61996341 case-study-myoma

77
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 - Physical Assessment & Nursing Care Plan Alpecho, Kathreen Mae - Drug Study Alunday, Radigundee - Medical and Surgical Management Awat, Cassandra Von - Etiology or Risk Factors Barzaga, Cristine - Diagnostic Procedure Cabarrubias, Alvin Ray D. -Gordon’s Health Pattern, Pathophysiology, Statement of Nursing Diagnosis & Nursing Care Plan 1

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Page 1: 61996341 case-study-myoma

PERPETUAL HELP COLLEGE OF MANILA

1240 V. Concepcion St., Sampaloc, Manila

Submitted to:

Mrs. Josephine Dela Cruz, RNClinical Instructor

Submitted by:

Abordo, Nena Bell Jill - Physical Assessment & Nursing Care PlanAlpecho, Kathreen Mae - Drug StudyAlunday, Radigundee - Medical and Surgical ManagementAwat, Cassandra Von - Etiology or Risk FactorsBarzaga, Cristine - Diagnostic ProcedureCabarrubias, Alvin Ray D. -Gordon’s Health Pattern, Pathophysiology,

Statement of Nursing Diagnosis & Nursing Care Plan Canlas, Veronica - General Objectives, Nursing Care Plan & Discharge PlanChangco, Mariaelis - Anatomy & PhysiologyCommendador, Maritonee - Client’s Data & Health HistoryCorpuz, Nichael Bonn - Introduction

PERPETUAL HELP COLLEGE OF MANILA

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Format for Case Presentation

I. Client’s Data

II. Health History• Family Health History

i. Maternal Health Historyii. Paternal Health History

• History of Past and Present Illness• Risk Factors Associated with Disease

i. Non- modifiable Factorsii. Modifiable Factors

III. Physical Assessment• Subjective- Gordon’s Health Pattern• Objective- Kozier’s reference

IV. Definition of Disease/Introduction

V. Pathophysiology of the Disease

VI. Anatomy and Physiology

VII. Diagnostic Procedures done to Client

VIII. Medical/Surgical Management done

IX. Drug Study

X. Statement of nursing problems/nursing diagnosis based on grouped data(Gordon’s)

XI. Priority Nursing Problem/Nursing Care Plan• Actual• Potential

XII. Discharge Plan

PERPETUAL HELP COLLEGE OF MANILA

Table of Contents

I. Client’s Data………………………………………….………..… 1

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II. Health History…………………………………………………… 2• Family Health History…………………………………………… 2

iii. Maternal Health History…………………………….. 2iv. Paternal Health History……………………………… 2

• History of Past and Present Illness………………….…....… 2• Risk Factors Associated with Disease……………………… 3

iii. Non- modifiable Factors……………………………… 3iv. Modifiable Factors…………………………………….. 3

III. Physical Assessment……………………………………………. 5• Subjective- Gordon’s Health Pattern……………………….. 5• Objective- Kozier’s reference…………….……………..…… 9

IV. Definition of Disease/Introduction…………………..…… 32

V. Pathophysiology of the Disease……………………………… 33

VI. Anatomy and Physiology……………………………….………. 34

VII. Diagnostic Procedures done to Client………………….…. 41

VIII. Medical/Surgical Management done……………….………. 46

IX. Drug Study………………………………………….……………. 50

X. Statement of nursing problems/nursing diagnosis based on grouped data(Gordon’s)…………………...………. 62

XI. Priority Nursing Problem/Nursing Care Plan………...…... 63• Actual• Potential

XII. Discharge Plan…………………………………………………… 64

General Objectives: 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

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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

Develop good Nurse-Patient relationship

Specific Objectives:In order to meet the general objective of the study, the ff intended to be done:

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

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

patients with myoma

I. Client’s 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

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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            symptom- dysmenorrheal

OB score

G1 2000               male               NSD           del. Midwife (-) complication

G2 2006              female            NSD           del. Midwife (-) complication

 G3 2007               preterm          (7mos)

G4 2008               female            NSD            del. Midwife (-) complication

No. of sexual partner – 1 partner

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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

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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 Diseasev. 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

• 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.

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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- Gordon’s Health Pattern

Health Patterns

Before HospitalizationDuring

Hospitalization Analysis

- Pt had abnormal uterine

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1. Health perception -

Health management

Pattern

bleeding for almost 4 days. Pt is a non smoker and a

occasional alcohol drinker. Pt have the family illness of

hypertension and diabetes. Mrs. D doesn’t have regular medical check-ups and only

seeks medical attention when the need arises. Whenever

she had headaches, she rest for a while and take

paracetamol when needed. Pt. perceived her menstrual cycle was regular until the

fourth day of excessive bleeding and presence of mass when she urinated.

- during her hospitalization,

she’s was rushed to the emergency room & a vaginal

myomectomy was done. after that

operation, she still feels weak

probably because of losing too much

blood. She’s anxious if the mass that was

taken is cancerous or not.

- 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 the one who always prepare

their food.

Patient’s WT 44.5 kgs HT 1.43 BMI 21.76 kg/m2

Normal BMI range:<18.5…………...underweight18.5-24.9………..healthy

- during her hospitalization, the

doctor ordered NPO until the third day wherein she was on soft diet.

- Normal eating pattern is at on the minimum of

3 times per day, depending upon metabolic

need and demands. Fluid intake is on the average of 8 to 10 glasses per

day.- She have to increase her

fluid intake. In terms of her

food intake and frequency,

There are no remarkable deviations

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25.0-29.9…………overweight30≥……………………obesity

3. Elimination Pattern

- Bowel Habits: Mrs. D defecates once a day with a

brownish stool.Bladder Habits: She voids 3-

5 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. D’s 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 she’s proud to say that it’s 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

sleep 7pm or 8pm at night and wakes up at 8 in the morning. When she don’t have anything to do after

lunch, he usually have a nap.

- during her hospitalization,

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 it’s benign or

- Based from Kozier

Fundamentals of Nursing, 8- 10 hours of

sleep is needed to have

an adequate rest and an environment

that is conducive to

health is necessary to

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malignant. 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. Cognitive-perceptual

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. Self-perception

and selfconcept pattern

- Patient described herself as a hardworking person. Sheclaimed her happiness andcontentment will be more felt

if only his illnesses were absent. Pt is contented to

have provided her family with good life.

- during in her hospitalization, she never think negative things

that will make her down while

recovering with her illness.

- pt is being a positive thinker despite of what

happened to her health

8. Role Relationship

- Patient described himself as a loyal wife to her husband

as well a responsible mother to her kids. Her husband

comes home every weekend

- during her hospitalization, her husband is aware of her

current situation.

- pt is still being a good mother

to her kids despite of her current health

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pattern from work as a contractual carpenter. She takes care of her kids and do the cooking and laundry form them. She

send them to school everyday.

She is worried about her kids if

they’re doing well without her. She is also concerned if

they’re eating well.

status.

9. Sexuality – Reproductive

pattern

- 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 doesn’t have any problem

with her sexual intercourse.

- 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 StressTolerance

- Defines stress as something that can make someone tired. Currently stressed because of current physical condition. Long term stressor include

financial problems, and short term stressor include the

problems in the community and family. Goes to

neighbors and friends to relieve stress and she shares

her problem them. Sometimes she brings her kids to shopping malls to stroll and in that way her

stress is relieved.

- during her hospitalization,

she doesn’t change her

perception toward her situation.

She’s aware that being hospitalized

is a stressful situation. She tries

to get well because she

misses her kids.

- Able to describe

general coping pattern and

effectiveness of the pattern in

terms of stress tolerance.

11.Value – Belief Pattern

- Patient is a Roman Catholic and goes to church on

Sundays with her kids and claims to pray everyday. She

values healthand sees it as a wealth.

- during her hospitalization,

there is no change with her religious life. She believes God will help her

- able to determine the

patterns of values and

beliefs(spiritual) or goals that

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Patient does not have any superstitious beliefs.

recover faster guides his choices and decisions.

.

• Objective- Kozier’s Reference

Vital signs

Vital signsNormal Actual

FindingsAnalysis Interpretation

Blood pressure 120/80 160/90

On the disease

process, any condition

that may affect the

cardiac output, blood

volume, blood viscosity

has direct effect on the

blood pressure.

The patient was in

distress during the

assessment.

(Kozier, B. (2004).

Fundamentals of

Nursing p. 510).

Cardiac output will often

affect the delivery of oxygen

to the cells of the body and

when the system or tissues

does not get the required

oxygen for the metabolic

process cellular function will

be altered.

Temperature 36.5-

37.5

39.4

Inflammation is a local,

nonspecific defensive

response of the tissues

to an injurious or

infectious agent. It is an

adaptive mechanism

that destroys or dilutes

Febrile

The rate of loss depends

primarily on the surface

temperature of the skin

which is intern a function of

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the injurious agent,

prevents further spread

of the injury, and

promotes the repair of

damaged tissue.

Patient has an

increased WBC count

of 12.3% (August 23,

2010)

(Kozier, B. (2004).

Fundamentals of

Nursing p. 634).

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.

Pulse rate 60-100 92

Normal Range

(Kozier, B. (2004).

Fundamentals of

Nursing p. 496).

Pulse wave represents the

stroke volume output or the

output or the amount for

blood that enters the

arteries with each

ventricular contraction.

Respiratory rate

16-20 24

Several factors that

increase respiratory

rate include stress and

increase environmental

temperature.

(Kozier, B. (2004).

Fundamentals of

Nursing p. 506).

The effectiveness of

respiration is important for

the uptake of oxygen from

the air into the blood and

release carbon dioxide from

the blood into expired air.

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SkinPARTS METHOD NORMAL

FINDINGSACTUAL

FINDINGSANALYSIS INTERPRETATION

Skin Inspection

Palpation

Skin color

varies from

light to deep

brown; from

ruddy pink to

light pink,

from yellow

overtimes to

olive.

Generally

uniform

except in

areas

exposed to

sun; areas of

lighter

pigmentation

(palms, lips

nail beds) in

dark skin

people.

No edema,

abrasions,

lesion.

Temperature

is uniform

and w/in

Fair

complexion

with dry and

flaky skin.

Pale in

appearance.

No edema,

abrasions,

lesion.

Temperature

is higher

than normal

range.

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

are due to localized

ischemia, a deficiency

in the blood supply to

the tissue.

Generalized edema is

most often an

indication of impaired

venous circulation and

in some cases reflects

cardiac dysfunction

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normal range 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

texture

- color is

highly

vascular&

pink in light

skinned

clients; dark

skinned

clients may

have brown

Convex,

smooth in

texture,

pallor,

capillary refill

is 4-5

seconds on

the hands.

Nail bed

color is pale

on both

lower and

upper

extremities.

Patient’s nail

beds are pale

may be due to

decreased

oxyhemoglobi

n level on the

blood.

Pallor may reflect poor

arterial circulation due

to diminished

circulating blood

volume.

(Fundamentals of

Nursing by Kozier,

p542)

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or black

pigmentation

in

longitudinal

streaks

with intact

epidermis on

tissue

surroundings

- blanch test-

prompt return

of pink or

usual color

(gen. <3 sec)

Head

PARTS METHODNORMAL FINDINGS

ACTUAL FINDINGS ANALYSIS INTERPRETATION

Hair Inspection

Palpation

Evenly

distributed hair

over the scalp

with thickness,

variable

amount of

body hair. No

infection or

infestation.

Hair is black,

thin and evenly

distributed over

the scalp. No

infection or

infestation

noted.

It is dry and

sticky.

Each hair

grows from a

single, live

follicle has its

own roots in

the

subcutaneous

tissue of the

skin. Oil

glands next to

hair follicle

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.

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provides gloss

and, to some

degree water

proofing of the

hair.

(Kozier, B.

(2004).

Fundamentals

of Nursing p.

541)

Scalp Inspection

Palpation

White, clean,

free from

masses, lumps

scars, lice, nits,

dandruff, and

lesions no area

of tenderness

Dry scalp.

Clean, free from

masses, lumps

scars, lice, nits,

dandruff, and

lesions no area

of tenderness

Normal Findings

Skull Inspection

Palpation

Rounded(

normocephalic)

& symmetrical,

with frontal,

parietal,

occipital,

prominences)

smooth,

uniform,

absence of

modules or

masses

Round

(normocephalic)

, smooth skull

contour.

Smooth,

absence of

nodules or

masses.

Normal

findings

(Fundamentals

of Nursing by

Kozier page

544.)

Normal findings

Eyes

PARTS METHODNORMAL FINDINGS

ACTUAL FINDINGS ANALYSIS INTERPRETATION

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Eyebrows Inspection Symmetrically

aligned.

Equally

distributed,

curled slightly

outward

Symmetricall

y aligned

and equal

movement.

Hair evenly

distributed.

Normal

findings.

(Kozier, B.

(2004).

Fundamentals

of Nursing p.

732).

Normal findings

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

discharge and

no

discoloration.

The lids close

symmetrically

blinks

involuntary

and with

bilateral

blinking.

Lids closes

symmetricall

y, bilateral

blinking and

no visible

sclera above

corneas

when lids

are open

Normal

findings

(Kozier, B.

(2004).

Fundamentals

of Nursing p.

548

Normal findings

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Sclera &Conjunctiva

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,

normally 3-7

mm in

diameter,

sound-

smooth border

iris flat &

sound. Pupils

constrict when

looking at near

object and

Iris black in

color, equal

in size and

round in

shape. Iris is

flat and

round. Pupil

diameter is

3mm.

Pupils

constrict

when light is

Normal

findings.

(Kozier, B.

(2004).

Fundamentals

of Nursing p.

554).

Normal findings

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dilate when

looking at far

objects.

directed

towards it,

and dilate

when light is

removed.

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

EarsPARTS METHOD NORMAL

FINDINGSACTUAL

FINDINGSANALYSIS INTERPRETATION

Auricles Inspection

Palpation

The color is

the same as

facial skin,

symmetrical,

the auricles

aligned with

outer canthus

of the eye

Mobile, firm

and not

Auricles

aligned at the

outer canthus

of the eyes,

symmetrical

and color is

the same as

the facial skin.

Normal

Findings

Normal Findings

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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.

(Kozier, B.

(2004).

Fundamental

s of Nursing

p. 556-557)

Normal findings.

Hearing Acuity

Inspection Normal voice

tones audible.

Sound is

heard in both

ears or

localized at

the center of

the head

(Weber

Negative).

Air conducted

hearing is

greater than

Normal Voice

tones audible.

Normal

findings

According to

Kozier page

597.

Normal findings

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bone

conducted

hearing

(positive

Rinne)

Nose

PARTS METHOD NORMAL FINDINGS

ACTUAL FINDINGS

ANALYSIS INTERPRETATION

Nose Inspection Symmetric

and straight

No

discharge in

flaring

Uniform in

color

Not tender,

no lesion

Symmetric and

straight

No discharge in

flaring

Uniform in

color

Not tender, no

lesion

Normal

Findings

Normal Findings

Facial Sinuses

Palpation No

tenderness

No tenderness

noted.

Normal

findings

(Kozier, B.

(2004).

Fundamental

s of Nursing

p. 561)

Normal findings.

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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

Kozier page

560-561

Normal findings

MouthPARTS METHOD NORMAL

FINDINGSACTUAL

FINDINGSANALYSIS INTERPRETATION

Lips InspectionPalpation

Uniform pink

color

Soft, moist,

smooth

texture

Symmetry of

contour

Ability to

purse lips

Pale, Dry Paleness is

due to

decrease in

hemoglobin

and dry

because of

dehydration

Blood loss decrease

hemoglobin level and

since the patient isn’t

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

Foul breath odor is

due to poor self

hygiene and lack of

motivation from others

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done

Gums Inspection Pink gums,

moist, firm

texture to

gums.

Pinkish gums,

no retraction,

moist and firm.

Normal

findings.

(Fundamental

s of Nursing

by Kozier,

p603)

Normal findings.

Tongue InspectionPalpation

Central

position

Pink color,

moist,

slightly

rough; then,

whitish

coating

Smooth;

lateral

margins; no

lesions

Raised

papillae

Moves

freely, no

tenderness

Smooth

Pink in color,

moist, no

lesions,

tenderness and

nodules.

Tongue is on

the middle.

Client was able

to move tongue

from side to

side and up

and down.

Normal

Findings

(Fundamental

s of Nursing

by Kozier,

p603)

Normal Findings

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tongue base

with

prominent

veins.

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.

(Fundamental

s of Nursing

by Kozier

p566)

Normal findings

Uvula Inspection Soft, moist,

smooth

texture Pink

and smooth.

Soft, moist, and

pink

Normal

findings.

(Fundamental

s of Nursing

by Kozier

p604)

Normal findings.

Tonsils Inspection No

discharge.

No discharge.

Pinkish in

Normal

findings.

Normal findings.

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Tonsils of

normal size.

Pink and

smooth

posterior

wall.

color. normal

size

(Fundamental

s of Nursing

by Kozier

p604)

Neck

PARTS METHOD NORMAL FINDINGS

ACTUAL FINDINGS

ANALYSIS INTERPRETATION

Neck Inspection

Palpation

Proportional

to size of the

head,

symmetrical

and straight.

Freely

movable

without

difficulty.

No palpable

lumps or

tenderness

The trachea

is in the

Central

placement in

midline of

Proportionate

to the size of

head and

symmetrical.

Unable to

move.

There are no

palpable lymph

nodes. Head

cannot easily

flex and rotate.

Trachea is in

the central

placement and

no indication of

Muscles in

the neck like

sternocleido

mastoid and

trapezius

draw the

head to the

side and

elevate the

chin and

elevate the

shoulders to

shrug them.

(Fundamental

s of nursing

by Kozier p5)

Normal Findings

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neck, spaces

are equal on

both sides.

possible neck

tumor or

thyroid

enlargement.

Thorax

PARTS METHOD NORMAL FINDINGS

ACTUAL FINDINGS

ANALYSIS INTERPRETATION

Chest size and shape

Inspection Anteroposterior

to transverse

chest is

symmetrical.

Anteroposterior

to transverse in

ratio of 1:2,

chest is

symmetrical

Normal

findings.

(Fundamental

s of nursing by

Kozier p549)

Normal findings

Breath sounds

Auscultation

Bronchovesicula

r breathe sound.

Patient has a

clear,

bronchovesicular

breath sound.

Normal

Findings

(Fundamental

s of Nursing by

Kozier p549)

Normal findings

Posterior Palpation Full and

symmetric chest

expansion.

Premitus tactile

Full and

symmetric chest

expansion. Quiet

and rhythmic,

Normal

findings

Normal findings

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Percussion

most clearly at

the apex of the

lungs

Quiet, rhythmic

and effortless

respiration.

Vesicular and

bronchovesicular

breath sound.

Notes resonate,

except over

scapula, the

lowest point of

resonance is at

the diaphragm.

and effortless

breathing.

Resonant except

on the scapula,

there is lowest

point of

resonance over

scapula.

(Fundamental

s of nursing by

Kozier p549)

Anterior Inspection

Palpation

Quiet, rhythmic

and effortless

respiration.

Full and

symmetric chest

expansion.

Same as

posterior vocal

fremitus, fremitus

is normally

decreased over

heart and breast

tissue.

Effortless

Respiration.

Full and

symmetric chest

expansion.

Normal

Findings

(Fundamental

s of nursing by

Kozier p549

box 29—5;

p617)

Normal findings

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BreastPARTS METHOD NORMAL

FINDINGSACTUAL

FINDINGSANALYSIS INTERPRETATIO

N

Breast InspectionPalpation

No masses and

lumps

n/a. The patient

refused to be

assessed

The patient

refused to be

assessed

Areola InspectionPalpation

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

Nipples InspectionPalpation

Size is

proportional. No

discharged or

secretions.

n/a The patient

refused to be

assessed

AbdomenPARTS METHOD NORMAL

FINDINGSACTUAL

FINDINGSANALYSIS INTERPREATTION

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Skin integrity

Inspection Unblemished

skin, uniform

in color.

Unblemished

skin, uniform

in color

Normal

findings

According to

Kozier page

592-598

Normal findings

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

vascular

pattern.

Normal

findings

According to

Kozier page

592-598

Normal findings

Bowel sounds

Auscultation Audible

bowel

sounds.

Normal

bowel

sounds = 5-

35 per

minute

Audible bowel

sounds.

hypoactive

Bowel

sounds= 4

per minute

Normal

Findings

Normal Findings

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Umbilicus InspectionClean Clean Normal

findings

According to

Kozier page

592-598

Normal findings

Bladder Palpation Not palpable Not palpable Normal

findings

According to

Kozier page

592-598

Normal findings

Liver Palpation May not be

palpable.

Border feels

smooth

No

enlargement.

Not palpable

Normal

findings

According to

Kozier page

592-598

Normal findings

Urogenitalia SystemMETHOD NORMAL FINDINGS ACTUAL

FINDINGSANALYSIS INTERPRETATION

InspectionPubic hair evenly

distributed, pubic skin

intact, no lesions

n/a

Foley catheter

intact.

The Patient

refused to be

assessed

The Patient refused

to be assessed.

Foley catheter is

due to patient’s

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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

n/a

The Patient

refused to be

assessed

The Patient refused

to be assessed

Inspection Clitoris does not

exceed 1cm in width

and 2cm in length, no

inflammation, swelling

or discharge

n/a

The Patient

refused to be

assessed

The Patient refused

to be assessed

Palpation No enlargement and

tenderness n/a

The Patient

refused to be

assessed

The Patient refused

to be assessed

Musculoskeletal SystemPARTS METHOD NORMAL

FINDINGSACTUAL

FINDINGSANALYSIS INTERPRETATION

Upper Extremitie

s

Inspection

Palpation

Equal in

size on

both sides.

Equal in

strength,

coordinated

movement.

Able to

tolerate

wide range

Equal in size

on both

sides.

Equal in

strength,

coordinated

movement.

Able to

tolerate wide

range of

Normal

Findings

(Fundamentals

of Nursing by

Kozier p1068)

Normal Findings

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of motion.

No difficulty

upon

bending

and

stretching.

No lesions,

no scars

and no

deformity.

motion. No

difficulty

upon

bending and

stretching.

No lesions,

no scars and

no deformity.

Lower Extremitie

s

Inspection

Palpation

Equal in

size on

both sides.

Able to

tolerate

wide range

of motion.

No difficulty

upon

bending

and

stretching.

No lesions,

no scars

and no

deformity.

Equal in size

on both

sides.

Able to

tolerate wide

range of

motion. No

difficulty

upon

bending and

stretching.

No lesions,

no scars and

no deformity.

Normal

Findings

(Fundamentals

of Nursing by

Kozier p1068)

Normal Findings

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Peripheral pulse

Palpation Symmetric

full

pulsation

Weak pulse

on right and

left dorsalis

pedis pulse

A weak pulse

both feet

indicates

reduced

capillary

perfusion

(Fundamentals

of Nursing by

Kozier, p496)

Patient has edema

and may be due to

reduced blood

circulation.

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.

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V. Pathophysiology of the Disease

Benign Tumors of the UterusFibroids

(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 Located lower In the body of Close beneath

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Lower uterus down on the cervix uterus its lining membrane

Pedunculated Intramural Intramural Protruding IntracavitaryIntracavitary myomas myomas myoma

Myoma Pedunculated serosal myoma

Danger during press upon the Childbirth bladder & rectum

Urinary problems Mennorrhagia Constipation Metrorrhagia Bloating

VI. Anatomy and Physiology

Ovaries

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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

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 (u’ter-in), or fallopian (fal-lo’pe-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 (fim’bre-

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e) 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

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 (u’ter-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.

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The wall of the uterus is thick and composed of three layers. The inner layer or

mucosa is the endometrium (en-do-me’tre-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.

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

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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

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 ¼ to ½ 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.

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(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

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:

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• 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

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 woman’s

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.

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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.

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.

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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.

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.

Laparoscopic myomectomy: removal of a fibroid through a laparoscope

inserted through a small abdominal incision

Laparoscopic myolysis: a laser or electrical needles are used to coagulate the

fibroid

Laparoscopic cryomyolysis: electric current is used to coagulate the fibroid

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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

childbearing, this procedure has been found to cause fewer complications than

hysterectomy, but women may need further treatment in future.

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.

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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.

X. Statement of nursing problems/nursing diagnosis based on grouped data (Gordon’s)

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

Assessment Nursing Dx Inference Planning Intervention Rationale Evaluation

Subjective:The patient verbalizes:“I felt pain on my surgical incision”

Objective:- Reported painwith the pain scaleof 8 (pain scale from 1–10)- Facial Grimacing- Guardingbehavior

Acute pain secondary tosurgical procedure(hysterectomy) as evidence by reportedpain with the pain scale of 8 (pain scale from 1 – 10), limited range of motion and sleep disturbance pattern

Hysterectomy↓

Breaking in the

continuity of the skin

Imflamation process

triggered↓

Nerve endingcompression

Pain

After 8 hours of

rendering nursing

intervention, the patient

will be able to:

- Decrease pain

scale of 8 to 4 as

evidence by

stable vital signs.

Independent:

1. Evaluate pain

regularly noting

characteristic,

location intensity (0-10).

2. Identify specific

activity limitations.

3. Reposition as

indicated.

4. Encourage of

relaxation

technique like deep

breathing exercise.

5. Monitor vital signs

DEPENDENT:

1.Administer analgesic

medication: Ketorolac

IVTT x 4 doses q 8

hours

as prescribe by the

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

tension.

5. Changes in vital

signs may be used

for rough estimate

of pain.

DEPENDENT:

1. To relieve mild or

After 8º of rendering nursing care, the goalswas met partially asevidenced by:- Decreasedpain scale to thelevel of 5.

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physician. moderate pain.

• Actual

Assessment Nursing Dx Inference Planning Intervention Rationale Evaluation

Subjective

“kanina pa po siya nilalagnat”

as verbalized by the patient’s

relative

Objective

> T – 39.4% C> Chilling> Clammy Skin> Skin warm to touch

Hyperthermia related to trauma as

manifested byIn body

temperature of 39.4 oC

Tumors of the uterus

Located in the body of the uterus

Invasive procedure

Removal of tumors

Damage of the tissues

Trauma of tissue

Hyperthermia

In body temperature

After 30 min. of nursing

intervention, the patient manifest thermo

regulating as evidenced by:

> Skin temperature in

expected range

> Body temperature w/in normal

limits

> describes to prevent or

minimize inc. in body temp

> describe proper

1. Render TSB

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

6. Teach the relative proper TSB techniques like avoiding long strokes and only

> 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

>Long strokes creates friction to the skin and it

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

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measures during TSB

patting the wet towel on the skin

produces heat.

• Potential

Assessment Nursing Dx Inference Planning Intervention Rationale Evaluation

Subjective

“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

Anxiety related to change in

Health status as manifested by

irritability

Changes in physiologic

status

Worsening of case

Hospitalization

Anxiety due to thoughts of not able to

recover

After continuous

nursing intervention, the client will be able to:

-Verbalize appropriate

range of feeling.

-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

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

-relieves discomfort and pain.

After continuous

nursing intervention,

the client was able to:

-verbalized appropriate

range of feelings.

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XII. Discharge Plan

M- medication

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.

Keep emotional stress under control by using relaxation techniques such as muscle relaxation exercises.

T- treatment

Provide Rest periods between activities. Provide adequate ventilation and a quiet calm environment.

H- health teaching

Instruct the client in energy saving activities. Instruct the patient to eat healty foods. Advise family to provide emotional support.

O- OPD

Advise patient to comply with clinic follow up. Advise patient to comply with treatments.

D- diet

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

S- spiritual

Advise the significant others to guide and support the Patient by uplifting her spiritual being.

Maintain positive outlook in life.

Reference Books53

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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, AACN’s Clinical Reference for Critical-Care 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

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