak into
the abdomen and pelvis
(called surgical spill). This is
stage IC1.
-Cancer is on the outer surface
of at least one of the ovaries or
fallopian tubes or the capsule
(tissue surrounding the tumor)
has ruptured (burst) before
surgery (which could allow
cancer cells to spill into the
abdomen and pelvis). This is
stage IC2.
-Cancer cells are found in the
fluid (ascites) or washings from
the abdomen and pelvis. This is
stage IC3.
-It has not spread to nearby
lymph nodes (N0) or to distant
sites (M0).

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II T2 The cancer is in one or both

N0 ovaries or fallopian tubes and
M0 has spread to other organs
(such as the uterus, bladder,
the sigmoid colon, or the
rectum) within the
pelvis or there is primary
peritoneal cancer (T2). It has
not spread to nearby lymph
nodes (N0) or to distant sites
(M0).
IIA T2a The cancer has spread to or has
N0 invaded (grown into) the uterus
M0 or the fallopian tubes, or the
ovaries. (T2a). It has not spread
to nearby lymph nodes (N0) or
to distant sites (M0).
IIB T2b The cancer is on the outer
N0 surface of or has grown into
M0 other nearby pelvic organs
such as the bladder, the
sigmoid colon, or the rectum
(T2b). It has not spread to
nearby lymph nodes (N0) or to
distant sites (M0).
IIIC T3c The cancer is in one or both
N0 or N1 ovaries or fallopian tubes, or
M0 there is primary peritoneal
cancer and it has spread or

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grown into organs outside the

pelvis. The deposits of cancer
are larger than 2 cm (about
3/4 inch) across and may be
on the outside (the capsule) of
the liver or spleen (T3c).
It may or may not have spread
to the retroperitoneal lymph
nodes (N0 or N1), but it has
not spread to the inside of the
liver or spleen or to distant
sites (M0).
IVA Any T Cancer cells are found in the
Any N fluid around the lungs (called a
M1a malignant pleural effusion)
with no other areas of cancer
spread such as the liver,
spleen, intestine, or lymph
nodes outside the abdomen
(M1a).

IVB Any T The cancer has spread to the

Any N inside of the spleen or liver, to
M1b lymph nodes other than the
retroperitoneal lymph nodes,
and/or to other organs or
tissues outside the peritoneal
cavity such as the lungs and
bones (M1b).

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b. ETIOLOGY
Non-Modifiable-Risk Factors
o Age (45 y/o and up)
o Hereditary (Family Cancer Hx)

Modifiable-Risk Factors
o Obesity
o Infertility
o Alcohol Abuse
o Nulligravida

c. INCIDENCE
According to American Cancer Society in 2019, about 22,530 women will receive a new
diagnosis of ovarian cancer and 13,980 women will die from ovarian cancer. Ovarian cancer
ranks fifth in cancer deaths among women, accounting for more deaths than any other cancer of
the female reproductive system. A woman's risk of getting ovarian cancer during her lifetime is
about 1 in 78. Her lifetime chance of dying from ovarian cancer is about 1 in 108.

According to Department of Health Philippines, cancer of the ovary is 12th overall, and
ranks 5th among females. An estimated 2,032 cases will occur in 1998. Incidence increase
starting at age 40. In 2002, An article in National Center for Biotechnology Information said that
ovarian cancer is the second most common gynecological cancer worldwide and the sixth most
common cancer in women overall. The ovarian cancer incidence rate of Philippine residents in
2002 was estimated at 11.5 per 100,000.

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d. SIGNS AND SYMPTOMS

The most common symptoms of ovarian cancer include:
 Bloating
 Pelvic or abdominal (belly) pain
 Trouble eating or feeling full quickly
 Urinary Frequency

Others symptoms of ovarian cancer can include:

 Fatigue (extreme tiredness)
 Back pain
 Pain during sex
 Ascites

III. PATIENT’S DATA

a.
Patient’s name: Patient Ova
Age: 46
Date of Birth: February 27, 1972
Sex: Female
Marital Status: Married
Nationality: Filipino
Occupation: Housewife
Religion: Roman Catholic
Address: Macabebe, Pampanga

B. NURSING HISTORY
i. CHIEF COMPLAINT
“Sobrang sakit ng tiyan ko at napansin ko na lumalaki itong tiyan ko” as verbalized by the
patient.

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ii. PRESENT HISTORY

Patient Ova was admitted at a tertiary hospital in Macabebe, Pampanga at 6:50 in
the evening of November 25, 2018 with complaints of abdominal pain and enlargement.

Patient Ova was apparently feeling well until late July 2018. Accordingly, she
occasionally experienced sharp right iliac pain that particular month. Despite her condition,
she never sought consultation believing that the pain would go away as she had been
dosing herself with Mefenamic Acid whenever the pain exists. In addition, she claimed that
she has not noted any changes in bladder and bowel movements. Aside from the complaint
of rapid abdominal enlargement that start 4 months ago before she was admitted, she
further claimed to have experienced amenorrhea, weight loss, anorexia, and nausea and
vomiting.

Furthermore, last October, she observed that the pain intensifies when her abdomen
gets exposed to cold. She experiences moderate to severe pain with an interval of about
10-30 minutes daily up to the date of consultation. At most parts of the day, she tolerates
mild-moderate pain and does not allow it to interfere with her ADLs.

3 days prior to admission, she decided to consult a physician because she was
suffering from unbearable abdominal pain. According to her, she suffers from an on and off
sharp stabbing pain in the right iliac region of the abdomen that is localized only to the right
side of her abdomen. She describes her pain to be 8 out of 10. She mentioned that the pain is
usually aggravated by a change in position – usually when she turns to the side when originally
on supine. The doctor ordered an abdominal ultrasound and they had found out that there is a
large intra-abdominal mass predominantly solid, to consider an ovarian tumor. A (+) moderate
ascites is also noted.
Upon admission, her condition persisted and with it, she saw her abdomen enlarge until
it eventually appeared like a visible elbow-like firm in the right iliac region of the abdomen.

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iii. PAST HISTORY

The patient claimed that she doesn’t have allergies. She also stated that she only had
chickenpox when she was in 10th grade.

iv. HEREDO-FAMILIAL HISTORY

Patient admitted that there are hereditary or familial origins of the disease in their
family. She stated that an aunt of hers, particularly her mother’s sister and another relative
were diagnosed with breast cancer. Meanwhile, she revealed that her father has a history of
hypertension. Patient stated that she has fear of dying with cancer so she decided to go on a
surgery called TAHBSO.

v. OB HISTORY
Surgical history reveals that her two (2) children were both delivered Cesarean Section,
as stated by the patient herself. At present, her GTPAL Score is G2T2P2A0L2.Her latest
delivery was last February 2000.

vi. NUTRITIONAL STATUS

Patient Ova was found to have had a good lifestyle. She has been maintaining a
healthy and balanced diet. In support, her husband said, “As to her lifestyle, wala akong
masabi. Kumakain siya ng prutas, gulay, at konting karne. The patient admitted that this past
month, she had lost her appetite, she insisted that she suddenly feels full even though she
didn’t even finished half of her meal. She also noticed that she had weight loss because
when she was admitted they got her weight and it dropped from 54 to 48kg.

vii. IMMUNIZATION HISTORY

Patient Ova stated that she didn’t have any immunization for the past 5 to 10 years.

viii. PHYSICAL EXAMINATION (upon admission)

a. General Survey

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Patient Ova is a petite young woman of 46. She stands at about 5 feet tall and she
weighed in at 48 kilograms. She appears irritable, weak, with facial grimace. Abdominal pain
and enlargement is noted.

VITAL SIGNS (upon admission)

Vital Signs Result Analysis
Temperature 36.5oC Normal
Pulse Rate 110bpm Tachycardia
Respiratory Rate 30cpm Tachypnea
Blood Pressure 120/80mmHg Normal

b. Integument Skin :
- (-) hyperpigmentation, no pallor and
generalized scaliness, nails without
clubbing or cyanosis.
c. Head -symmetrical, smooth, firm
-(-)lesions on the scalp
-normocephalic
d. Eyes -symmetrical blinking
-bulbar conjunctiva clear with tiny
vessels visible
-non-tender lacrimal apparatus
e. Ears -(-)discharges on external ear
-(-)tenderness
f. Nose -(-)nasal discharges
-pink and moist mucosa with no
lesions
-(-)non-tender nasal sinuses
-sinuses clear upon illumination

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g. Mouth and Throat -(-)hoarseness

-moist lips
-(+) pale lips
-tonsils not enlarged
h. Neck -(+) full ROM
-smooth, firm and non-tender thyroid
-(-)cervical lymph nodes enlargements
i. Breast and Axillary -(-)skin lesions, no dimpling; non-
tender on palpation, no
palpable masses or lumps. No
discharge.
-(-) axillary lymph nodes enlargement
j. Respiratory - no abnormal breath sounds
(+) tachypnea AEB RR of 30cpm
k. Cardiovascular - radial pulse of 110 bpm
-normal heart sounds
-regular rate, normal rhythm
l. Abdomen - (+)abdominal enlargement
-(+)abdominal pain (pain scale of
8/10)
m. Urinary -(-) bladder distention

n. Musculoskeletal -full ROM of upper extremities

-less lower extremity movement due
to incision site pain
o. Hematologic -(-) bleeding
-(-) bruising
p. Endocrine -no excessive sweating
-heat and cold tolerance

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C.GORDON’S FUNCTIONAL HEALTH PATTERN

PATTERN BEFORE DURING ANALYSIS
HOSPITALIZATION HOPITALIZATION
Health Perception “Diko pinapansin pag “Akala ko wala lang The patient is still in
may sumasakit sa tiyan yung sakit na denial phase due to
ko, umiinom nalang nararamdaman ko her sudden illness.
ako ng mefenamic para noon, yun pala may
mawala yung sakit.” As sakit na pala ako.” As
verbalized by the verbalized by the
patient. patient.
Nutritional She eats 3 times a day She has lack of Due to her illness.
but she eats green appetite.
leafy vegetables but
only consumes half of
the food in her plate
because she always
feels full.
Elimination She urinates 3 to 5 She has no bowel and Her condition does not
times a day with bladder problems. affect her condition.
>30ml/hr. She also
defecates once a day.
Activity/ Exercise Her daily routine is She has ROM For faster recovery
doing her household exercises, and walking and to have proper
chores such as as tolerated. circulation.
cooking, cleaning the
house, then her
exercise is jogging
around their house.

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Sleep/Rest She sleeps around 10 She has more time to

pm after her household sleep and rest because
chores and her favorite she is just in the
television show is hospital for her post-op
done. And wake up at recovery.
6am. -usually naps 4 hours
in the afternoon.
Sexuality/Reproductive The patient is a mother She stated that she is The patient is being
of 2 children. contented of having 2 optimistic rather than
children even though, die with cancer and
she had TAHBSO. not being cured.
Cognitive/Perceptual The patient is able to The patient has facial Due to S/P TAHBSO
comprehend and grimace due to pain felt
answer the questions in her incision site.
before admitting to
hospital.
Coping-stress The patient stated that The patient is able to Due to her family’s
tolerance whenever she felt pain cooperate with medical support
in her abdomen she advices
just do her ADL’s.

C. COURSE IN THE WARD

Day 1
Patient Ova was admitted in the hospital last November 25, 2018 for further exam. CBC test
was ordered by the doctor. Vital signs were taken: Patient’s appears to have (+) tachycardia,
tachypnea and weakness is also noted. IVF of D5LRS1Lx 15-16gtts/min was also given infused @left
metacarpal vein.

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Day 2
Patient Ova doctor ordered Chest x-ray and Tumor Marker biopsy.

IV. ANATOMY AND PHYSIOLOGY

Ovaries

The ovaries are the female gonads. Paired ovals, they are each about 2 to 3 cm in length,
about the size of an almond. The ovaries are located within the pelvic cavity, and are supported by
the mesovarium, an extension of the peritoneum that connects the ovaries to the broad ligament.
Extending from the mesovarium itself is the suspensory ligament that contains the ovarian blood and
lymph vessels. Finally, the ovary itself is attached to the uterus via the ovarian ligament.
The ovary comprises an outer covering of cuboidal epithelium called the ovarian surface
epithelium that is superficial to a dense connective tissue covering called the tunica albuginea.
Beneath the tunica albuginea is the cortex, or outer portion, of the organ. The cortex is composed of a
tissue framework called the ovarian stroma that forms the bulk of the adult ovary. Oocytes develop
within the outer layer of this stroma, each surrounded by supporting cells. This grouping of an oocyte
and its supporting cells is called a follicle.

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V. PATHOPHYSIOLOGY

Modifiable Risk-factors
Non- Modifiable Risk-factors
 n/a
 Age (45 y/o and up)
 Hereditary (Family
Cancer Hx)

Cell Division

Cancer

Malfunction in
gonadogenesis

Immature formation of germ cells

Malignant transformation of the germ cells

Enlargement of malignant
tumor of the right ovary

Hormonal  Uterine  Intra-abdominal

Imbalances contractility pressure

 abdominal
size

Amenorrhea Abdominal
Pain

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Anorexia Feeling of Nausea and Weight loss Frequency of

Fullness Vomiting Urination

Ovarian
Cancer

TAHBSO

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VI. LABORATORY EXAMS

Procedure/ Indications Normal Result Nursing Responsibilities

Date Values/Findings (pre,intra,post)
In diagnosing ovarian Pre:
Complete cancer, blood is WBC: Leukocytes -Assist the client when having CBC
Blood Count taken and studied to exam.
see if the different Intra:
types of blood cells Reference Range: Initial: 5.39x10^9/L -Provide instructions to the client such
Novermber 25, are normal in number 5.0-10.0x10^9/L Repeat:11.66x10^9/L as deeply inhale when the needle is
28, 2019 and appearance. The inserted through her artery.
results show how Post:
well the organs are WBC: Neutrophils -Inform the patient that the result will
working and may Reference Range: be given to her as soon as it is done.
suggest whether one 0.50-0.70 Initial: 0.803
has cancer and if it Repeat: 0.75
has spread

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Procedure/ Indications Normal Result Nursing Responsibilities

Date Values/Findings (pre,intra,post)

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Urinalysis A urinalysis is simply Pre:

November an analysis of the Color: light yellow Color: dark-yellow -Explain the procedure to the
28,2018 urine. It is a very amber Appearance: turbid patient –what it is for and how it
common test that can Appearance:clear Specific gravity: 1.020 is done such as catch the
be performed in Specific Gravity:1.010- pH: 6.0 midstream urine.
many healthcare 1.030 Bilirubin: positive one Intra:
settings including pH:4.5-8 Bacteria: few -Provide privacy
doctors' offices, Blirubin:negative Epithelial cells: many Post:
urgent care facilities, Bacteria:not seen -Inform the patient that a written report
laboratories, and Epithelial cells:few of the urinalysis results will be
hospitals.Urine can forwarded to the referring physician
be evaluated by its and the physician will discuss the test
physical appearance results.
(color, cloudiness,
odor, clarity), or
macroscopic analysis

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DIAGNOSTIC EXAMS
Procedure/ Indications Normal Result Nursing Responsibilities
Date Values/Findings (pre,intra,post)
Ultrasound is often Pre:
Abdominal UTZ the first test done if a There must be no - Large intra-abdominal -Reiterate to the patient who will
November problem with the tumors present and no mass predominantly perform the test and where and
22,2018 ovaries is suspected. enlargement in solid, to consider an when it will be performed
It can be useful abdominal organs. ovarian tumor. -Inform the patient that there will be
finding an ovarian minimal discomfort during the test.
tumor and seeing if it - Moderate ascites. Intra:
is a solid mass -Accompany patient to the ultrasound
(tumor) or a fluid- - Normal liver, gallbladder, room
filled cyst. It can also CBD, pancreas, kidneys -Provide privacy
be used to get a and urinary bladder. Post:
better look at the -Inform the patient that a written report
ovary to see how big of the ultrasound results will be
it is and how it looks forwarded to the referring physician
inside and the physician will discuss the test
results

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Procedure/ Indications Normal Result Nursing Responsibilities

Date Values/Findings (pre,intra,post)
Chest In the diagnosis of No active lung Pre:
X-ray ovarian cancer, this infiltrations, Heart is No active lung infiltrations. -Inform the patient who will perform
November 26, procedure is being not enlarged, the test and where and when it will
2018 done to determine Pulmonary vascular -Heart is not enlarged. be performed
whether ovarian markings are within Intra:
cancer has normal range. -Pulmonary vascular -Instruct the client when to do purse-
spread(metastasized) markings are within lip deep breathing.
to the lungs. This normal range. -Provide privacy
spread may cause Post:
one or more tumors -Both costophrenics sulci -Inform the patient that results will be
in the lungs and most and hemi diaphragm are forwarded to the referring physician
often causes fluid to intact. and the physician will discuss the test
collect around the results where you can ask your
lungs. -Visualized osseous questions about the result.
structures are
unremarkable.

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Procedure/ Indications Normal Result Nursing Responsibilities

Date Values/Findings (pre,intra,post)
Tumor Marker For ovarian cancer, Pre:
Testing (CA- the blood may be Reference Range: Result: 328.50 U/mL -Ask the patient for any questions
125) tested for several 0 – 32.2 U/mL before taking the blood exam.
November tumour markers, Intra:
26,2018 including CA-125. -Provide privacy
CA-125 is a Post:
substance found in -Inform the patient that a written report
ovarian cancer cells of the ultrasound results will be
and in some normal forwarded to the referring physician
tissues. CA-125 can and the physician will discuss the test
also help tell whether results
the cancer has
spread.

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Procedure/ Indications Normal Result Nursing Responsibilities

Date Values/Findings (pre,intra,post)
Biopsy The way to determine Pre:
November for certain if a growth No abnormal cells Malignancy” of the -Secure inform consent of the patient.
27,2018 is cancer is to must be present. sample was confirmed Intra:
remove a sample of -Maintain a sterile technique during
the growth from the the procedure.
suspicious area and Post:
examine it under a -Monitor VS of the patient.
microscope.

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VII. DRUG STUDY

Generic & Brand Classification Action Indication Dosage Nursing
Name Responsibilities
Elevates the serum Ferrous sulfate
Ferrous sulfate Iron Supplement iron concentration, helps in increasing 1 capsule OD PO  Monitor
(Feosol) which that helps to the levels of hgb as hemoglobin level,
form Hgb in the it replaces iron hematocrit and
blood. stores needed for reticulocyte count
red blood cell during therapy.
development,  Give liquid
energy, and oxygen preparations
transport utilization. through plastic
straw to avoid
discoloration of
tooth enamel.
 Instruct patient to
take tablet with
juice (preferably
orange juice) but

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not with milk,

antacids, and
caffeine as they
interfere with the
absorption.

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Generic & Brand Classification Action Indication Dosage Nursing

Name Responsibilities
Bactericidal: Inhibits It is indicated for 2g q6o
Cefoxtin Sodium Antibiotic synthesis of infections such as intravenously  Identify onset,
(Mefoxin) 2ndGen bacterial cell wal, intra-abdominal after negative severity, location, and
Cephalosphorin causing cell death. infections, sensitivity test 1 other association
gynecologic hour prior to OR factors
infections,  Ask patient if he
septicemia, and also is allergic to penicillin
as a perioperative or cephalosporins
prophylaxis. before administering.
Infection is common  Advise patient to
after surgery, thus report any adverse
this antibiotic was reactions and signs
ordered to combat and symptoms of
possibilities of superinfection.
acquiring such.  Instruct patient
to report severe
diarrhea, difficulty of

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breathing, unusual
tiredness or fatigue,
and pain at injection
site.

Generic & Brand Classification Action Indication Dosage Nursing

Name Responsibilities
Anti-inflammatory It is indicated for 30 mg
Ketorolac (Toradol) NSAID and analgesic short-term intravenously  influenza-like
activity: inhibits management of pain every six hours Assess pain (note
prostaglandins and (up to 5 days) for four doses type, location, and
leukotriene intensity) prior to
synthesis. and 1-2 hr following
administration
 Caution patient
to avoid concurrent
use of alcohol,
aspirin, NSAIDs,
acetaminophen, or
other OTC

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medications without
consulting health
care professional.
 Advise patient to
consult if rash,
itching, visual
disturbances,
tinnitus, weight
gain, persistent
headache, or
syndromes
(chills,fever,muscles
aches, pain) occur.

Generic & Brand Classification Action Indication Dosage Nursing

Name Responsibilities
Binds to opioid It is indicated for 30 mg
Tramadol (Ultram) Centrally Acting recepors and inhibits Right lower intravenously  Reassess
analgesic thereuptake of abdominal pain was every six hours patient’s pain level
norepinephrine and manifested by the for two doses at least 30 minutes

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serotonin. patient, partly after administration.

attributed to the  Assess bowel
direct pressure from function and need
the tumor in her right for stool softeners or
ovary. The presence laxatives.
of the tumor irritates  Monitor I and O:
the nerve endings, check for
causing decreasing output
prostaglandin as this may indicate
stimulation resulting urinary retention.
to the sensation of  Instruct that
pain. drowsiness,
dizziness and
confusion may
occur.

Generic & Brand Classification Action Indication Dosage Nursing

Name Responsibilities
It accelerates gastric A prophylaxis of 10 mg

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Metoclopramide Anti-emetic emptying and postoperative intravenously  Report

(Apo-Metoclop) intestinal transit nausea and vomiting every six hours immediately the
thereby reducing the PRN onset of
possibility of restlessness,
nausea and involuntary
vomiting. movements, facial
grimacing, rigidity,
or tremors.
 Monitor BP
carefully during IV
administration.
 WARNING:
Keep
diphenhydramine
injection readily
available in case
extrapyramidal
reactions occur (50
mg IM).


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FLUIDS
Dextrose 5% in Lactated Ringer’s Solution

Fluid Description and Purpose Nursing Interventions or

Considerations
Dextrose 5% D5LRS contains sodium, - Calculate and maintain appropriate
in Lactated chloride, potassium, calcium flow rate. Avoid hypervolemia.
Ringer’s and lactate. Lactate is - Do not administer unless solution is
Solution x 16 metabolized in the liver to clear and container is undamaged.
hours form bicarbonate saline and - Discard unused portion.
balanced electrolyte - Properly label the IV Fluid.
solution commonly are used - Observe aseptic technique when
to restore vascular volume, changing IV fluid.
particularly after trauma or
surgery. It is a hypertonic
solution that has an
effective osmolality greater
than the body fluids. This
pulls the fluid into the
vascular compartments by
osmosis resulting in an
increase in vascular
volume.It also serves as a
route for administration for
intravenous medication
especially if the patient is for
preoperative

4 D5LRS bottles were given preoperatively to prevent electrolyte imbalance and to serve as
fluid and caloric supply for the patient. It also serves as a route for administration for intravenous
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medication especially if the patient is for preoperative. Thereafter, 3 bottles of the same IVF were
administered. LRS contains sodium, chloride, potassium, calcium and lactate. Lactate is metabolized
in the liver to form bicarbonate saline and balanced electrolyte solution to restore vascular volume,
particularly after surgery.

Plain Normal Saline Solution

Fluid Description and Purpose Nursing Interventions or

Considerations
Plain Normal Normal Saline is a sterile, - Calculate and maintain appropriate
Saline non-pyrogenic solution for flow rate. Avoid hypervolemia.
Solution x 24 fluid and electrolyte - Do not administer unless solution is
hours KVO replenishment. It contains clear and container is undamaged.
no antimicrobial agents.It is - Discard unused portion.
indicated as a source of - Properly label the IV Fluid.
water and electrolytes. It is - Observe aseptic technique when
also for fluid and electrolyte changing IV fluid
replenishment as well as
for medication
administration.

1 bottle of PNSS was administered preoperatively after all the preceding D 5LRS bottles
were consumed. Conversely, the patient was given another bottle of PNSS x KVO as a postoperative
IVF solution. The patient responded well to the treatment and did not manifest any signs of
dehydration of electrolyte imbalances. The patient had an effective fluid balance during the entire
therapy.

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SURGERY
Description of Indication Nursing Responsibilites
Procedure/Date (PRE, INTRA, POST)
Total Abdominal This surgery allows for the Pre:
Hysterectomy Bilateral removal of the mass as - Reduce the anxiety of the
Salpingo Oophorectomy – possible. To reduce the risk patient and their relatives by
November 28, 2018 of metastasis, the surgeon orientation of the
removes surrounding organs environment.
Anesthesia used: General as well. Hence, even though - Informed consent
Position of client: the tumour may have started - Check results of lab
Litothomy on the ovary, that the uterus - Monitor VS
Incision: Pfannensteil and tubes are also removed - Assess I and O
incision - Examine level of anxiety
-Teach - Bowel preparation
-Light dinner, NPO
-Cleansing enema
- Prophylactic antibiotics
- IV fluids

Intra:
-Maintain aseptic, controlled
environment.
-Ready the equipment, and
supplies for individualized
patient care.
-Position the patient:
function alignment,
exposure of surgical site.
-Complete intraoperative

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documentation.

Post:
-Transport to PACU
-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)

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VIII. NURSING CARE PLAN

PROBLEM #1: Imbalanced Nutrition: Less than body requirements related to decreased appetite as evidenced by weakness and a
marked decrease in body weight
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Risk for ST: After 4 hours >Monitor daily food >Daily food intake ST: The patient
“Wala akong gana ineffective tissue of nursing intake and explore identifies nutritional shall verbalized
kumain” as perfusion related interventions, the attitudes toward eating strengths or understanding the
verbalized by the to surgical patient will and food. deficiencies and many need of adequate
patient. incision 2o to verbalize psychological, intake.
TAHBSO understanding the physiological, and
Objective: need of adequate cultural factors LT: The patient
>consumes 50% of intake. determine the types, performed the
meals served LT: After 2-3 days amount, and patient shall
of nursing appropriateness of have demonstrat
>weight loss of interventions, the food consumed. ed behaviors,
about 6 kilograms patient >Ascertain amount of >If these lifestyle changes
over a month period will demonstrates recent weight loss. measurements fall to recover and/or
(from 54 kg to 48 kg behaviors, Weigh daily or as below minimum keep appropriate
as claimed) lifestyle changes indicated. standards, client’s weight.

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to recover and/or chief source of stored

keep appropriate energy (fat tissue) is
weight. depleted.
>Observe for weakness, >Helps in
pallor, delayed wound identification of
healing, and brittleness protein-calorie
of nails. malnutrition,
especially when
weight is less than
normal.
>Promote a pleasant >Eating is in part a
environment for eating social event, and
with company if appetite can improve
possible. with increased
socialization.
>Offer small frequent >Decreased gastric
feedings as indicated. motility causes client
to feel full and
reduces intake.
Offering small

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frequent feedings may

compensate for the
decreased
consumption during
major meals of the
day.
>Provide balanced diet >Adjustments may be
with individually needed to deal with
appropriate protein, the body’s decreased
complex carbohydrates, ability to process
and calories. protein, as well as
decreased metabolic
rate and levels of
>Administer activity.
vitamin/mineral >Supplements can
supplements play an important role
(multivitamin + ferrous in maintaining
sulfate) in between adequate caloric and
meals as ordered. protein intake.
>Encourage use of >Promotes sense of

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relaxation techniques, well-being and may

moderate exercise improve appetite.
before meals, with Metabolic tissue
adequate fluid intake. needs are increased
by fluids.

PROBLEM #2: Acute pain related to surgical incision

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
S: “masakit ang tahi Acute pain ST: After 2-3 hours -Assess the patient’s >To identify and ST: The patient’s
ko pag gumagalaw” related to surgical of nursing perception, level of assess the different pain scale shall
as verbalized by the incision interventions, the understanding and nursing interventions have decreased
patient. patient will needs. to be done from 8/10 to 2/10
manifest a or lower.
O: decrease in pain
The patient scale from 8/10 to -Obtain patient’s VS >To assess the
manifested the ff: 2/10 or lower. including the pain scale effectiveness of
-Pain scale of 8/10 and help with nursing interventions
-facial grimace upon administering analgesics and obtain baseline for
moving LT: After 1-2 days as indicated future comparison; to LT: The patient
of nursing alleviate pain. shall be able to

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interventions, The move and do

patient will be able exercises.
to move and do -Encourage deep >To inhibit pain
exercises. breathing

-Encourage verbal report >Because pain is

. during and after each highly subjective
nursing intervention

-Teach patient >To divert attention

diversional activities. from pain and to
determine degree of
fatigue.

>Administer analgesics >to alleviate pain

as prescribed by the
physician.

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PROBLEM #3: Risk for infection related to immunosuppression

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
S: O Risk for infection ST: After 1-2 >Examine general >Provides information ST: The patient
related to hours of nursing condition and laboratory regarding external and shall have
O: The patient immunosuppressi interventions, the results. internal problems that verbalized
manifested the ff: on patient will may be associated understanding in
> appears weak verbalize with the presence of ways to prevent
>status post understanding in infection. the risk of having
TAHBSO ways to prevent >Assess wound >Red swollen draining infection.
>leukocyte and the risk of having appearance. incision is indicative of
neutrophil count infection. infection.
above normal >Check tension of >Prevent tape skin
WBC: Leukocytes dressings. Apply tape at abrasions. Covering

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Initial:11.66x10^9/L LT: After 2-4 days the outer margin of most of the area using LT: After 2-4 days
WBC: Neutrophils of nursing dressing of incision. tape can of nursing
Initial: 0.75 interventions, the Avoid wrapping or impair/occlude interventions, the
client will be able covering the affected circulation to wound. client the shall
>presence of pus to participate in area with tape. have participated
cells and bacteria in interventions to >Perform aseptic >This is to avoid in interventions to
the urine (as reduce risk of dressing changes. Keep introducing infectious reduce risk of
indicated in the infection. wounds clean and dry. organisms to the site infection.
urinalysis result) thus preventing further
spread of infection.
>Cleanse wound and >Aids in removal of
skin surface (if needed) drainage/exudates (if
with NSS and betadine present) and in the
solution. reduction of skin
contaminants.
>Stress to avoid >Rubbing and
vigorous rubbing and scratching can cause
scratching and to pat further injury and
skin instead of rubbing delay healing. It helps
when itchiness can no prevent skin

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longer be tolerated. friction/trauma to

sensitive tissues.
>Emphasize importance >Hand hygiene is an
of frequent hand important method in
hygiene and also to the reducing spread of
family members. microorganisms,
thereby lessening
occurrence of
contamination.

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IX. DISCHARGE PLANNING

Medications:
Follow the schedule of medication
Clindamycin
- It is important to take this medication on time and to finish all of them as prescribed even
when improvement in condition is observed prior to the prescribed duration of intake.
developing resistance to the drug Non-compliance may predispose the bacteria to. One
capsule is taken three times a day, at 8 am and 6 pm, or before or after breakfast and
dinner.

Naproxen Sodium
- Advise to take this medication with a full glass of water and to remain in an upright position
for 15–30min after administration. It may be taken with food or milk to prevent nausea.
Explain that this is used to decrease swelling and pain or fever. One tablet should be taken
three times a day, after breakfast, lunch, and dinner.

Bisacodyl suppository
- This is used for occasional constipation. Inform the patient that is for rectal use only.
Instruct to watch out for abdominal discomfort, faintness, feeling of rectal burning, and mild
cramps.
Exercise:
Instruct patient on the following:
-Exercise for atleast 30 minutes daily for proper perfusion especially at the surgical site for
faster wound healing.
-Avoid lifting heavy objects because it may open the surgical incision site.

Treatment:
 Wound care

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-Keep the wound clean and dry and avoid touching the wound. Regularly clean it with
betadine and change the dressing. Wash hands before and after handling the wound.
-Change the bandages any time they get wet or dirty.
-Inspect the incision site every day for redness, drainage, swelling, or separation of the skin.
-Advise the patient to avoid use oils, powders, lotions, or creams on the incision.

Health Teaching:
Teach the patient and family about the treatment plan including the need to 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.

Out-Patient Follow-Up Care:

 Advise patient to visit hospital or a physician when:
A. Severe pain that does not diminish after pain management is experienced.
B. Fever, swelling and purulent discharge at the incision area are observed.

 Inform the patient to come back at the OPD after a week from her discharge for follow-
up check-up.

Diet:
Encourage patient on the following:
 The inclusion of protein rich foods in her diet such as lean meat, egg and fish to
promote wound healing.
 An increased intake of vitamin C rich foods such as oranges to boost immunity and
prevent infection.
 Increase oral fluid intake up to 3 liters per day.

Spirituality:

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 Ask the patient what is her preferred way of worshiping God such as going to mass
every Sundays and refer her and her family to the nearest church where that can go and
attend mass.

X. IMPLICATIONS OF THE CASE STUDY TO THE FF. AREA:

a. Nursing Research
This study should be continuously reviewed so that updates and improvement will be recognized
and be the way for decreasing complications during the operation. Also, there must be the use of
rigorous research strategies in providing effective outcomes. In that way, results of research will be
free from scientific misconduct.

a. Nursing Education
Knowledge about this study is beneficial to student nurses, so that they will know about the
etiologies and what signs and symptoms of the disease that led into a TAHBSO operation. Together
with their Clinical instructor, they would be able to give better health teachings to patients.

b. Nursing Practice
Since the Total Abdominal Hysterectomy Bilateral Salpingo-oophorectomy are more common
know a days, it is important that nursing professionals be knowledgeable about the procedure and the
instruments that are commonly used. The aim of this study is to explore the nurse’s role in relation to
the needs of women undergoing hysterectomy.

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XI. BIBLIOGRAPHY

Books:
AST. Surgical Technology for the Surgical Technologist: A Positive Care Approach. 3rd ed. Stanford:
Example Product Manufacturer, 2009.
Doenges, M. et. El. Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales. 10th
ed. Philadelphia: F.A. Davis Company, 2006.
Fairchild, S. Perioperative Nursing: Principles and Practice. Canada: Jonesand Barlett Publishers,
2008.
Karch, A. Nursing Drug Guide. 1st ed. Rochester, New York: Lippincott Williams & Wilkins, 2007.

Internet:
Key Statistics for Ovarian Cancer. (n.d.). Retrieved from https://www.cancer.org/cancer/ovarian-
cancer/about/key-statistics.html

(n.d.). Retrieved from https://www.doh.gov.ph/Health-Advisory/Ovarian-Cancer

Redaniel, M. T., Laudico, A., Mirasol-Lumague, M. R., Gondos, A., Uy, G. L., Toral, J. A., . . .
Brenner, H. (2009). Ovarian cancer survival population differences: A "high resolution study"
comparing Philippine residents, and Filipino-Americans and Caucasians living in the US. BMC
Cancer,9(1). doi:10.1186/1471-2407-9-340

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