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Chapter 5

Management

Medical

Laboratory/Diagnostic Procedures

Ideal

Transvaginal examination

- Transvaginal means across or through the vagina. Transvaginal ultrasound is a type of pelvic

ultrasound. It is used to look at a woman's reproductive organs, including the uterus,

ovaries, cervix, and vagina.

- The patient will lie down on a table with her knees bent and feet in holders called stirrups. The

health care provider will place a probe, called a transducer, into the vagina. The probe is covered

with a condom and a gel. The probe sends out sound waves, which reflect off body structures. A

computer receives these waves and uses them to create a picture. The doctor can immediately

see the picture on a nearby TV monitor. The health care provider will move the probe within the

area to see the pelvic organs.

- The patient will be asked to undress, usually from the waist down. A transvaginal ultrasound is

done with the bladder empty or partially filled. The test is usually painless, although some women

may have mild discomfort from the pressure of the probe. Only a small part of the probe is placed

into the vagina.

- This test is important to evaluate abnormal findings on a physical exam, such as

cysts, fibroid tumors, or other growths, abnormal vaginal bleeding and menstrual problems,

certain types of infertility, and ectopic pregnancy

Complete Blood Count

- A CBC is a routine laboratory test for most patients. The CBC count helps gauge blood loss,

although the accuracy of findings to help determine acute blood loss is not entirely reliable. Other

important information provided includes platelet and white blood cell counts, with or without

differential.

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- The complete blood count test is performed by drawing a few milliliters (one to two teaspoons)

of blood from a vein. Most commonly, the sample is obtained from a vein that is visible from the

skin, such as a vein on the back of the hand or the inner angle of the elbow (antecubital fossa). A

tourniquet is usually applied to the area proximal to the vein (closer to the center of the body than

the vein itself). This technique will make the vein more visible and plump by limiting the blood

from the vein going back toward the heart. The tourniquet is only applied for a brief period of time

(a few minutes at the most) and it is removed as soon as blood is drawn. The skin overlying the

vein is cleaned using an alcohol pad, and then a needle is inserted through the area of cleansed

skin into the vein below where the tourniquet is applied. The blood is then pulled from the vein via

the needle by gently pulling the plunger on the syringe or by a connection of the needle to a

special vacuum vial that collects the blood. This sample is then taken to the laboratory for

analysis, and the complete blood count results may be available within hours after collection.

Prompt delivery of the blood sample to the laboratory for analysis is important.

Table 1. Table of Values and Indication of the Complete Blood Count Exam

Hematology Normal Values Indication

White Blood Cell Count

(WBC Count)

4.8 – 10.8 10^9/L is a count of the actual number of white blood cells per

volume of blood. Both increases and decreases can be

significant.

Hemoglobin ( Hgb) 140-180 g/L measures the amount of oxygen-carrying protein in the

blood.

Hematocrit (Hct) 0.42-0.52 L/L measures the percentage of red blood cells in a given

volume of whole blood.

Mean Corpuscular

Volume (MCV)

80-94 fl  is a measurement of the average size of your RBCs.

The MCV is elevated when your RBCs are larger than

normal (macrocytic), for example in anemia caused

by vitamin B12 deficiency. When the MCV is

decreased, your RBCs are smaller than normal

(microcytic) as is seen in iron deficiency

anemia or thalassemias.

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Mean Corpuscular

Hemoglobin (MCH)

27-35 pg  is a calculation of the average amount of oxygen-

carrying hemoglobin inside a red blood cell. Macrocytic

RBCs are large so tend to have a higher MCH, while

microcytic red cells would have a lower value.

Red Blood Cell Count

(RBC Count)

4.70-6.10 10^12/L is a count of the actual number of red blood cells per

volume of blood. Both increases and decreases can

point to abnormal conditions.

Mean Corpuscular

Hemoglobin

Concentration (MCHC)

330-370 g/L  is a calculation of the average concentration of

hemoglobin inside a red cell. Decreased MCHC values

(hypochromia) are seen in conditions where the

hemoglobin is abnormally diluted inside the red cells,

such as in iron deficiency anemia and in thalassemia.

Increased MCHC values (hyperchromia) are seen in

conditions where the hemoglobin is abnormally

concentrated inside the red cells, such as in burn

patients and hereditary spherocytosis, a relatively

rare congenital disorder.

Red Cell Distribution

Width (RDW)

11-16 fl  is a calculation of the variation in the size of your

RBCs. In some anemias, such aspernicious anemia,

the amount of variation (anisocytosis) in RBC size

(along with variation in shape – poikilocytosis) causes

an increase in the RDW.

Mean Platelet Volume

(MPV)

7.2-11.1 fl  is a machine-calculated measurement of the average

size of your platelets. New platelets are larger, and an

increased MPV occurs when increased numbers of

platelets are being produced. MPV gives your doctor

information about platelet production in your bone

marrow.

Platelet Count 150-400 10^9/L is the number of platelets in a given volume of blood.

Both increases and decreases can point to abnormal

conditions of excess bleeding or clotting.

Differential Count

Neutrophil 40-74 % can increase in response to bacterial infection or

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inflammatory disease. Severe elevations in neutrophils

may be caused by various bone marrow disorders,

such as chronic myelogenous leukemia. Decreased

neutrophil levels may be the result of severe infection

or other conditions, such as responses to various

medications, particularly chemotherapy.

Lymphocyte 19-48 % can increase in cases of viral infection, leukemia,

cancer of the bone marrow, or radiation therapy.

Decreased lymphocyte levels can indicate diseases

that affect the immune system, such as lupus, and the

later stages ofHIV infection.

Monocyte 3-9 %  levels can increase in response to infection of all kinds

as well as to inflammatory disorders. Monocyte counts

are also increased in certain malignant disorders,

including leukemia. Decreased monocyte levels can

indicate bone marrow injury or failure and some forms

of leukemia.

Eosinophil 0-7 % can increase in response to allergic

disorders, inflammation of the skin,

and parasitic infections. They can also increase in

response to some infections or to various bone marrow

disorders. Decreased levels of eosinophils can occur

as a result of infection.

Basophil 0-2 % can increase in cases

of leukemia, chronic inflammation, the presence of a

hypersensitivity reaction to food, or radiation therapy.

Urinalysis

- The urinalysis is used as a screening and/or diagnostic tool because it can help detect

substances or cellular material in the urine associated with different metabolic and kidney

disorders. It is ordered widely and routinely to detect any abnormalities that require follow up.

Often, substances such as protein or glucose will begin to appear in the urine before patients are

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aware that they may have a problem. It is used to detect urinary tract infections (UTI) and other

disorders of the urinary tract. In patients with acute or chronic conditions, such as kidney disease,

the urinalysis may be ordered at intervals as a rapid method to help monitor organ function,

status, and response to treatment.

- A urine sample is needed. A health care provider will tell the patient what type of urine sample is

needed. The sample is sent to a lab, where it is examined for its physical color and appearance,

microscopic appearance, and chemical appearance.

Table 2. Table of Values and Indication of Urinalyis Exam

Clinical Microscopy Normal Results/ Values Indication

Color Straw yellow to amber Normal urine is straw yellow to amber in color. Abnormal

colors include bright yellow, brown, black (gray), red, and

green. These pigments may result from medications,

dietary sources, or diseases. For example, red urine may

be caused by blood or hemoglobin, beets, medications,

and some porphyrias. Black-gray urine may result from

melanin (melanoma) or homogentisic acid (alkaptonuria,

a result of a metabolic disorder). Bright yellow urine may

be caused by bilirubin (a bile pigment). Green urine may

be caused by biliverdin or certain medications. Orange

urine may be caused by some medications or excessive

urobilinogen (chemical relatives of urobilinogen). Brown

urine may be caused by excessive amounts of

prophobilin or urobilin (a chemical produced in the

intestines).

Transparency Clear to slightly hazy Normal urine is transparent. Turbid (cloudy) urine may be

caused by either normal or abnormal processes. Normal

conditions giving rise to turbid urine include precipitation

of crystals, mucus, or vaginal discharge. Abnormal

causes of turbidity include the presence of blood cells,

yeast, and bacteria.

Specific Gravity 1.015-1.025  reflects the ability of the kidneys to concentrate the urine

(conserve water). . Specific gravity varies with fluid and

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solute intake. It will be increased (above 1.035) in

persons with diabetes mellitus and persons taking large

amounts of medication. It will also be increased after

radiologic studies of the kidney owing to the excretion of x

ray contrast dye. Consistently low specific gravity (1.003

or less) is seen in persons with diabetes insipidus. In

renal (kidney) failure, the specific gravity remains equal to

that of blood plasma (1.008–1.010) regardless of changes

in the patient’s salt and water intake. 

pH 4.5-8.0 pH measurements are useful in determining metabolic or

respiratory disturbances in acid-base balance. For

example, kidney disease often results in retention of

H+ (reduced acid excretion). pH varies with a person’s

diet, tending to be acidic in people who eat meat but more

alkaline in vegetarians.

Glucose Negative glycosuria (glucose in the urine) may be the first indicator

that diabetes or another hyperglycemic condition is

present. 

Protein Negative  Albumin is important in determining the presence of

glomerular damage.  Albuminuria occurs when the

glomerular membrane is damaged, a condition

called glomerulonephritis.

RBC 0-2/hpf Testing for blood in the urine detects abnormal levels of

either red cells or hemoglobin, which may be caused by

excessive red cell destruction, glomerular disease, kidney

or urinary tract infection, malignancy, or urinary tract

injury.

WBC 0-2/hpf The presence of white blood cells in the urine usually

signifies a urinary tract infection, such as cystitis, or renal

disease, such as pyelonephritis or glomerulonephritis.

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Actual

CBC

Table 3. Table of Values and Indication of Patient’s CBC

Hematology Result Indication

White Blood Cell Count

(WBC Count)

10.6 10^9/L Within normal range

Hemoglobin ( Hgb) 91 g/L Low

Hematocrit (Hct) 0.30 L/L anemic

Mean Corpuscular

Volume (MCV)

79 fl low

Mean Corpuscular

Hemoglobin (MCH)

24.2 pg low

Red Blood Cell Count

(RBC Count)

3.76 10^12/L low

Mean Corpuscular

Hemoglobin

Concentration (MCHC)

306 g/L low

Red Cell Distribution

Width (RDW)

22.3 fl high

Mean Platelet Volume

(MPV)

7.30 fl Within normal range

Platelet Count 236.0 10^9/L Within normal range

Differential Count

Neutrophil 55.7 % Within normal range

Lymphocyte 22.1 % Within normal range

Monocyte 3.5 % Within normal range

Eosinophil 18.6 % high

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Basophil 0.10 % Within normal range

Urinalysis

Table 4. Table of Values and Indication of Patient’s Urinalysis

Clinical Microscopy Normal Results/ Values Indication

Color yellow Normal

Transparency clear Normal

Specific Gravity 1.030 Slightly high

pH 5.5 Within normal range

Glucose Negative Normal 

Protein Negative Normal

RBC 0-1/hpf Within normal range

WBC 0-2/hpf Within normal range

Blood Typing

Table 5. Table of Values and Indication of Patient’s Blood Typing

Blood Type O

Rh Positive (+)

Coagulation Time 3’30”

Bleeding Time 2’30”

Transvaginal Ultrasound

Table 6. Table of results of patient’s TVE

Uterus Endometrium Adnexal Cervix Others Conclusion

14.1x8.8x9.6cm, 0.7 cm, isoechoic Right Ovary: 4.2x 2.5cm, No free fluid >Enlarged

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anteverted. The

myometrium is

diffusely thickened

with coarsened

echotexture. There is

a well-defined

hypoechoic mass in

the uterine isthmus

measuring

5.5x4.7x4.6cm

suggestive of an

intramural myoma

with intact

subendometrial

halo

Compatible with:

Proliferative Phase

not visualized

Left Ovary:

4.3x 2.3cm with

a 2.2x 1.9cm

dominant

follicle

closed

homogeneous

Nabothian cyst:

present

in the cul-de-

sac

anteverted

uterus with

diffuse

adenomyosis

>intramural

myoma

>normal left

ovary with a

dominant follicle

>right ovary not

visualized

>no adnexal

masses

demonstrated

>long and closed

cervix with

nabothian cyst

>no cul-de-sac

fluid

Pharmacologic Management

Mefenamic Acid

Patient is ordered by the doctor to take Mefenamic Acid, 500mg 1 tab TID. This drug is

an analgesic and does its job by inhibiting prostaglandin synthesis by selectively inhibiting

cyclo-oxygenase-2 (COX-2). The general indications of this drug include acute or chronic use in

the treatment of the signs and symptoms of osteoarthritis, rheumatoid arthritis; postsurgical or

dental pain and acute flare pain of osteoarthritis; acute pain including primary dysmenorrhea;

familial adenomatous polyposis; and as an adjunct to usual care (e.g. endoscopic surveillance

and surgery). The patient’s actual indication for this medication is pain due to the compression

of the nerves as the patient is suffering from uterine fibroids. Contraindications include known

sulfonamide hypersensitivity, asthma, urticaria or allergic reactions after taking aspirin or other

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NSAID’s; lactation; severe hepatic impairment; severe heart failure; inflammatory bowel

disease; and renal impairment associated with creatinine clearance of less than 30 mL/min,

though none are present/ manifested by the patient. Precaution should be exercised when

having edema, hypertension, heart failure, liver dysfunction and pre-existing asthma;

compromised cardiac function and other conditions predisposing to fluid retention; patients on

long-term treatment should have their hematocrit and hemoglobin checked for any signs of

anemia or blood loss; patients less than 18 years old; risk for GI ulceration; anaphylactoid

reactions; and impaired renal and hepatic functions.

Adverse reactions include constipation, diverticulitis, dysphagia, esophagitis, gastritis,

gastroenteritis, gastroesophageal reflux, hemorrhoids, hiatal hernia, melena, dry mouth,

stomatitis, tenesmus, tooth disorder, vomiting, diarrhea, dyspepsia, flatulence, nausea,

headache, dizziness, insomnia, pharyngitis, rhinitis, sinusitis, upper respiratory infection,

pruritus, rash, peripheral edema, aggravated hypertension, and angina pectoris.

Before administering the medications, the important nursing responsibilities are: assess

for appropriateness of therapy for pain; use cautiously in patients with history of GI bleeding,

advanced renal disease, hypertension, heart failure or asthma; check range of motion; check

results of blood tests; and assess the patient’s and family’s knowledge of the drug therapy.

On the course of medication giving, medication should be administered with food or milk

to decrease gastric symptoms; should not be crushed, dissolved or chewed; and lastly should

be taken with a full glass of water.

After the medication administration, important nursing responsibilities are: teach patient

that drug must be continued for prescribed time to be effective; instruct patient to report

bleeding and fatigue; tell patient that having black tarry stool is a normal occurrence; and

assess if celecoxib is being taken prior to surgery.

Metoprolol

Another drug prescribed to the patient is Metoprolol 50mg 1 tab BID. Metoprolol is in a

group of drugs called beta-blockers. Beta-blockers affect the heart and circulation (blood flow

through arteries and veins). Metoprolol is used to treat angina (chest pain) and hypertension

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(high blood pressure). It is also used to treat or prevent heart attack. This is given to the patient

to control her blood pressure.

Contraindications for this medication include hypersensitivity to metoprolol, or a serious

heart problem such as heart block, sick sinus syndrome, or slow heart rate.

Metoprolol may impair one’s thinking or reactions. Thus, nursing responsibilities for this

drug include telling client to be careful if the patient drives or does anything that requires mental

alertness. Drinking alcohol can increase certain side effects of this medicine. Advising the

patient not to stop taking metoprolol without first talking to the doctor is also important because

stopping suddenly may make the condition worse. If the patient needs surgery, nurse should

inform surgeon ahead of time that she is using metoprolol.

Metoprolol is only part of a complete program of treatment for hypertension that may also

include diet, exercise, and weight control. So, the nurse must tell the patient to follow a strict

diet, medication, and exercise routines very closely.

Tranexamic Acid

The last drug prescribed to the patient was Tranexamic Acid 500mg 1tab TID. This

medication is used short-term in people with a certain type of bleeding disorder to prevent and

reduce bleeding from having a tooth pulled (extraction). It is also used in people with other high-

risk bleeding conditions to control bleeding at such times as after surgery or an injury, during

heavy nosebleeds, or during heavy menstrual bleeding. Tranexamic acid works by helping the

blood clot normally to prevent and stop prolonged bleeding. It belongs to a class of drugs

known as anti-fibrinolytics.

Some side effects of this medication include nausea and vomiting, dizziness, diarrhea,

chest/jaw/left arm pain, sudden shortness of breath, coughing up blood, fainting,

pain/swelling/warmth in the groin/calf, swelling/weakness/redness/pain in the arms/legs,

confusion, slurred speech, weakness on one side of the body, vision changes (e.g., color vision

changes, loss of vision), and change in the amount of urine.

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Contraindications for this drug include hypersensitivity, history of blood clots, a certain

serious blood clotting problem (disseminated intravascular coagulation-DIC), kidney problems

(including blood in the urine), and irregular menstrual bleeding of unknown cause.

So, nursing responsibilities would focus on telling the patient to continue the medication

as prescribed. It would also be advisable for the patient to eat foods high in iron such as green,

leafy vegetables. Likewise, rest is very important. As a nurse the basic nursing care are

indispensable such as monitoring vital signs. This would let the health care providers know

about the status of the patient and how she responds to the medication.

Surgical Management

Hysterectomy

The proposed surgical operation is hysterectomy. Hysterectomy is the surgical removal of

the uterus, usually performed by a gynecologist. Hysterectomy may be total or partial. It is the

most commonly performed gynecological surgical procedure.

Total abdominal hysterectomy was the type of hysterectomy that would be performed to

the patient. This would remove her entire uterus down to the cervix. Removal of the uterus

renders the patient unable to bear children.

Surgeons use different approaches for hysterectomy, depending on the surgeon’s

experience, the reason for the hysterectomy, and a woman's overall health. The hysterectomy

technique will partly determine healing time and the kind of scar, if any, that remains after the

operation.

There are two approaches to surgery – a traditional or open surgery and surgery using a

minimally invasive procedure or MIP.

An abdominal hysterectomy is an open surgery. This is the most common approach to

hysterectomy, accounting for about 70% of all procedures. To perform an abdominal

hysterectomy, a surgeon makes a 5 to 7 inch incision, either up-and-down or side-to-side, across

the belly. The surgeon then removes the uterus through this incision. On average, a woman

spends more than three days in the hospital following an abdominal hysterectomy. There is also,

after healing, a visible scar at the location of the incision.

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There are several approaches that can be used for an MIP hysterectomy: One is Vaginal

hysterectomy in which the surgeon makes a cut in the vagina and removes the uterus through

this incision. The incision is closed, leaving no visible scar. Next is Laparoscopic hysterectomy.

This surgery is done using a laparoscope, which is a tube with a lighted camera, and surgical

tools inserted through several small cuts made in the belly. The surgeon performs the

hysterectomy from outside the body, viewing the operation on a video screen. Third is

Laparoscopic-assisted vaginal hysterectomy in which a surgeon removes the uterus through an

incision in the vagina using laparoscopic surgical tools. And last is Robot-assisted laparoscopic

hysterectomy. This procedure is similar to a laparoscopic hysterectomy, but the surgeon controls

a sophisticated robotic system of surgical tools from outside the body. Advanced technology

allows the surgeon to use natural wrist movements and view the hysterectomy on a three-

dimensional screen.

Nursing Management

Patient has had menorrhagia for the last weeks. She consumes up to 4 napkins per day.

She reports pain in the suprapubic area. She reported that her doctor told her that the fibroid’s

size is equal to that of a 6-month fetus. She appears disheveled by the fact that she is

undergoing this situation not to mention that they’d already spent more than a month in the

hospital. She needs no assistance in doing her activities of daily living because she can

manage. She is not comfortable with her menses though and verbalizes that it is very disturbing

when she moves about. She is not able to sleep well due to the discomfort she feels, as well as

she doesn’t find the environment conducive for sleeping. She is sometimes irritable and

anxious about her upcoming surgery

Fatigue related to related to inadequate oxygenation of cells secondary to low

hematocrit and hemoglobin count

The nursing diagnosis is Fatigue related to inadequate oxygenation of cells secondary to

low hematocrit and hemoglobin count. “Murag pirmi lang ko kapuyon day, nindot kayo matulog

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pirmi,” as verbalized by the patient is the subjective cue. Objective cues include consumption of

up to 4 soaked napkins per day, weakness, sleepiness, and a latest hematocrit of 0.30.

As the expected outcome criteria, the short term goal states that within 8 hours of nursing

interventions, patient will be able to do activities of daily living as tolerated. The long term goal

states that within 3 days of nursing interventions, patient will participate in behaviors and

activities to prevent complications.

For the physical strategies, the nursing interventions include the following: assess for

individual risk factors; promote bed rest; monitor for bleeding; elevate the head of the bed;

assist in activities of daily living as indicated. For the psychological strategies, the nursing

interventions include the following: ensure there is establishment of rapport before initiating any

procedure; use of therapeutic communication to the patient; encourage verbalization of feelings

and make time for listening/ interacting, and encourage patient to develop assertiveness skills,

prioritizing goals/activities; and to make use of beneficial coping behaviors. For the spiritual

strategies, the nursing interventions include the following: ascertain religious beliefs of family of

origin and environment in which the patient grew up. For the dependent strategies, the nursing

interventions include: administer IV fluids, as needed and administer prescribed medications.

And for the collaborative strategies, the nursing interventions include: investigate sudden signs

of adverse effects of drugs or worsening of condition and report symptoms to physician.

Ineffective Tissue Perfusion related to increased peripheral resistance

The nursing diagnosis is Ineffective Tissue Perfusion related to increased peripheral

resistance. “Taas man jud ko ug BP day uy, sa una pa man ni, mao bitaw sige ko ka premature

labor,” as verbalized by the patient is the subjective cue. Objective cues include dizziness,

nausea, BP of 140/90mmHg but no flushing noted.

As the expected outcome criteria, the short term goal states that within 8 hours of nursing

interventions, patient’s blood pressure will drop to 120/80 mmHg. The long term goal states that

within 3 days of nursing interventions, patient will demonstrate techniques/lifestyle changes to

control blood pressure.

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For the physical strategies, the nursing interventions include the following: note

concomitant medical problems/existing conditions that may factors for care; perform/assist with

meeting patient’s needs when she is unable to meet own needs; develop plan of care

appropriate to the individual situation, scheduling activities to conform to patient’s usual/desired

schedule; monitor BP regularly; and allow sufficient time for patient to accomplish tasks to

fullest extent of ability. For the psychological strategies, the nursing interventions include the

following: ensure there is establishment of rapport before initiating any procedure; use of

therapeutic communication to the patient; encourage verbalization of feelings and make time for

listening/ interacting, and encourage patient to develop assertiveness skills, prioritizing

goals/activities; and to make use of beneficial coping behaviors. For the spiritual strategies, the

nursing interventions include the following: be aware of the religious practices the patient’s

observe to avoid misunderstandings. For the dependent strategies, the nursing interventions

include: administer IV fluids, as needed and administer prescribed medications. And for the

collaborative strategies, the nursing interventions include: review instructions from other

members of the health care team and provide a written copy.

Anxiety related to upcoming surgery

The nursing diagnosis is Anxiety related to upcoming surgery. “Kulbaan man gihapon ko

bisag nakasuway nako ug operasyon day uy,” as verbalized by the patient is the subjective cue.

Objective cues include coldness on extremities, increased heart rate, decreased eye contact,

and restlessness.

As the expected outcome criteria, the short term goal states that within 8 hours of nursing

interventions, patient will be able to report that anxiety is decreased to a manageable level. The

long term goal states that within 3 days of nursing interventions, patient will develop a healthy

coping mechanism for anxiety.

For the physical strategies, the nursing interventions include the following: determine

presence of physical and/or psychological stressors; note environmental factors that affect

anxiety; determine patient’s coping mechanism in the past; promote adequate physical exercise

and rest; and manage controllable anxiety-producing factors. For the psychological strategies,

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the nursing interventions include the following: ensure there is establishment of rapport before

initiating any procedure; use of therapeutic communication to the patient; encourage

verbalization of feelings and make time for listening/ interacting, and encourage patient to

develop assertiveness skills, prioritizing goals/activities; and instruct in relaxation techniques

like music therapy. For the spiritual strategies, the nursing interventions include the following:

be aware of the religious practices the patient’s observe to avoid misunderstandings. For the

dependent strategies, the nursing interventions include: administer IV fluids, as needed and

administer prescribed medications. And for the collaborative strategies, the nursing

interventions include: review with patient physician’s recommendations for medications or

surgery.

Focus Charting

9/19/11 – Body Weakness

The focus is body weakness. Data collected are as follows: received sitting on bed,

conscious, and coherent; without IVF; weakness and pallor noted, bleeding of up to 4 soaked

napkins per day reported, with a latest hematocrit of 0.30. Actions initiated are as follows:

monitored vital signs and recorded, environmental care done, promoted adequate rest periods,

medications given, limited activities to level of tolerance, encouraged to eat iron-rich foods such

as leafy vegetables, encouraged to drink orange juice for better iron absorption. The response

was that the patient was seen sitting comfortably in bed about to sleep.

9/20/11 – Hypertension

The focus is increased BP. Data collected are as follows: received sitting on chair,

conscious, and coherent; without IVF; dizziness reported, no flushing noted, BP of

140/90mmHg recorded. Actions initiated are as follows: monitored vital signs and recorded,

environmental care done, medications given, facilitated moderate high back rest position,

reinforced knowledge about the importance of managing BP, taught non-pharmacological ways

of managing BP such as using garlic, promoted bed rest, ensured safety, monitored for

unusualities. The response was that the latest BP of the patient was130/80mmHg.

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9/21/11 – Ineffective Tissue Perfusion related to increased peripheral resistance

The focus is ineffective tissue perfusion. Data collected are as follows: received sitting on

bed, conscious, and coherent; without IVF; anxiety reported, no flushing noted, BP of

130/100mmHg recorded. Actions initiated are as follows: monitored vital signs and recorded,

environmental care done, medications given, promoted bed rest, taught active and passive

ROM, stressed importance of managing BP, oriented in the OR setting, encouraged

verbalization of feelings and concerns. The response was that the patient’s latest BP was

130/80mmHg.

Discharge Summary

JSM, 41 years old, female, Roman Catholic, a resident of Cogon West, Carmen, Cebu

was admitted in Vicente Sotto Memorial Medical Center due to hypopelvic pain and bleeding

per vagina.

The focus would be Health teaching: Home care management. Data would be: received

sitting on bed without IVF; with dry, intact dressing on abdomen; with discharge order as of

September 30, 2011. Actions include: instructed SO to continue patient’s medications as

prescribed by the doctor; advised to sit and ambulate as tolerated; instructed SO to bring

patient to VSMMC-OPD for follow-up on October 5, 2011; instructed SO to aid patient in

performing activities of daily living but still promote independence as much as possible;

instructed to ensure that dressing and bandage be intact, clean, and dry at all times; instructed

SO to contact healthcare facility if unusualities, such as heavy bleeding or severe pain, may

occur at home; stressed the importance of eating a variety of food high in protein to promote

faster wound healing; and advised SO to guide patient in religious practices. Response would

be that the patient is discharged.