myoma case

Uterine Myoma

Presented by:Abu, Camile

Granada, Glyde PebblesLandicho, Katrina

Linatoc, Jeanne LynLuza, Ailen

Maralit, Ma. KrishnaSim, Khay

Ulan, DarleneUmali, Marianne LynAvena, Gaudencio

Dimaculangan, Argenald JosephHernandez, Michael Franklin

INTRODUCTION

Uterine myoma is the most common tumors of the female genitalia tract. Myoma commonly called

fibroid. It is the benign tumor of the smooth muscle in the wall of the uterus. Hysterectomy has been a

common therapy in patients who have completed reproduction. Total hysterectomy plus unilateral

salphingo oophorectomy TAHBSO- this procedure removes the utereus, cervix, one ovary and one

fallopian tube, while one ovary and one fallopian tube are left in places.

Fibroids can be present and be apparent. However they are clinically apparent in up to 25 % of the women. Although, myoma is generally considered to be slowly growing tumor in 20-40% of women at the age of 35 and more have uterine fibroids of significant sizes with severe clinical symptoms. Moreover, myoma can be relapse in 7-28% of patient after surgical treatment and in certain case it may even turn to malignant tumor, this could causes significant morbidity including prolonged or heavy menstrual bleeding, pelvic pleasure and pain and in rare cases reproductive dysfunction. Myoma affects one of every four women ¾ of woman with this condition,however, experience no symptoms.

Uterine myoma is developing on the background of hyper estrogen, progesterone, deficits in hyper gonodotrophine. The majority of the researches say that the growth of myoma depends on concentration of cystosolic receptors to the sex hormones and their interactions, with the endrogen or extrogen hormones. In accordance to clinical observations, it can be admitted that both growth and regressions of myoma are estrogen-dependent, is the tumor size gets increased during pregnancy and is regressed after menopause. The only that needs to clear is to find out whether it is decreased in receptors numbers of estrogen, progesterone and androgen- hormones quantities which lead to regression in myoma size ( regarding androgen there is an hypothesis that myoma is sensitive to androgen ) for growth that formed tumors, the need to be further supported by negative factors.

Abortions, long term used of inadequate contraceptive pills, chronic sub-acute and acute inflammation of uterus or its appendices, stress, ultraviolet radiation, cystic formation of ovary etc. for example, the woman who had ten abortions by the age of thirty have double to developed uterine myoma at fourty years old. In fact, uterine myoma = account for 20% of 650,000 hysterectomies performed annually in the U.S interest in the uterine preservation and organ preserving surgery through techniques minimally invasive surgery has increased the first reports of laparoscopic myomectomy.

SPECIFIC OBJECTIVES

To be able to:

> know the disease ,its clinical manifestations, risk factors, pathophysiology and diagnostic procedures for the disease.> Identify different medical and surgical management of a patient diagnosed with uterine myoma.> Enhance our skills in caring a patient with uterine myoma.> Familiarized us with the medications used to managed the disease.> Recognized appropriate nursing care and management.> Help the patient realized her role in maintaining and improving health.

GENERAL OBJECTIVES

> Our group aims to be formulate a comprehensive case analysis that would provide essential knowledge and skills in delivering quality health care to patient’s diagnosis with uterine myoma.

PATIENT’S PROFILE

PATIENT’S NAME: Lady L.AGE: 48 years oldGENDER: Female

PERMANENT ADDRESS: Inosluban, Lipa CityBIRTHDATE: August 26, 1960

BIRTHPLACE: Lipa City, Batangas CIVIL STATUS: MarriedCITIZENSHIP: Filipino

RELIGION: Roman CatholicADMISSION DATE: August 22, 2008

ADMISSION DIAGNOSIS: Uterine MyomaATTENDING PHYSICIAN: Dra. Lovely Cacho

Dra. Alice Lojo

HISTORY OF PRESENT ILLNESSS

Present condition started about 6 years prior to admission. When patient noted heavy vaginal bleeding and body weakness every menstrual period that last almost a week. Due to that instance, she went to the hospital for check-up and she found out that she has a myoma. Her

attending physician said that she need to undergo surgery but they didn’t have enough money that time, they would need to save for the hospitalization and operation that will undergo. Until August 22, 2008, when her relative noted

her to be pale, having dizziness and body weakness bought her to the hospital. After a series of examination,

she was scheduled and prepared her to surgery.

PAST MEDICAL HISTORY

She has never been hospitalized except when she had two breech presentations with her two sons. Other than that, she usually experiences

cough, cold, fever and buys over the counter drugs to treat the said illnesses. Prior to that, sometimes

she consults the said quack doctors or faith healers if she thinks that it’s just that a simple

illness.

SOCIO – CULTURAL

She is a friendly person. She is closed with her four sons and loves them so much. She admitted that few years ago, she used to smoke when she is defecating

and after eating. She said that she loves to eat vegetables and she exercises regularly. She cooks in a

canteen in Lipa bus stop which sustains their basic needs.

PHYSICAL ASSESSMENT

ACTUAL VITAL SIGNS

NORMAL VALUES

INTERPRETATION

RR- 24 12-20 beats/min.

Normal

PR- 80 60-100 beats/min.

Normal

BP- 120/70 90/60- 130/90 mmHg

Normal

Height = 5’1 cm Weight = 57 Kg.

Body Parts

Technique used

Normal findings

Actual findings

Significance

Head InspectionPalpation

NormocephalicNo abdominal mass

Normocephalic No abdominal mass

NormalNormal

Hair and scalp

Inspection Evenly distributed,Thick hair,no infection and infestation

Even distribution of hair , no infection and infestation

Normal

Eyes Inspection Symmetric to the face, both eyes coordinated with parallel alignment.

Sunken eyeball

Not Normal.Due to dehydration

External eye StructureEyebrows

Inspection Hair evenly distributed, Skin intact

Evenly distributed with skin intact

Normal

Eyelashes Inspection Equally distributed,Curled slightly outward

Equally distributed,Curled slightly outward

Normal

Eyelids Inspection Skin intact,No discharge, Nodiscoloration,Lids close symmetrically

Skin intact, no discharge, no discoloration, lids are symmetrical.

Normal

Lacrimal gland

Inspection No edema or tearing.

No edema and tearing

Normal

Pupils (color , shape and symmetry of size)

Inspection Black in color, equal in size normally 3-7 mm in diameter, round smooth border , iris flat and round.

Black in color, equal in size 4mm in diameter

Normal

Ears Inspection Symmetrically aligned to the face, firm and not tender with no discharged noted.

Positioned symmetrically to the face,No notable ear discharge, clean and dry,.

Normal

Nose Inspection Symmetric and straight, no discharges or flaring

Symmetric and straight , no nasal discharges noted, no flaring noted

Normal

Mouth Lips

Inspection Uniform pink in color, soft and moist and smooth

Uniform dark color dry

Not Normal due to chemical content of cigarette such as nicotine.

Tongue Inspection Tongue at midline without lesion

Dry and free of lesion

Normal

Teeth Inspection Complete, white, shiny tooth enamel, free of debris

Incomplete, missing teeth, ill fitting dentures

Not normal.Aging is a factor affecting loss of teeth and also insufficient calcium and fluoride.

Neck Inspection Palpation

Coordinated , smooth movement with no discomfortNo masses, tenderness

Coordinated movement with no discomfortNo masses, tenderness

NormalNormal

Upper Extremities Skin

Inspection Pinkish in color

Pallor Not normal.It is a manifestation of in adequate circulating blood or hemoglobin.

Palpation Slightly moist

Poor skin turgor

Not normal due to dehydration

Palpation Normothermia

Not warm, not cold to touch, T=36

Normal

Arms InspectionPalpation

Normally firm, no contracture, no swelling, equal size on both sides of bodyPulse Rate: 60-100

Normally firm, no contracture, no swelling, equal size on both sides of bodyPulse rate: 80

NormalNormal

Nails InspectionPalpation

Smooth, highly vascular and intact epidermis Capillary Refill of 1-2 seconds

Pink, smooth texture, convex curvatureCapillary refill: 2 seconds

NormalNormal

Chest and Lungs

Inspection Symmetric chest expansion, quiet, rhythmic and effortless respiration

Symmetric chest expansion, quiet, rhythmic and effortless respiration

Normal

Palpation No retraction, no tenderness, no masses

No retraction, no tenderness, no masses

Normal

Auscultation

Quiet, rhythmic

Bronchovesicular and vesicular breath sounds

Normal

Heart Auscultation

Normal heart rate 60-100bpm

Cardiac rate of 80

Normal

Abdominal Inspection Unblemished skin, uniform in color

Lesions noted on the surgical site

Not normal because of post procedure done

Auscultation Average normal bowel sounds 5-25 per minute

Audible bowel sound of 8 per minute

Normal

Lower extremities Skin

InspectionPalpation

No lesion, can move freelyCapillary refill: 1-2 seconds

No edema, no deformities and can move freelyCapillary refill: 2 seconds

NormalNormal

IV. ANATOMY AND PHYSIOLOGYANATOMY OF FEMALE REPRODUCTIVE ORGAN

STRUCTURELOCATION & DESCRIPTION

FUNCTION

CervixThe lower narrower portion of the uterus.

During childbirth, contractions of the uterus will dilate the cervix up to 10 cm in diameter to allow the child to pass through. During orgasm, the cervix convulses and the external is dilates

Fallopian tubes

Extending upper part of the uterus on either side.

Egg transportation from ovary to uterus (fertilization usually takes place here).

Ovaries (female gonads)

Pelvic region on either side of the uterus.

Provides an environment for maturation of oocyte. Synthesizes and secretes sex hormones (estrogen and progesterone).

Vagina

Canal about 10-8 cm long going from the cervix to the outside of the body.

Receives penis during mating. Pathway through a woman’s body for the baby to take during childbirth. Provides the route for the menstrual blood (menses) from the uterus, to leave the body. May hold forms of birth control, such as an IUD, diaphragm, neva ring, or female condom

Uterus EndometriumMyometriumPerimetrium

Located in the center of the pelvic cavityThe innermost layer of uterine wall.Smooth muscle in the uterine wall.Outer layer of the uterus

House and nourishes the fetus.Contains glands that secrete fluids that bathe the uterine lining.Contract to help expel the baby.Covers the uterus

Uterus EndometriumMyometriumPerimetrium

Located in the center of the pelvic cavityThe innermost layer of uterine wall.Smooth muscle in the uterine wall.Outer layer of the uterus

House and nourishes the fetus.Contains glands that secrete fluids that bathe the uterine lining.Contract to help expel the baby.Covers the uterus

ESTROGENIt is the most important hormone during puberty

in female and is responsible for secondary sexual characteristics (e.g. breast enlargement, menstruation,

pelvic enlargement, long bones). Generally secreted by the ovary specifically secreted by the Grafian follicle.

Estrogen production

Hypothalamus↓

GnRH↓

Anterior Pituitary Gland↓

FSH↓

Graafian Follicle↓

Estrogen

V. PATHOPHYSIOLOGY

Pregnancy Early Menarche(11 years old)

Increase Estrogen productionIncrease the lifetime exposure

to estrogen

Stimulates the growth of fibroid

Grows in the anterior wall of the uterus

Pelvic pain

Deform uterine cavity

Menorrhagia

Myoma

VI. COURSE IN THE WARD

Day 1A 48 years old female was admitted at exactly 2:16:07 p.m last

August 22, 2008, accompanied by her son, with a chief complaint of body weakness. She was admitted under the service of Dra. Lovely Cacho and Dra. Alice Lojo and following orders are

given. Diet as tolerated, temperature, pulse rate and respiratory rate must be recorded every shift, for chest x-ray posterior-

anterior, for electrocardiogram x 12 leads, for complete blood count blood typing and for chem. 7. It was done at the same day. The physician ordered a 5% Dextrose in Lactated Ringers 1 liter

plus 1 ampule of EC to be regulated at 20 gtts/min. The physician ordered four units of whole blood that are properly typed and

cross matched to be run for 4-6 hours. The physician also ordered “Lady L” that may have full diet at 4:40 p.m. The first unit of whole blood with a serial number B-08-4660 started at 10:00 p.m.. Diphenhydramine 1 ampule intravenous 30 min. prior to

blood transfusion.

Day 2The above unit of blood finished at August 23, 2008, 2:20 a.m. There

is no reaction during and after the blood transfusion. At the same time, the second unit of whole blood with a serial number B-08-4681 was hooked and consumed at 7:20 a.m. The third unit of blood with a

serial number B-08-4666 was started at same time. The blood transfusion site was transferred from left to right at 11:20 a.m. At

12:30 p.m., the third unit of whole blood with a serial number B-08-4668 was consumed and followed up of fourth unit of whole blood and consumed at 4:30 p.m. Intravenous fluid number one consumed

and followed the number two 5% Dextrose in Lactated Ringers 1 liter plus one ampule of EC regulated at the same rate. By 11:10 p.m.

“Lady L” is under nothing per orem. “Lady L” informed about Total Hysterectomy Bilateral Salphingo Oophorectomy with signed consent of her husband and her son at the same day. Anesthesiologist on deck was informed. Cefuroxime 750 mg, intravenous started every 8 hours

after negative skin testing. At 11:40 p.m. Valium tablet 5 mg one tablet was given as pre-operative drugs.

Day 3August 24, 2008, at exactly 7:00 a.m. “Lady L” was brought to

the operating room. At 4:50 p.m. post-op orders were given. Monitor vital signs every 15 minutes until fully stable. Nothing

per orem temporarily. The patient was instructed to lie flat on bed and low back rest for pneumonia precaution. Oxygen inhalation

administered at 3 liters per minute. Suction secretion when necessary. Intake and output were recorded hourly. 5% Dextrose

Lactated Ringers 1 liter post-op to run at 15gtts/min then to follow 5% Dextrose Lactated Ringers 1 liter at same rate. Last dose of Cefuroxime to consumed, Metronidazole 500 mg slow

intravenous push every 6 hours. Tramadol 500 mg after negative skin testing every 6 hour. Intravenous fluid regulated at 30

gtts/min when blood transfusion finished. Repeat hemoglobin and hematocrit.

At 5:20 p.m. the operation ended and at 6:40 p.m. patient was bought to the intensive care unit and hooked to ventilator and

Furosemide 40 mg IV was given. At around 8:45 p.m Omeprazole 40 mg IV was given. Serum, sodium, potassium, chloride, prothrombin time, partial prothrombin time done and

result in “Lady L” was nebulized if Combivent 1 neb and maintained every 8 hours potassium 30 millequivalent

incorporate to her intravenous fluid and decrease it to 8 hours. Another one unit of packed red blood cell, Calcium gluconate

one ampule was given thru slow intravenous push.

Day 4August 25, 2008, 5a.m. patient was brought to room 206 and then

nebulization started and extubated at the time and secretion suctioned. Oxygen maintained at 4 liters per minutes via nasal

canula. Diphenhydramine one ampule was given at 3:30 p.m, 30 minutes prior to blood transfusion. Blood type “B” with a serial #

of BO8-445 run at 4-6 hours. At 6:05 p.m “Lady L” was confirmed that she is positive in flatulence and may sips of water

and hot soup. Measuring drained output was recorded shiftly.

Day 51 a.m. of August 26, 2008, to follow intravenous fluid 5%

Dextrose Lactated Ringers 1 liter regulated at same rate and encouraged patient to turn side to side. Serum, creatinine, and

complete blood count done. At 9:37 a.m. the physician advised to continue medications. At 10:00 p.m. patients temperature is 38.2˚C and paracetamol 200 mg one ampule was given thru intravenous. At 11:03 a.m. nebulization was stopped. The

physician suggests changing Cefuroxime to Tazocin 4.5 grams intravenous every 8 hours. Above intravenous fluid consumed

and followed up of 5% Dextrose in Lactated Ringers 1 liter regulated at same rate. At 3:15 p.m. incentive spirometer every 8

hours and two minutes oxygen inhalation was discontinued. Patient was encouraged to ambulate. At 8:30 p.m. intravenous to follow of 5% Dextrose Lactated Ringers 1 liter regulated at same

rate. Foley catheter was removed at 9:15 p.m. At 10:45 p.m “Lady L” was gargled a one tablespoon of Orahex solution plus

30 cc water every 6 hours.

Day 6Nursing care done. Vital signs are monitored and recorded. Intravenous fluid regulated at 15 gtts/min “Lady L” has no

further complaint. The patient is ambulatory. Tazocin 4.5 grams intravenous every 8 hours was given. Attending Physician did not

visit’s the patient and no new orders were made that day.

Day 7August 28, 2008, patient may have clear liquid then soft diet at 4 p.m., above intravenous fluid consumed and followed up of 5% Dextrose Lactated Ringers 1 liter regulated at the same rate. For

possible discharge on the next day.

Day 8August 29, 2008, removal of jackson-pratt drain was done and intravenous fluid was terminated. There is no o objection for discharge. Home medications instructed and patient may go

home and start oral medication. At 8 p.m. patient was discharged accompanied by her son via the wheelchair.

VII. LABORATORY

AUGUST 22, 2008ULTRASOUND

Transvaginal Ultrasound

Transabdominal pelureus shows an enlarged uterus measure about 12.6x7.5x9.1 cm (LxWxAP). There is a large hypo echoic

mass in the posterior lower segment of the uterus, measuring approximately 10.0x10.0x9.0 cm.

There is a cystic structure with internal echoes and septations in the night adnexae, measuring about 60x4.5x4.3 cm.

There is no fluid in the posterior culde-sac.

Impression:Enlarged uterus with large sub serous myoma wit

intramural component, posterior lower segment consider ovarian cyst at the right. Normal left ovary.

AUGUST 22, 2008CLINICAL CHEMISTRY

Laboratory Test Normal Value Result Significance/Interpretation

FBS 3.89-5.84 mmol/L

4.24 mmol/L Normal

BUN 2.5-8.33 mmol/L 2.80 mmol/L Normal

Creatinine 45-235 u/L 89.0 u/L Normal

Bld. Uric Acid 143-345 mmol/L 179.0 mmol/L Normal

Triglyceride 0.11-2.37 mmol/L

0.58 mmol/L Normal

HDL 0.25-2.65 mmol/L

1.50 mmol/L Normal

LDL 1.10-3.81 mmol/L

2.52 mmol/L Normal

AUGUST 22, 2008

HEMATOLOGY

Diagnostic/Laboratory Test

Normal Value Result Significance/Interpretation

Hemoglobin M 13.0-18.0 g/dL F 12.0-16.0 g/dL

6.93 g/dL Anemia, recent hemorrhage

Hematocrit M 40-54%F 37-47%

21 % Anemia

WBC 5,000-10,000 5,000 Normal

Platelet Count 150,000-450,000 cu/mm

337,000 cu/mm

Normal

Segmenters 0.51-0.57 0.70

Lymphocytes 0.21-0.35 0.20

Monocytes 0.02-0.35 0.10 Normal

AUGUST 23, 2008HEMATOLOGY

Diagnostic/Laboratory

Test


Hemoglobin M 13.0-18.0 g/dL

F 12.0-16.0 g/dL



36.70 % Anemia

WBC 5,000-10,000 6,500 Normal


247,000 cu/mm

Normal

Segmenters 0.51-0.57 0.83 Infection

Lymphocytes 0.21-0.35 0.11 Infection


AUGUST 24, 2008

HEMATOLOGY

Diagnostic/Laboratory Test



F 12.0-16.0 g/dL

12.5 g/dL Normal


37.5 % Normal

WBC 5,000-10,000 20,600 Infection


225,000 cu/mm Normal



Monocytes 0.02-0.35 0.04 Infection

Eosinophill 0.01-0.04 Infection


Laboratory Test

Normal Value

Result Significance/Interpretatio

n

Sodium 135-145 mmol/L

142.3 mmol/L Normal

Potassium 4-4.5 mmol/L 3.133 mmol/L Hypokalemia

Chloride 99.9-110 mmol/L

106.7 mmol/L Normal

Pro- time 12-15 seconds 13 seconds Normal

AUGUST 24, 2008CHEST X-RAY AP

> There are no active parenchemal infiltrates.> The heart is not enlarged.

> Aorta is tortous.> The rest of the findings are unremarkable.

> ET at level of T4.

Impression: > Tortous Aorta

`AUGUST 24, 2008

ABDOMEN AP

> Hx: S/P TAHBSO> Free air is noted at the pelvic cavity.

> There are feces filled undilated bowel loops obscuring the renal and psoas shadows.> The flank stripes are intact

> No abnormal calcification noted.

Impression:>Pneumoperitoneum, likely post surgical.

AUGUST 25, 2008HEMATOLOGY


Test

Normal Value

Result Significance/Interpretation


F 12.0-16.0 g/dL



32.70 % Anemia

WBC 5,000-10,000

16,600 Infection

Platelet Count

150,000-450,000 cu/mm

206,000 cu/mm

Normal



Monocytes 0.02-0.35 0.01 Infection

Eosinophill 0.01-0.04 0.01 Normal


Test

Normal Value



F 12.0-16.0 g/dL


AUGUST 26, 2008

HEMATOLOGY


35.10 % Anemia

WBC 5,000-10,000

15,200 infection.

Platelet Count

150,000-450,000 cu/mm

196,000 cu/mm

Normal


Lymphocytes

0.21-0.35 0.08 Infection



Laboratory Test

Normal Value


Potassium 4-4.5 mmol/L

3.56 mmol/L

Hypokalemia

Creatinine 45-235 u/L 102.0 u/L Normal

IX. DRUG STUDY

NAME CLASSIFI-CATION

ACTION INDICATION&DOSAGE

ADVERSE REACTION

NURSING CONSIDE-RATION

Generic Name:MetronidazoleBrand Name:Flagyl

Antiprotozoals or Antimicrobia

Direct -acting trichomonacide and amebicide that works inside and outside the intestines. It’s thought to enter the cells of microorganisms that contain nitroreductase, forming unstable compounds that bind to DNA and inhibit synthesis, causing cell death.

>Amebic liver abcess>To prevent post operative infection in contaminated or potentially contaminated colorectal surgery Dosage:500mg IV

>CNS: headache, seizure, fever, vertigo, ataxia, dizziness>CV: flattened T wave, edema, flushing>EENT: rhinitis, sinusitis, pharyngitis>GI: nausea, abdominal cramping or pain, stomatitis, vomiting, diarrhea>GU: vaginitis, darkened urine, polyuria,

> Monitor liver function test result carefully in elderly patient.> Observe pt. for edema especially if receiving corticosteroid>Record number and character of stools when drug is used to treat.



ADVERSE REACTION


Generic name:CefuroximeBrand Name: Zinacef

Cephalosporins Inhibits cell wall synthesizes promoting osmotic instability

Serious lower respiratory tract infection, UTI, skin structure infection, bone or joint infection, gonorrheaDosage:750mg IV

> CV: thrombophlebitis, phlebitis > GI: diarrhea, nausea, vomiting, anorexia> Skin: maculo papular, erythematous rashes

> Before giving drugs, ask patient if he allergic to penicillin or cephalosporins> Obtain specimen for culture and sensitivity test before giving first dose



ADVERSE REACTION


Generic Name:TramadolBrand Name:Ultram

Opioid Analgesic

> Bind to opioid receptors and inhibit reuptake of norepinephrine or serotonin

> Moderate to moderately severe painDosage:50mg IV

> CNS: dizziness, headache, vertigo, anxiety, confusion> CV: vasodilation > EENT: visual disturbances> GI: constipation, nausea , vomiting, abdominal pain> GU: menopausal symptoms urine retention

> Monitor CV, and respiratory status withhold dose and notify prescriber if respiration decrease or rate is below 12bpm> Monitor bowel and bladder function > For better analgesic effect give drug before onset of intense pain.



ADVERSE REACTION


Generic Name:OmeprazoleBrand Name:Losec

Anti Ulcer Drug

> Inhibits activity of acid pump and bind to hydrogen potassium adenosine, triphosphatase at secretory surfaces of gastric parietal cells to block formation of gastric acid

> Symptomatic GERD without esophageal lesion> short term treatment of active benign gastric ulcerDosage:40mg IV

> CNS: asthenia, dizziness, headache> GI: abdominal pain, constipation, nausea, vomiting

> Drug increases its bioavailability with repeated doses. Drug is unstable in gastric acid; less drug is loss to hydrolysis because drug increases gastric pH.>Dosage adjustment may be necessary in Asians and patients wit hepatic impairment.



ADVERSE REACTION


Generic Name:SalbutamolBrand Name:Combivent

Bronchodilators

>Relaxes bronchial, uterine and vascular smooth muscle by stimulating beta2 receptors.

>To prevent or treat bronchospasm in patients with reversible obstructive airway diseaseDosage:1 nebule

>CNS: tremor, nervousness, headache >CV: tachycardia , palpitations, hypertension>EENT: dry and irritated nose>GI: nausea, vomiting,anorexia

>Drug may decrease sensitivity of spirometry used for diagnosis of asthma.>Use of a AeroChamber may improve drug delivery to lungs.>Tell patient to remove canister and wash inhaler with warm, soapy water at least once a week.



ADVERSE REACTION


Generic Name:Piperacillin SodiumBrand Name:Tazocin

Antibiotics >Inhibits cell-wall synthesis during bacterial multiplication.

>Moderate to severe infections from piperacillin-resistantDosage:4.5g IV

>CNS: headache, insomnia, fever >CV: hypertension, tachycardia, chest pain>EENT: rhinitis >GI: diarrhea, nausea, vomiting

>Before giving drug, ask patient about allergic reactions to penicillins>Obtain specimen for culture and sensitivity test before giving first dose.>Monitor patient’s sodium intake.

X. NURSUNG CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING NURSING INTERVENTIONS EVALUATION

SUBJECTIVE:“Masakit ang tahi ko” as verbalized by the patient.OBJECTIVE:RestlessnessIrritabilityWith cold clammy skinExcessive perspiration Facial grimaceIncreased respiration RR=26 bpmPain scale = 7: pain scaling of 1-10 where 1 is the least painful and 10 is the most painfulImpaired thought

Pain related to tissue trauma and incisional discomfort as manifested by grimace and pain scale =7.

After 4 hours of nursing intervention patient’s pain evidenced by pain scale =7 be reduced to 3.

INTERVENTIONS RATIONALE After 4 hours of nursing intervention the patient reported pain was lessened to pain scale =3.

Change the position of the patientProvide comfort measuresAssist patient in breathing techniquesProvide quiet environmentRelay on the patient report of painEncourage divertional activities Monitor vital signAdminister analgesic as ordered by the AP

Pain is sometimes due to the position of the patient To reduce the discomfortTo assist in muscle and generalized relaxationFor patient comfortabili-ty and lessen the discomfort.To reduce anxiety felt by the patientTo divert the attention from pain to activitiesUsually altered in pain.To maintain acceptable level of pain.

ASSESSMENT DIAGNOSIS PLANNING NURSING INTERVENTIONS EVALUATION

OBJECTIVE:Poor skin turgorDry lipsWeak in appearancePale lookingv/s of:BP = 100/80PR = 64RR = 26T = 37.8

Fluid volume deficit related to the risk of post-operative hemorrhage.

After 8 hours of nursing intervention the patient will maintain fluid at a functional level.

INTERVENTIONS

RATIONALE

After 8 hours of nursing intervention, the patient was maintained fluid as manifested by good skin turgor

Change dressings frequentlyProvide frequent oral careMeasure input and outputMonitor v/sAdminister IV fluids as indicatedGive medications as ordered by the attending physician

To protect the skin and monitor lossesTo prevent injury from drynessHelps maintaining fluid in the bodyTo monitor fluids in the bodyTo assess the patient and it serve as base line dataTo reduce blood loss

ASSESSMENT DIAGNOSIS

PLANNING NURSING INTERVENTIONS

EVALUATION

SUBJECTIVE:“Hindi ako makagalaw ng ayos” as verbalized by the patient.OBJECTIVE:Impaired ability to turn side to side.Cannot eat without supportSlowed movementIrritableLimited ROM

Impaired mobility related to decreased muscle strength as manifested by limited ROM.

After 8 hours of nursing intervention the patient will be able move safety and independently.

INTERVEN-TIONS

RATIONA-LE

After 8 hours of nursing intervention, the patient was able to move safely and independently.

Provide activities with adequate rest period.Encouraged adequate intake of fluidsAdvise to move hands and legs slowly Encourage participation in self care

To reduce the fatiguePromotes well being and maximize energy productionTo exercise/mobilization of body parts and develop muscle strengthEnhances self concept and sense of independence

XI. DISCHARGE PLANNING

MedicationCiprofloxacin 500 mg 1tablet 3x a day for

1 weekMetronidazole 500 mg 1 tablet 3x a day

for 1 weekTramadol (Dolcet) 1 tablet 3x a day for

pain

Environment Instruct patient’s relative to provide the

patient an environment conducive for her easy recovery. Her place/room in their house must be the most accessible area. Her environment should be free from contamination and infection.

TreatmentThe patient should follow the physician’s prescription and

should take his home medication on the right time and right dose.

Health TeachingInstruct the patient the importance of proper taking of medication on time. Instruct the patient and her family the proper wound care to avoid contamination and infection at surgical site.Instruct the patient to eat nutritious foods. Encourage ambulation for early recovery.Good sanitation is advised.

Out Patient DepartmentThe patient should return on the scheduled date of her

follow up check-up on September 5, 2008 in Metro Lipa Medical Center from 4:30 pm to 6:30 pm and should continuously take her home medication as prescribed by her physician. The patient should visit her physician whenever she feels any discomfort.

DietDiet as Tolerated. In order to attain proper diet, the

patient should be guided to the prescribed foods as advised by her physician. Her meals should include Vitamin C-rich foods for wound healing.

SpiritualPatient should enhance her spiritual relationship with

God. Have faith and trust in God’s divine power, and believed that the lord will help in her early recovery. Keep on praying, because praying is the number one key to live a healthy life and to be close to God.

XII. PROGNOSISThe mortality rate in uterine myoma is low provided early

diagnosis and management are made and no complication will occur. According to the attending physician the case of Lady L

greatly improved after the management, therefore, the prognosis is good.

I.EVALUATIONI.EVALUATION

XII. EVALUATION

Date 22 23 24 25 26 27 28 29

D5LR

1L

√ √ √ √ √ √ √

BT FWB

√ √

TPR

temp 36.7 36.2 36 37.3 36.8 36.2 37.6 36.2

BP 120/70 120/80 120/70 130/80 130/80 110/70 140/90 120/70

RR 24 20 21 24 22 20 28 22

PR 80 90 72 91 68 75 80 68

MEDS 22 23 24 25 26 27 28 29

Omeprazole

√

Salbutamol (combivent)

√ √ √ √ √

Piperacillin (Tazocin)

√ √ √ √ √ √

Tramadol (ultram)

√ √

Diphenhydramine HCl (Benadryl)

√ √ √ √

Metronidazole (Flagyl)

√ √ √ √ √ √

Metronidazole (Flagyl)

√ √ √ √ √ √

Cefuroxime (Zinacef)

√

Paracetamol √

CXR AP √

Abdomen AP √

UTZ √

Clinical Chemistry

√ √ √

Cross Matching

√

Hematology √ √ √ √ √

DIET 22 23 24 25 26 27 28 29

DAT √ √

Soft diet √

NPO √ √ √ √