Case Study Myoma

8/3/2019 Case Study Myoma

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AUB prob 2 to Submucous Myoma

I. Data from TextbookCause

Submucous myoma has no known cause, it is idiopathic. Although there have been many

theories developed.Some say it could be caused by increased Estrogen hormones.Some say that it is

hereditary and has a tendency to run in the family.

Signs and Symptoms

Submucousmyoma is generally symptomless. But some of itsmost common features were

experienced byclient ILN and they are:

Swollen breasts Lossofsex drive Profuse bleeding or heavymenstrual bleeding Hypermenorrhea Dysmenorrhea Metrorrhagia Massespalpated in the abdomen Pain Constipation and increased urination Increased abdominal girth or abnormally enlarged abdomen Anemia like signs and symptoms (paleness, decrease respiratory rate, dizziness)

Treatment

Antibiotic treatment Hormone treatment Myomectomy Current trend presents Radio Frequency Energywhich shrinksmyomas and reducessymptoms

in newminimally invasive procedure

TAHBSO (Total Abdominal Hysterectomy Bilateral Salphingo-oophorectomy)

Diagnosis

SubmucousMyomasmaybe diagnosed through manyways.They are palpated during pelvic

examinations. An ultrasound is also done which could be the Transvaginal Ultrasoung and Vaginal Probe

Ultrasound.Hysteroscopymay alsobe done wherein the uterus isbeing viewed.

Anatomy and Physiology of Affected Areas

The uterusconsistsofmanystructures like the ovaries, broad ligament, mesovarium, ovarium

ligament and the like.Here are the detailed functionsof each.

ovary-One of the paired female reproductive organswhich produce ova and female sex hormones,

estrogens and progesterone; it is located laterally in the pelviccavity, near the opening to the oviduct,


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and attached to the posterior surface of the broad ligament; it is regulated by FSH and LH from the

anterior pituitary in a complex cycle which begins at puberty and ends at menopause. See endoscopic

viewsbelow:

broad ligament- A broad fold of the peritoneumwhich extends from the side of the uterus to the wall

of the pelvis, it helps hold the uterus, oviducts, and ovaries in place in the pelviccavity.

mesovarium-The fold ofperitoneum, a subsection of the broad ligament, connecting the over to thewall of the pelviccavity.

ovarian ligament- A cord or strapof dense fibrousconnective tissue which is found between the folds

of the broad ligament, passing from the side of the uterus to the lower end of the ovary; it helps hold

the uterus and ovaries in place in the pelviccavity.

suspensory ligament- A band of the peritoneum containing dense fibrous connective tissue which

extendsupward from the upper pole of the ovary; it contains the ovarian vessels and nerve supply; it

helps hold the ovary in place in the pelviccavity.

hilus (ovary)-The opening on medial side of the ovarywhich leads into the renal sinus and throughwhich the ovarian blood vessels and nerves enter/leave the ovary

germinal epithelium- A thin layer ofsimple cuboidal epitheliumcovering the ovary, a portion of visceral

peritoneum, through which eggs are released at ovulation.

stroma (ovary)-The coarse connective tissue framework of the ovarywhich contains irregular fibrous

connective tissue (stroma) and the blood vessels and nerve supply, it is found in both the cortex and

medulla of the ovary; the term may be used to generally describe the internal connective tissue

structural framework of anyorgan.

cortex (ovary)-T

he outer layer of the ovarywhich contains the variousovarian follicles interspersed byirregular fibrousconnective tissue (stroma) and small blood vessels; the outer surface iscovered by the

germinal epithelium.

medulla (ovary)-The inner layer of the ovarywhich contains dense irregular fibrousconnective tissue

(stroma) and the larger blood vessels and nerve supplyof the ovary.


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The most affected area is the intrauterine wall which is the Endometrium.Submucousmyoma

affectspartially in the cavity and partially in the wall of the uterus.This iswhy it iscalled Submucous

Myoma. It is a tumor lying under or involving the tissuesunder a mucousmembrane.


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II. Physical Examination

Assessment

A. General InformationClient ILN was admitted at CSMCon July 12, 2011 at room3273Main.She is a 42year

old female, who issingle, a Filipino and a Christian.She is a graduated BS ECE in UST and is now

an employee.Her chiefcomplaint was that she was having very heavymenstrual bleeding.

She was preoperatively and postoperatively diagnosed to have AUB prob 2 to

submucousmyoma and her admitting vital signsof36.5C temperature, a blood pressure of

120/80mmHg, a pulse rate of 80bpm and respiratory rate of 18 bpm.She weighed 32 kg and is

153cm tall.She arrived at the hospital bycar and arrived on the unit bywalking.Client ILN has

no allergies for food but tested (+)with tegaderm. She also took Primolut asprescribed by her

physician prior to admission.

B. Nursing HistoryPatient ILN described at present that her health iswell aside from the pain she is feeling.

She verbalized that her pain is rated 5/10on a pain rate scale where 10 is the most painful.She

said that her plan tomanage her health isby eating more fish and vegetables and complyingwith medications given by her physician.

Client ILN stated that five years prior to admission, she developed heavymenstrual

bleeding with mensesoccurring every twenty to thirty days lasting for ten daysconsuming one

napkin to three baby diapersper day.They are fullysoaked with occasional blood clots for her

usual menses every twenty-eight to thirty-two days lasting for seven daysconsuming three baby

diapers fully soaked.Thiswas associated with hypogastricpain, cramps that are not radiating

and rated it as 4/10 in a scale of 1 to 10, 10 being the most painful. There was no pelvic

heaviness.There were changes in the bladder and bowel habits, the patient stated shes having

a hard time moving her bowels and has less frequency in urinating.T

here is an increase in theabdominal girth masseswhen palpated and soshe consulted with a private OBG.

She said that her Transvaginal Ultrasound revealed multiple myoma uteri ofunrecalled

size and location and left ongoing site was given Primolut 2 tabsOD for 3months. Patient was

advised observation and monitoring and was then lost to follow up checkups because of

spontaneous resolution ofsymptoms.

Seven monthsprior to admission, recurrence of heavymenstrual bleeding aspreviously

described was noted. No associated hypogastricpain, pelvic heaviness and changes in bowel

and bladder habits.There is an increase in the abdominal girth and masseswere palpated.Client

ILN consulted with a private OBG. TRS revealed multiple myoma uteri ofunrecalled size and

location with left ongoing site started Primolut 3 tabsOD for 3months and tranexamic acid TID

PRN. Patient was advised observation and monitoring every 3months. Twomonths prior to

admission, patient still has heavymenstrual bleeding as described before.


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Her past illnesses were the common colds, cough and fever. She said she was

hospitalized at Makati Medical Center on the year 1996because of heavymenstrual bleeding as

well. There she was diagnosed to have had Endometriotic Cyst and was given medications.

Client ILN also stated that her mother had hypertension and took maintenance drugswhich

relieved her mother. She expects to heal well and be kept rested while being admitted at

Cardinal SantosMemorial Center and that she knew the treatments done to her would stop the

bleeding.She knew that her uteruswas going tobe removed.Her reaction to the medications

given to her prior to her admission did not stop her bleeding, but the treatment done on her

lessened the bleeding.

Clien ILN stated that for breakfast, she usually eatsone cupof rice, one fish and one cup

ofMilo. For lunch she would eat one cupof rice and one fish and drinksone glassofwater or

orange juice. For snacksshe would eat one slice ofbread with butter and one plate ofpancit. As

for supper, she only eatsone bowl ofcereal with milk and drinksone glassofwater or orange

juice.She prefers to drink orange juice among other juicesbut stated that she is not pickywith

food. She estimated that she drinkswater four to five glasses in a day and prefers to drink

orange juice.She has no restrictions in food and has noproblemswith her ability to eat.She

takesCalcium (+) and Vit. B assupplementsonce a day every day.

She estimated that in a day, she voids seven to eight times a day and it iscolor light

yellow.She alsostated that when there is heavymenstrual bleeding, her urine iscolor orange.

She has nocomplaintswhen urinating, she said that there is nopain.Client ILN alsostated that

she moves her bowel four times a week usually in the morning or in the afternoon.She said that

sometimesshe isconstipated soshe drinksDulcolax but uses no assertive devices.

Client ILN has no exercise because she doesnt have time. But she likes towalk a lot, she

would walk to nearbyplaces instead ofusing a car.She listens to the radio and reads the Bible

for leisure.She used to have n limitations in physical abilitiesbut now that she is newlyoperated

on, she couldnt go towork yet and cant walk somuch or get tired because she would feel pain

on her operation site. Sometimeswhen she laughsor breathes deeply, she would feel pain as

well. Client ILN alsostated that she used to feel dizzinessbefore her treatment.

At 10:00pm, client ILN sleeps and wakesup at 6:00 am.This is her usual sleeppattern

and she gets eight hoursofsleep.She sleepswith twopillows and praysbefore sleeping.She

would also applybeautyproductson her face before sleeping.She has noproblems regarding

sleep.Client ILN has noproblems in hearing, smelling, touching and seeing.She is able to read

and write, and it is evident with her degree in Electrical Engineering from the UniversityofSto.

Thomas.

Client ILN ismost concerned about her health and wants tobe well immediatelysoshe

could go home and goback towork. Because of her treatment, she isstill healing her operation

site which isstill painful so her activities are limited and soshe could not go towork yet.Client

ILN can speak English, Filipino and Bicolano, she speakswell English with correct grammar, her

sentences are complete and make sense.The significant person with client ILN was her niece

and she said that she had noproblems regarding her family.Client ILN lives alone aswell and

has never had coitus and expects to have no change in her sexual relations because of her

illness.

She has noproblems in making decisions, she iswell capable tounderstand and choose

the decisionsshe makes.She said that she had had some stress in the past year but didnt want

toshare thembecause she said theywere confidential.She said that tomanage thisstressshe


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just went on with her life.She slept, ate and listened tomusic a lot.Client ILN expects that the

nursesofCardinal SantosMemorial Center and student nurses toprovide the best care possible

and make her heal better and faster while keeping her comfortable and rested.

Client ILN stated that her source of strength and meaning isGod and that He is very

much important to her and her life.She reads the Bible a lot as her religiouspractice.She would

read it every day ifshe had time.

Developmental Stage:

Frueds Five stagesofDevelopment

Stage Age Characteristics Implications

Oral Birth to 1 year old Mouth is the center of

pleasure

Feeding produces

pleasure and sense of

comfort and safety.

Feeding should be

pleasurable and

provided when required

Anal 1 to3yearsold Anus and bladder are

the sourcesofpleasure

Controlling and

expelling feces provide

pleasure and a sense of

control. Toilet training

should be a pleasurableexperience

Phallic 4 to6yearsold Genitals are the center

ofpleasure

The child identifies with

the parent of the opposite

sex and later takes on a

love relationship outside

the family. Encourage

identity

Latency 6yearsold topuberty Energy is directed to

physical and intellectual

activities

Encourage child with

physical and intellectual

pursuits. Encourage

sports and otheractivitieswith same sex

peers

Genital Puberty and after Energy is directed

toward full sexual

maturity and function

and development of

skills needed to cope

with the environment

Encourage separation

from parents,

achievement of

independence and

decision making

Client ILN has not yet fully reached the Genital Stage yet for she has not yet used her sexual

function to its extent because she has never had coitusbut could make decisionson her own and had

achieved independence.She haspassed all the other stagesbut has not yet completed thisstage.


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C. Physical Assessment Date Performed: July 18, 2011The patient has good hygiene and good grooming. It is evident by her clean hands, face, and

pleasant breath.She haswhite complexion but pale looking.She isoriented of time, place and person.

She can make eye contact and answers questionswell and with sense.The patient is awake, alert and

responsive.She had a blood pressure of 110/70mmHg, a temperature of36.3C, a pulse rate of75bpmand a respiratory rate of 19 bpm.

Her cranium is symmetricwith no signsof depression, lesions, masses and tenderness.There

were signsofsome flakesbut noparasites.Her temporal arterieswere present upon palpation but they

are not visible, they are not tender but they are elastic.The face issymmetric, with white complexion

and there were no involuntarymovements.There were 2moleson the mid portion of her nose.One

which is the higher one is approximately3mm and the one below it is2mm.There were no signsof

tenderness, swelling, masses, depressions and edema.The skin issoft and warm to the touch. No flakes

were present on her eyebrows.

The patient can identifysharp and soft when touched on her face.She is able tomove jawwhen

speaking and when eating.There is noproblemwith the tongues ability to taste and the patient has

good speech. Eyesclose involuntarywhen stimuli ispresented and closes voluntarily aswell.She can

perform all facial expressionswhen instructed.The face also has good muscle strength with a score of

4/5when there is active movement against gravity and some resistance.The patient could perceive

odor on each nostril and could identify it. Noobstructions are present.

The eyes are symmetric, circular and protruding.The sclera are white and the conjunctivas are

pink.They eye lashes are curled and the skin surrounding the eyes are white in complexion, warm and

soft to the touch without anypresence of involuntarymovements, masses, edema, tenderness, lesions,

depressions and swelling.The eyes are conjugate and parallel. Eyelids also had good muscle strength.

The patient has normal vision and can read in a 20/20 distance.Her eyes dont deviate, theycan

follow direction of gaze and they are conjugate and parallel.Could follow extraocular movements in the

six cardinal directionsof gaze and convergence ispresent.The pupils are 3mm in size.Theyconstrict

when subjected to light and dilates in the absence of light.There was nochance toobserve the internal

structure of the eye because there was noophthalmoscope present.

The external ears are symmetricwith no signsof deformities, lesions, lumps and tenderness.

There is no redness and no involuntarymovements.Secretions, foreign bodies and obstructionswere

not present.The patient could hear correctlyon both ears even of the other ear isoccluded.The ear

canal and tympanicmembrane were not observed because noophthalmoscope waspresent.

The patients neck iswhite in complexion, warm and soft to the touch.There are no signsof

deformities, edema, swelling tenderness and involuntarymovements. Lymph nodeswere not palpable.

There are no deviations in the thyroid gland and the spacesbetween the trachea and sternomastoid are

symmetrical.The thyroid gland movesupward as the patient swallowed and it issymmetric.The patient

is able to taste on the 1/3posterior area of the tongue and is able toswallow.Gag reflex ispresent and

there issensations from the ear drum and ear canal.The carotid arteries are present when palpated and

they are elastic.They are not visible and not tender.

There are no deformitieson the upper extremities.The skin iswhite in complexion, warm andsoft to the touch.The skin haspoor skin turgor of4-5seconds and the nails have a good capillary refill or

2-3 seconds aswell.There are no lesions, masses, tenderness, swelling and depression present.The

nails are convex and the nail beds are pink in color.There are normal movement of the joints.The

shoulders, the arms and the neck have good muscle strength and they all have a score of4/5 for muscle

strength where in there is activity against gravity and some activity.There is activity to some activity

onlybecause the patient still experiencespain from the operation site.The brachial and radial arteries


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are present when palpated and are elastic. They are not tender and not visible. There is also good

tendon reflex of (+)3.

There are nopresence of lumps, masses, edema, swelling, tenderness and depression on the

breasts and axillae.There are also no lesions, secretions and flakinessof the nipples.The skin iswhite in

complexion, warm and soft to the touch.The patient has good tactile fremitus and chest excursion.Thepatient uses axillarymuscleswhen breathing as it risesup and down.There are no liftspresent in the

precordium and there were nomurmors, parasternal impulses and thrillspresent.

The back issymmetric and has nosignsof deformities.There are nosignsof edema, masses,

swelling, tenderness, depression and lesions.The skin iswhite in complexion, iswarm and soft to the

touch. Palpation and percussion was not done over the kidneysbecause the patient was experiencing

pain on the operation site at the abdomen and it maycause bleeding.The posterior thorax issymmetric,

has the curvature of the spine which iscervical, thoracic and lumbar.There are no lateral deviations.

There is good chest excursion and tactile fremitus.The jugular vein is not distended.

The skin of the four abdominal quadrants iswhite in complexion, warm and soft to the touch.

There is an operation site at the midline of the abdomen which wascovered in dressing and the patient

refused toshow it.percussion and palpation over liver, spleen and kidneyswere not done because the

patient was experiencing pain because of the operation site and it maycause bleeding.

There are no signsof deformities, swelling, tenderness, depression, edema and lesion on the

lower extremities.The skin iswhite in complexion, warm and soft to the touch.Haspoor skin turgor of

4-5seconds and toenails have good capillary refill of2-3seconds aswell.There are normal movement of

joints and legs have good muscular strength of4/5where there is activity against gravity and some

resistance.The popliteal, posterior tibial and pedal arteries are present upon palpation and they are

elastic.They are not tender and are not visible.

The patient refused toshow genitalsbut stated that there are no rashes, lesions and secretions

present except the lessened bleeding.The patient alsostated that there is a mild haemorrhoid present

externally.The patient failed tostate further details.

Summary of abnormal findings:

The patient ispale-looking; she has external haemorrhoids, hasslowskin turgor of4-5seconds

and has pain of 5/10 at operation site at the abdomen. The patient also verbalized that she has

orange colored urine when there is heavybleeding

D. Review ofRecordsi. Medical Plan ofCare

1. TAHBSO2. Pethidine HCL (Demerol)25mg IV q4 for 24 hours3. Pantoprozole (Patoloc)40mg IV ODwhile on NPO4. Nalbuphin (Nubain)25mg IV q4 for Pruritus5. Co-amoxiclav (Amoclav)625mg tab BID6. Biscandyl (Dulcolax) ifstill no BM7. Paracetamol + Tramadol (Algesia) 1 tabonce on general liquids

ii. DiagnosticTest:1. Blood Typing2. ECG3. CBC4. Hematology


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LaboratoryTests

LabTest & Date Test Result

Blood Typing

July 12, 2011

Blood Type O

RH (+)

LabTest & Date Test Result

July 12, 2011 ECG Normal

LabTest & Date Test Result Normal level Significance Nursing Responsibility

CBC July 12, 2011 WBC 8.0 x

10^9/L

4.8-10.8 x

10^9/L

= Normal

RBC 3.0 x

10^12/L

4.7-6.1 x

10^12/L

Low Note anybleeding and

stop immediately

Hgb 9.2 g/L 13-17 g/L Low Provide oxygen if

needed

Hct 0.30

MCV 90 fl 82-88 fl High In accordance with

disease process

Mean Corpuscular

Hgb

29 pg 27-31 pg = Normal

MCHC 32ml

Red Cell

Distribution width

0.177ml 0.115-0.150ml High In accordance with

disease process

Platelet count 0.319 X

10^12/L

0.140-0.440 X

10^12/L

= Normal

Differential H

count:

Segmenters 0.58 0.50-0.70 = Normal

Lymphocytes 0.32 0.20-0.44 = Normal

Monocytes 0.07 0.02-0.09 = Normal

Eosinophils 0.03 0.00-0.04 = Normal

LabTest & Date Test Result Normal level Significance Nursing Responsibility

CBC July 14, 2011 WBC 8.1 x

10^9/L

4.8-10.8 x

10^9/L

= Normal

RBC 3.2 x

10^12/L

4.7-6.1 x

10^12/L

Low Note anybleeding and

stop immediately

Hgb 9.0 g/L 13-17 g/L Low Give oxygen if neededHct 0.29

MCV 92 fl 82-88 fl High In accordance with

disease process

Mean Corpuscular

Hgb

29 pg 27-31 pg = Normal

MCHC 31 ml

Red Cell

Distribution width

0.174ml 0.115-0.150ml High In accordance with

disease process

Platelet count 0.227 X

10^12/L

0.140-0.440 X

10^12/L

= Normal

Differential Hcount:

Segmenters 0.77 0.50-0.70 High In accordance withdisease process

Lymphocytes 0.12 0.20-0.44 Low In accordance with

disease process

Monocytes 0.10 0.02-0.09 High In accordance with

disease process

Eosinophils 0.01 0.00-0.04 = Normal


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Lab Test &

Date

Test Result Normal level Significance Nursing

Responsibility

Hematology

July 14, 2011

Hgb 8.8** 12-14 Low Give oxygen if

needed

Hct 27.0** 37-47 Low In accordance

with disease

process

WBC 5500 5000-10000 = Normal

Basophil 0 0-6 = Normal

Eosinophil 5** 0-4 High In accordance

with disease

process

Stabs 0 0-5 = Normal

Segmenters 62 55-65 = Normal

Lymphocytes 27 25-35 = Normal

Monocytes 6 0-6 = Normal

Platelets Adequate = Normal

E. Data from TextbookDefinition ofDiagnosis:

Uterine myoma is the most common tumorsof female genitalia tract.Myoma

commonlycalled fibroid is the benign tumor of the smooth muscle in the wall of the uterus.

Theystart of verysmall, actually fromone cell and generally growover the yearsbefore they

cause anyproblem.Most myomas are benign, malignant myomas are very rare.The cause of

fibroids isstill unknown, although it is known that fibroids have a tendency to run in the family.

It may grow as a single nodule or in clusters and may range from 1mm tomore than 20cm in

diameter.Myomas are the most frequently diagnosed tumor of the female pelvis, and the most

common reason for hysterectomy.Their name dependson their location, submucousmyomas

are located at the submucouscavityof the uterine wall and the endometricwall.


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F. Pathophysiology

Uterine cavitystretches in

size

The vascular supply in the

uterus is interfered

Anemia-like

s/sx: paleness,

low rbc,

decreased RR

Proliferation ofCells in the submucous

Overstimulation

Overgrowth of Endometrial

Lining

Myoma or development of

uterine fibroid

Excessively thickened

Endometrium

Predisposing Factors:

- Age- Race- Heredity- EarlyMenarch- Nulliparity

Precipitating Factors:

- Vegetable diet- Anxiety/Stress

Vegetable

diet

Stress

Etiologyunknown

(Idiopathic)Containsover 5000sterols that

have progestogenic effects

Adrenal gland

exhaustion

Increased

Estrogen

Production

Decreased

Progesterone levels

- Swollen breasts- Lossofsex drive- Dysmenorrhea

Pain

Masses

palpated in the

abdomen

Excessive sloughing

of the uterine wall

during menses

Excessive bleeding,

heavymenstrual

Doesnt desquamate easily at the

end ofcycle

Prolonged menstrual

bleeding, dysmenorrhea

Pain, increase pelvic

pressure, increased

abdominal girth & size


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The vascular supply in the

uterus is interfered

Deterioration of

surrounding tissues

Fibroids replace smooth

muscle cells

Degenration of the interior

part of fibroids

Fibroid grows in size

Pressure on adjacent

organssuch as the bladder

and rectosigmoid

Hypermenorrhea,

abnormal bleeding,

dysmenorrhea

Masses

palpatedConstipation and

increased

urination

Disease

Process

Sign and

Symptomsof

Client ILN

Legends:


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G. Drug StudyName Dose,

Frequency,

Classificatio

n

Action Indication Contraindic

ation

Side Effects Nursing

Responsibilit

y

Meperidine

(Demerol/Pe

thidine HCL)

25mg IV q4

for 24 hours

Opioid

Analgesic

Depresses

pain impulse

transmission

at the spinal

cord level by

ineracting

with opioid

receptors;

producesCNS

depression

Moderate

to severe

pain,

preoperat

ively

Hypersensit

ivity

Drowsiness,

dizziness,

constipation,

cramps,

pruritus

Assess renal

function

before

initiating

therapy, poor

renal

function can

lead to

accumulation

of toxic

metabolite

and seizuresPantoprozol

e (Patoloc)

40mg IV OD

while on

NPO

Proton

Pump

Inhibitor

Suppresses

gastric

secretion by

inhibiting

hydrogen/po

tassium

ATPase

enzyme

system in

gastric

parietal cell;characterized

as gastric

pump

inhibitor

since it

blocks final

step of acid

production

Long term

hypersecr

etory

condition

s

Hypersensit

ivity

Headache,

abdominal

pain

Advice

patient to

avoid

hazardous

activities as

dizzinessmay

occur and to

avoid alcohol

as it may

cause GI

irritation

Nalbuphin

(Nubain)

25 mg IV

q4 for

Pruritus

Opioid

Analgesic

Inhibits

ascending

pain

pathways in

limbic

system,

thalamus,

midbrain,

hypothalamu

s by binding

to opiate

receptor

sites, thus

altering pain

perceptionand response

Moderate

to sever

pain,

balanced

anesthesi

a

Hypersensit

ivity

Dizziness,

cramps,

increased

urinary

output,

pruritus

Monitor CNS

changes:

dizziness,

drowsiness,

monitor

allergic

reactions and

give onlywith

resuscitative

equipment

available.

Give slowly

to prevent

rigidity.

Co-

amoxiclav

(Amoclav)

625 mg tab

BID

antiinfective

Interferes

with cell wall

replication of

susceptible

organisms by

Infections

of the

skin

Hypersensit

ivity

Abdominal

pain

Monitor for

bleeding,

identify urine

output, if

decreasing


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binding to

the bacterial

cell wall; the

cell wall,

rendered

osmotically

unstable,

swells and

bursts from

osmotic

pressure

notify

physician

Bisacodyl

(Dulcolax)

15mg in pm

or am if still

no BM

Laxative,

stimulant

Acts directly

on intestines

by increasing

motor

activity;

thought to

irritatecolonic

intramural

plexus;

increases

water in the

colon

Short

term

treatment

for

constipati

on

Hypersensit

ivity,

abdominal

pain

Cramps Discontinue

drug if

cramping,

rectal

bleeding,

nausea and

vomiting areassessed;

give alone

with water

for better

absorption

Acetaminop

hen

(Paracetamo

l )

1 tab PRN

once on

general

liquids

Non opioid

analgesic

May block

pain impulses

peripherally

that occur in

response toinhibition of

prostaglandin

synthesis;

does not

possess

antiinflamma

tory

properties;

antipyretic

action results

from

inhibition of

prostaglandin

s in the CNS

Mild to

moderate

pain or

fever

Hypersensit

ivity

Drowsiness,

abdominal

pain

Monitor renal

function,

check I&O,

assess for

fever andpain

Tramadol

(Algesia)

1 tab PRN

once on

general

liquids

Central

analgesic

Binds to

receptors

and inhibits

reuptake of

norepinephri

ne,

serotonin;

does not

causehistamine

release or

affect heart

rate

Managem

ent of

moderate

to severe

pain

Hypersensit

ivity

Dizziness,

constipation,

pruritus

Monitor I&O,

decreasing

urinary

output may

indicate

urinary

retention

Mefenamic

Acid

500 mg 1

tab as

Inhibits

prostaglandin

Relief of

moderate

Hypersensit

ivity

Headache,

dizziness,

Assess for

risks for CV


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15 | P a g e

needed for

pain (PRN)

Antiinflamm

atory,

analgesic,

antipyretic

synthesis pain tiredness, GI

pain, renal

impairment

events, GI

bleeding and

monitor

accordingly.

Give drug

with food. If

rash,

diarrhea, or

digestive

problems

occur,

discontinue

drug

Ferrous

Sulfate

(Fero-Grad)

1 tabTID x 1

month

Hematinic

Replaces iron

stores

needed for

RBC

development; energy and

oxygen

transport,

utilization,

fumarate

contains 33%

elemental

iron;

gluconate, 12

%, sulphate,

20%; iron,30%; ferrous

sulphate

exsiccated

Iron

deficiency

anemia

Hypersensit

ivity

Constipation,

epigastric

pain

Monitor

blood studies

for toxicity,

bowel

eliminationand nutrition.

Identify

cause of iron

loss or

anemia. Give

between

meals for

best

absorption

and give at

least 1 hourbefore

bedtime

because

corrosion

may occur in

the stomach


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II. Nursing Care PlanDate

identification

Problem List Prioritization

Nursing

Diagnosis

1: Pain

related to

disease

process

2: Risk for

delayed

surgical

recovery

related to

bleeding

tendency

3: Activity

intolerance

related to

pain, surgical

procedure

Assessment Nursing

Diagnosis

Goal Objectives Interventions Rationale Evaluation

Subjective:

The patient

verbalized

that she haspain on the

operation

site and

rated it as

5/10, 10

being the

most

painful

Objective:

>there isguarding on

paint site

>there is a

restriction

in activity as

guarding

motion is

done

Acute

Pain

related to

diseaseprocess,

surgical

procedure

After 4 hours

of nursing

interventions,

the patientspain will be

lessened

After 4 hoursof

nursing

interventions,

the patient will:>describe non

pharmacological

methods to help

control pain

>perform

activities with

reported

acceptable level

ofpain

>describe how

unrelieved painwill be managed

>Prevent any

pain possible

during

procedures>Refer to

physician for

opioid

analgesics

>Teach patient

non

pharmacological

methods to help

control pain

such as

distraction,imagery,

relxation and

application of

heat and cold

>Plan care

activities

around periods

of greatest

comfort

possible

>All pain

must be

avoided

>May help

in pain

relief

>Restores

clients

self

control

and helps

relieve

pain and itis

economic

>Pain

diminishes

clients

activity

After 4 hours of

nursing

interventions:

> the patientspainis rated 3/10

>the patient is able

to describe the

different non

pharmacological

methods to help

control pain and

uses them

>the patient

performs activities

with acceptablelevel ofpain

>the patient could

describe how

unrelieved pain

could be managed

by opioid

prescribed

medications and

nonpharmacological

methods

Assessment Nursing

Diagnosis


Subjective:

Patient stated that

there isstill vaginal

bleeding, pain of

5/10, nausea and

lossof appetite

Objective:

Wound isstill freshinside the dressing

Risk for

delayed

surgical

recovery

related to

bleeding

tendency

After 8 hours

of nursing

interventions

the patient

will show

evidence of

healing: no

redness,

draining orimmobility

After 8 hours

of nursing

interventions

the patient

will:

>State that

appetite is

regained

>State the nonausea is

present

>Demonstrate

activity to

move about

>State that

>Play music

of clients

choice

>Consider

using healingtouch and

other mind

body spirit

interventions

such asstress

control and

>This has

positive

effects in

reduction of

physiological

parameters

and anxiety

>A powerful

way topromote

relaxation

and enhance

healing

process

After 8 hours

of nursing

interventions

the patient:

>showed

evidence of

healing as she

could now and

move aboutand there are

no redness

and drainage

>stated that

her appetite is

gradually


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17 | P a g e

pain is

controlled

and relieved

imagery

>Use careful

aseptic

technique

when caring

for wounds

>Promote

mobility and

deep

breathing

exercises

>Teach

systematic

muscle

relaxation for

pain relief

>If infection

is prevented,

there is faster

healing

>Reduces

pain and

increases

walking

function

>Relieved ain

prevents

complications

and does not

delay

recovery

regained

>stated that

no nausea is

present

anymore

>could go to

the bathroom

by herself

>stated that

her pain is

now3/10

Assessment Nursing

Diagnosis


Subjective:

The patient

stated that

there is pain

on her

operation site

which she rateas 5/10, 10

being the most

painful. She

says that it is

hard to walk,

breathe

deeply, cough

and laugh

because it

causespain

Objective:

>There is

guarding of

pain site

>Patient

remains at bed

rest

>Patient is

careful on her

activities

Activity

intolerance

related to

pain,

surgical

procedure

After 4 hours

of nursing

interventions,

the patient

will

demonstrate

increasedactivity

tolerance

After 4 hours

of nursing

interventions,

the patient

will:

>Maintain

normal skincolor and skin

is warm and

dry with

activity

>Express an

understanding

of the need to

balance rest

and activity

>Position on

high back rest

>Gradually

increase

activity

allowing client

to assist inpositioning,

transferring

and self care

activities

>Perform ROM

>Observe and

document skin

integrity

several times a

day

>Assess for

constipation

>provide

emotional

support andencouragement

to the client to

gradually

increase

activity

>minimizes

cardiac

deconditioning

>Increases

activity

tolerance and

self esteem

>Prevents

muscle

shortening

>activity

intolerance

may lead to

pressure

ulcers

>Impaired

mobility is

associated

with risk for

constipation

>Increases

willingness to

increaseactivity

After 4 hours

of nursing

interventions,

the patient:

>Has

demonstrated

activitytolerance by

being able to

go to the

bathroom

>has

maintained a

normal skin

color and is

dry and warm

with activity

>expresses an

understanding

of the need to

balance rest

and activityby

doing muscle

activitieswhile

on bed rest


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III. Discharge PlanDate ofDischarge: July 18, 2011

1. Medicationsa. Co-amoxiclav 625mg 1 tab BID x 5more daysb. Mefenamic acid 500mg 1 tab as needed for painc. FerrousSulfate 1 tabTID x 1 monthd. Followupon Friday July22, 2011

2. Diet: Diet as tolerated with high protein and high iron diet

3. Activities Restricted: Strenuous exercises Long walks May goback towork ifoperation site is healed and dry

4. Special Health TeachingsObjective: After 2 hoursof health teaching, the patient and her familywill be able to

understand the special health teachings and their importance. Thus theywill follow

suggested teachings and comply.

Methods: Discussion, demonstration and the use of leaflets

Topics:

Teach how tochange dressings and clean wound Remind the patient to take a complete bed rest for three months Discuss how the patient is not in the position tomove around much for a period

ofone month

Discuss that she is not allowed toclimb stairs for three months and not to liftheavy load

Teach significant other how tochange bed linenswith patient in bed rest Teach significant other how to dobed bath and bed shampoo tobe done to the

patient when in bed rest

Teach significant others how toprovide urine bed pan topatient in bed rest Teach significant other and client how tomove patient in bed for every2 hours

toprevent bed sores

Emphasize the importance of complying to medications prescribed by thephysician

Emphasize the importance for showing up for follow up checkups with thephysician

Evaluation:

After 2 hoursof health teachings, the patient and her significant other understood the

importance of following the treatment regimen advised by the doctor and the

importance of the health teachings done.

Documents

Case Study Myoma