GCC Finaal Output

7/29/2019 GCC Finaal Output

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Introduction

A cyst is an abnormal growth that develops as a closed sacsomewhere in the body. A dermoid cyst is a specialized typecontaining many different kinds of tissues including hair, teeth,nerves, bone or fat. It may be present at birth and can be found inthe face, spinal cord or skull. It may also develop in the ovary inwomen during the childbearing years as an ovarian dermoid cyst.

There are two classifications of ovarian cyst; the functional thatinvolves the normal physiology of ovary and non-functional that isindependent from the functions of the ovary. Dermoid ovarian cyst isa non-functional cyst.

Dermoid ovarian cyst is considered a cystic teratoma, consisting ofmixtures of tissues not normally found in ovary that contains matureskin that is complete with sweat glands, hair follicles, pockets ofstale blood, fat, bone, cartilages, nails, teeth, and even traces ofthyroid tissues.


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It is common among women in pre-menauposal age, those with

unhealthy lifestyle like smokers and heavy drinkers, and women withirregular menstrual cycle.

No statistical data available at DOH Region VII and the onlyavailable data is the Vicente Sotto Memorial Medical Center 2012Statistics. Statistically, there were 153 case as of 2012.

Jan-Dec 2012 total cases of ovarian cysts: 153

Breakdown:

Malignant = 42 (27%)

Dermoid = 31 (20%)

Other types= 80 (52%)


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DATA BASE AND SOCIAL HISTORY:

Name : Maria Clara (fictional)

Sex : Female

Age : 36 years oldCivil Status : Married ( year of marriage - 2001 )

Nationality : Filipino

Religion : Roman Catholic

Address : Tuburan, Cawayan, Masbate

Occupation : HousewifeDate of Admission : February 13, 2013

Time of Admission : 12:15pm

Height : 5 feet 3inches

Weight : 49kgs (107lbs)

Accompanied by : Cris Ybarra (Husband - fictional name )

Mode of Admission : Ambulatory

Vital signs : T - 36.6C

P - 95 bpm

R - 20 cpm

BP - 130/90mmHg


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Has client received blood in the past : No

Allergies :

Food : No known food allergy

Drug : No known drug allergy

Admitting Diagnosis : Ovarian cyst, bilateral

Attending Physician : Dr. Melvin Justimbaste


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CHIEF COMPLAINT AND HISTORY OF PRESENT ILLNESS:

Two weeks PTA, client complained of a 2-day, on and off, sharpabdominal pain, both lower quadrants, graded at 8/10 and was admitted for4 days (February 1-4, 2013) at Masbate Provincial Hospital. Client was also

treated for Urinary tract infection during her admission and was prescribedCiprofloxacin, BID. Client unable to recall dose.

Two days PTA, client complained of a 2-day sharp abdominal pain,both lower quadrants, graded at 6/10, and nausea and vomiting secondaryto gastritis. Client did not take any pain medication. Vomited several times

after every ingestion of food but could not recall exactly how many times.Characteristics of vomitus: watery, yellowish, unable to quantify the amount.Client was prescribed Omeprazole, 20mg, BID with very minimal relief.

Client was diagnosed of Bilateral ovarian cysts in 2008. Her primarycare physician told her that no surgery was needed at that time since the

size was too small. Client made few follow-up visits regarding her conditionbut missed the succeeding follow-up visits because her doctor went out oftown and eventually stopped going.


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In November of 2012, client was admitted at Masbate Provincial

Hospital for 6 days due to vaginal bleeding of two (2) week duration

consuming one pad per day and UTI. Client unsure whether or not

bleeding was medically managed during hospitalization.

In December of 2012, client had another episode of Urinary Tract

Infection with accompanying fever.


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I. PERSONAL AND SOCIAL HISTORY

A. Family History

Father : aliveMother : alive

Note : Client is a biological daughter

Rank in the family : youngest, has 6 other siblings

Number of children : none (client had never been pregnant)

Educational attainment : 1st year collegeOccupation of husband : carpenter

B. Living Conditions

Client and her husband owned a house

- house is made of wood and metal roofing

Number of rooms : 2

Number of people staying in the house: 3 ( client, husband and1 year old adopted daughter )


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Note: Client lived in a remote village in the barrio, away from the

town proper where public transportation is poorly accessible.


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C. Nutrition

Mealtimes : breakfast- 8am, lunch- 12nn, dinner- 7pm

Client had snacks in between meals

Usual 24-hour diet : rice, fish, dried fish, egg, vegetables, pork,bread, banana, papaya

Water intake : 4-6 glasses per da

very seldom drinks other beverages such as soft drinks, juice andcoffee

Food likes and dislikes : None


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D. Sleeping Patterns

Nap : 2-3hours per day between

1pm and 4pm

Awaken at night as she had to tend to their adopted daughter

Client snored

Comfortable sleeping position : varies ( supine and side-lying )

Used 2 pillows for comfortable sleeping

Denied any other sleeping abnormality


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E. Elimination Patterns

Frequency of bowel movements : once every 2-3days (2-3x/week)

Usual time of defecation : morning

Consistency : hardColor : brown

Amount : 1/4 to 1/2 cup (50-100ml)

Note : Frequently experienced constipation

Frequency of urination : 7x per day

Color : yellow

Amount : 50ml


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F. Physical Hygiene

Frequency of Bathing : once a day

Used "SAFEGUARD" brand

Frequency of Shampooing : daily

Used "HEAD AND SHOULDER" brand

Frequency of handwashing : as often as necessary

Frequency of Toothbrushing : once to twice per day

Used "CLOSE-UP" brand


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G.Environmental Sanitation

Water source : deep well for laundry and bathing

purified water for drinking (water is stored in

a jar with cover)

- as per client, they had their

own water purifier

Mode of humanwaste disposal : toilet pit

Garbage disposal : they burned their garbage at the backyard on

a daily basis

Note: Clients house is away from industrial factories


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H. Social Activity

Sports: None

Hobby / Habits: Watching TV, vegetable gardeningVices: Denied engaging in any vices

Denied smoking, drinking alcoholic beverages and

gambling

NOTE: Client's lifestyle is very laid back.


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II. MEDICAL HISTORY

A. Heredo-Familial Disease

Diabetes Mellitus - maternal side

Hypertension - paternal side

B. Communicable Diseases

Client denied any communicable diseases occurring in the family.


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C. Obstetrical and Gynecological

Menstruation

Onset - 16 years old

Duration - 3-5daysCycle - abnormal since the last 10 years ( unable to

determine variations )

Character - scanty

Discomforts - frequently experienced dysmenorrhea

OB score - client had never been pregnantLMP - November 28, 2012


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D. Previous Illness/Surgery

Client denied any other illness not related to the current

medical condition except for fever, cough and common cold.


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SYSTEMS ASSESSMENT

A. COMMUNICATION

Subjective: " Wala ra koy problema sa akong panan-aw, pandungogug pag-istorya" as verbalized by the client.

Objective: - client did not wear eyeglasses / contact lenses

- pupils equal in size (4mm)

- (+) PERRLA- able to read fine prints without difficulty usingmagazines

- had slight difficulty identifying letters at a distancemore than 10feet

- client did not wear hearing aides

- able to hear normal voice tone clearly- able to hear whispered words without difficulty

- responded to every question asked correctly

- spoken without difficulty

- spoken and understood Cebuano


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B. OXYGENATION

Subjective: " Okay lang ang akong pag-ginhawa; wala ra man kogiubo; dili man ko manigarilyo ug wala pud ko kasulay " as

verbalized by the client.

Objective: - face and lips evenly colored, no prominentdiscoloration

- nailbeds have light pink tones

- breathing is quiet, relaxed and effortless

- RR- 20cpm, regular- capillary refill time normal (less than 2 sec)

- (+) equal chest expansion

- (+) resonance on percussion

- no noise heard during normal breathing

- no adventitious sound on auscultation- no cough


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C. CIRCULATION

Subjective: " Wala ra koy gipamati nga sakit ug pamanhod sa akong

dughan ug tiil " as verbalized by the client.

Objective: - no ankle edema

- Radial pulse - 95bpm, Apical pulse- 98bpm, regular,

strong

- BP- 130/90 mmHg- capillary refill time normal (less than 2 secs)

- lower extremity sensation intact on palpation


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D. NUTRITION

Subjective: " Hangtod karon, naa gihapon panahon nga kasukaon ko;mahadlok ko mokaon kay ako ra unya isuka; wala ra koy problemasa pagtulon; ninggamay akong timbang " as verbalized by the client.

Objective: - no dentures

- did not eat hospital food

- ate 1/2 cup oatmeal prepared by her husband (5times a day)

- consumed 2 individual packs of skyflakes whole day- consumed 1/2 glass water after having oatmeal

- body weight in Feb. 1, 2013 - 53kgs ( 116lbs )

- body weight in Feb 13, 2013- 49kgs ( 107lbs )

- always lying in bed

- appeared tired and weak- on DAT (diet as tolerated)

- D5 Normal saline solution

- D5 normosol-M


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E. ELIMINATION

Subjective: " Sukad sa akong pagka-admit, kausa pa lang konakalibang, ganinang alas 830 sa buntag; gahi man gihapon

akong ta-e; magsige gihapon ko ug ihi-ihi ika-7 sa usa ka adlaw;wala ray sakit inig pangihi nako" as verbalized by the client.

Objective: - stool characteristics: hard, yellow, aromatic, 50ml inamount

- urine: yellow in color, 50ml- (+) tenderness on both lower quadrants on palpation

- (+) dullness on percussion

- hypoactive bowel sound on auscultation

- Dulcolax suppository given on Feb. 14, 2013


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F. MANAGEMENT OF HEALTH AND ILLNESS

Subjective: " Namaligya na lang mi ug yuta para ibayad sa hospital ugsa operasyon; nabalaka gyud ko sa resulta sa operasyon; walaman gyud ko kasulay anang pap smear ug eksaminasyon sa totoy"as verbalized by the client.

Objective:

- compliant with medications during hospital stay

- preoccupied

- weakness- diminished productivity

- client always lying in bed

- expressed concerns

- decreased appetite


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G. SKIN INTEGRITY

Subjective: " Wala ra man koy problema sa akong panit; wala ra koy

mga katol-katol " as verbalized by the client.

Objective: - presence of IV line on the right wrist

- no rashes/lesions

- skin turgor normal

- skin was dry and warm to touch


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H. ACTIVITY AND SAFETY

Subjective: " Dili ra man ko malipong kung mobangon ug mobarog ko;kapoy ug luya lang gyud akong pamati sa akong lawas " asverbalized by the client.

Objective:

- V/S : BP-130/90mmHg, RR- 20cpm, PR- 95bpm

- observed client always lying in bed

- though client hesitant to get up and move around,

was able to use toilet with supervisionfor safety

- alert, awake and oriented (time, place and person)

- able to walk without assistive device but slow paced,decreased cadence

- slow, steady gait with supervision for safety

- no joint limitation of movement on active-range-of-motion

- minimal guarded movements

- exhibited decreased endurance during activity


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I. COMFORT / SLEEP / AWAKE

Subjective: " Sakit pa gihapon akong tiyan pero madala ra man (4/10), magwala-wala lang ang sakit; panagsa makamata ko inig kagabii para mangihi " as verbalized by the client.

Objective: - V/S : BP - 130/90mmHg, RR - 20cpm, PR - 95bpm

- observed minimal facial grimaces duringmovements/activities

- exhibited minimal guarded movements during

activities- observed client always lying in bed

- client hesitant to smile during interview

- facial expression looked tired


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J. COPING

Subjective: " Nag-guol ko sa akong kahimtang; gusto man ko

magpa-opera, wala pa lang schedule" as verbalized by the client.

Objective : - client frequently demonstrated attention-seeking

behavior from the husband

- client open to questions regarding her medical

condition- observed client dependent on the husband and

hesitant to perform ADLs

- observed client not smiling during

interview/assessment


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HEAD TO TOE ASSESSMENT

A. HEAD AND FACE

HAIR:- hair color was black

- shoulder length

- scalp was clean and oily

- no dandruff and head lice noted

- no lesions

HEAD:

- symmetrical, round, erect and in the midline

- no visible lesions noted

- no involuntary movements noted- consistency was hard and smooth without lesion on palpation


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FACE:

- symmetrical with an elongated appearance

- no abnormal movements noted

- temporal artery non-tender on palpation and pulsation is palpable

- Temporo Mandibular Joints no swelling, non-tender and no crepitationduring movement

- mouth opened and closed fully

- lower jaw moved laterally both sides

B. NECK

- symmetrical with the head at the center and without bulging masses

- the thyroid cartilage, cricoid cartilage and thyroid gland moved upwardsymmetrically during swallowing

- neck movements Within Normal Limits during active range of motion(flexion, extension, lateral flexion and rotation)

- trachea located at the midline


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C. LYMPH NODES OF THE HEAD AND NECK

- no swelling, no enlargement and no tenderness on palpation ( pre-auricular, post-auricular, occipital, tonsillar, submandibular,submental, superficial cervical, posterior cervical, deep cervical andsupra-clavicular nodes)

D. EYES

- the upper and lower eyelids closed easily and met completely whenclosed

- eyelashes were evenly distributed

- eyelids no redness, no swelling, no lesions- sclera is white

- pupils equal in size (4mm), round and centered in the iris

- iris round and evenly colored (black)

- pupils equally round, reactive to light and accommodation (PERRLA)


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E. EARS

- the auricles aligned with the corner of each eye, equal in size

- skin is smooth

- color consistent with facial color

- no lesions, lumps or nodules

- no discharges noted

- no tenderness on palpation

F. MOUTH- lips are smooth, dry and without lesions/swelling

- lip color- light pink

- complete set of teeth noted

- no repaired or decayed areas

- gum color- light pink , no lesions/masses- tongue- light pink, dry and no lesions


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G. NOSE

- nasal color is consistent with facial color

- nasal structure is smooth and symmetrical

- no lesions/tenderness

- no swelling/flaring- no discharges

- presence of nasal hairs noted

H. THORAX AND LUNG

GENERAL ASSESSMENT

- lips and face evenly colored and no prominent discoloration

- nail beds light pink in color

- no cough noted

- no pain/discomfort during respiration

- breathing is relaxed, effortless and quiet

- no noise heard during respiration-breathing pattern is normal ( no abnormality in the rate, rhythm and

depth )

- RR 20cpm


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POSTERIOR THORAX:

- scapulae are symmetrical and non-protruding

- no kyphosis noted

- no tenderness/pain or unusual sensations- no masses noted

- symmetrical chest expansion noted

-normal tones elicited on percussion (resonance over lung tissue and

flatness over the scapula)

- no adventitious sounds noted on auscultation


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ANTERIOR THORAX:

- anteroposterior diameter is less than the transversediameter

- sternum is straight and positioned at midline

- no sternal retractions noted

- ribs sloped downward with symmetrical intercostal spaces

- no retractions/bulging of intercostal spaces duringrespirations

- chest color is fairer compared to the rest of the body andwithout lesions/masses

- expansion of the abdomen and lower ribs noted oninspiration and return to resting position on expiration

- no tenderness/pain on palpation

- no masses/lesions- symmetrical chest expansion noted

- normal tones elicited on percussion ( resonance over lungtissue and intercostal spaces )

- no adventitious sounds noted on auscultation


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I. HEART

- apical impulse not visible on inspection

- heart sound audible with the use of a stethoscope

- apical pulse - 98bpm

J. ABDOMEN

- skin is fairer compared to the rest of the body

- smooth and without lesions/rashes

- no scars noted

- umbilical skin tone similar to the surrounding abdominal skin tones- umbilicus is located at midline, inverted (recessed)

-abdominal contour- distended, protuberant due to the cysts

- abdominal asymmetry noted; left side is bigger than the right side

- abdominal girth- 28 inches (measurement taken at the level of theumbilicus)

- hypoactive bowel sounds noted- dullness elicited on percussion on both lower quadrants

- palpable masses noted on both lower quadrants

- tenderness elicited on palpation


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K. UPPER EXTREMITIES ( Shoulders, Elbows, Wrists, Hands andFingers )

- skin color is brown

- no redness

- no swelling- no lesions, masses, nodules

- no tenderness

- no numbness, sensation is intact

- no joint limitation on AROM except the right wrist due to presence ofIV line

L. LOWER EXTREMITIES ( Hips, Knees and Ankles )

- skin color-brown

- no redness

- no swelling

- no lesions, masses and nodules- joints are stable, no tenderness, no crepitus

- sensation is intact, no numbness

no joint limitation on AROM against resistance

O S SO SS SS


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NEURO-SENSORY ASSESSMENT

Fainting spells / Dizziness : Denied experiencing dizziness; no faintingspells

Headache : Denied occurrence of headacheHistory of Stroke : Denied history of stroke

Seizure : Denied occurrence of seizures

Mental Status : Oriented x 3 (time, place and person)

Memory : Intact both recent and remote memory

Client was able to recall both recentand remote events

Speech Pattern : Normal Speech pattern

No slurring of speech

Words are clear and comprehensible

Deep Tendon Reflexes : Triceps, Biceps and Patellar Reflexes : 2+(Normal)


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CRANIAL NERVES

1) OLFACTORY NERVE (CN 1)

Remarks : Intact. Client was able to identify scent correctly (bath

soap).

2) OPTIC NERVE (CN II)

Note : Snellen chart not available

Remarks : Client was able to read fine prints without difficultyusing magazines.

Exhibited difficulty identifying letters at a distance ofmore than 10feet.

Peripheral vision intact.

3) OCULOMOTOR NERVE (CN III)

Remarks : PERRLA ( Pupils Equally Round, Reactive to Lightand Accommodation )

4) TROCHLEAR AND ABDUCENS NERVES (CN IV AND


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4) TROCHLEAR AND ABDUCENS NERVES (CN IV ANDVI)

Remarks : Intact cardinal gaze

Client able to move each eye upward,

downward, diagonally and laterally.

5) TRIGEMINAL NERVE (CN V)

Remarks : Intact motor function

Positive contraction of the temporal andmasseter muscles when clientclenched her teeth

Positive corneal reflex.

Client's eyelids blinked bilaterally when

cornea was lightly touched with a finewisp of cotton.

Intact sensory function

Client was able to correctly identify sharp anddull stimuli and light touch to the

forehead, cheeks and chin.


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7) ACOUSTIC NERVE (CN VIII)

Remarks : Intact cochlear component.

Client was able to hear whispered words at a distanceof 2feet.

Note : Weber and Rinne Tests not done. Tuning fork notavailable.

Intact Vestibular component.

Balance was intact.

(-) Romberg test. Client was able maintain standingposition for 20secs with minimal swaying with

feet together and arms on the sidesand eyes open and then closed.

8) GLOSSOPHARYNGEAL NERVE (CN IX)

Remarks : Motor function intact.

Gag reflex elicited upon touching the posterior pharynxwith a tongue depressor.

Sensory function intact.

Client was able to correctly identify coffee and tablesalt.

9) VAGUS NERVE (CN X)


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9) VAGUS NERVE (CN X)

Remarks : Motor and Sensory functions intact.

Client was able to swallow without difficulty by drinkinga glass of water.

10) ACCESSORY NERVE (CN XI)

Remarks : Intact

Client was able to do shoulder shrugs againstresistance.

11) HYPOGLOSSAL NERVE (CN XII)

Remarks : Intact

Client was able to protrude the tongue, put it back inthe mouth and move it side to side against

resistance.


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Laboratory tests and Diagnostic Tests


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Hematology

Laboratory Patients

Result

Feb 1311:40pm

Significance Patients

Result

Feb 141:55pm

Significance Reference

Value

Hgb

mass conc.

9.5 Decreased

due to

history of

blood loss

12 There shows

an

improvement

in the value.

Based onreference

values its

within

normal limit

F: 12.0 -

16.0 gm/dL

Hct

(RBC vol.fraction)

0.3 Decreased

due tohistory of

blood loss

0.36 There shows

animprovement

in the value.

But based

on reference

value its

below

normal limit

F: 0.37 -

0.47 %


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Laboratory Patients

Result

Feb 13

11:40pm


Result

Feb 14

1:55pm


Value

WBC 9.25 Within

normal limit

10.38 Within

normal limit

5-10.8 x

109cells/L

RBC 3.76 Decreased

due to

history ofblood loss

4.06 There shows

an

improvementin the value.

Based on

reference

values, its

within

normal limit

F: 4.0 - 5.5 x

1012 cells/L

L b P i Si ifi P i Si ifi R f


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Laboratory Patients

Result

Feb 13

11:40pm


Result

Feb 14

1:55pm


Value

Thrombocytes

(Platelets)

469 Increased

due to

history of

blood loss

410 There

shows an

improveme

nt in the

value.

Based on

reference

value, its

within

normal limit

140-440 x

109/L

Diff ti l C t


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Differential Counts

Neutrophils 0.55 Within

normal

limit

0.63 Within

normal

limit

0.51 0.67

Lymphocyt

es

0.38 Within

normal

limit

0.31 Within

normal

limit

0.25 0.40

Monocytes 0.05 Withinnormal

limit

0.06 Withinnormal

limit

0.02-0.08

Eosinophils 0.02 Within

normal

limit

No data

available

0.01-0.06

F b 13 2013 2 45 PM U i l i


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Feb. 13, 2013 2:45 PM Urinalysis

Laboratory Patients Result Reference

Value

Significance

Macroscopic:

Color Yellow Yellow Normal

Transparency Clear Clear Normal

Specific gravity 1.02 1.003 1.03 Within normal

limit

Protein Negative Negative Normal

Glucose Negative Negative Normal

Mi i


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Microscopic

RBC/HPF 0-2 1-2 Within normal

limit

WBC/HPF 3-6 2-4 Increased in

UTI

Epithelial cells Moderate None Increased in

UTI

Bacteria Abundant None Increased in

UTI

F b 13 2013 C ti i


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Feb. 13, 2013 Creatinine

Laboratory Patients Result Reference

Value

Significance

Creatinine

Priority: routine

Fluid : serum

0.7 mg/dL 0.7-1.5 Within normal

limit

F b 13 2013 1 00 PM Ch i t


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Feb. 13, 2013 1:00 PM Chemistry

Laboratory Patients

Result

Reference

Value

Significance

Glucose

(RBS)

119 70 130

mg/dL

Within

normal limit

F b 13 2013 1 07 AM Bl d T i


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Feb. 13, 2013 1:07 AM Blood Typing

Laboratory or

Diagnostic Testing

Patients Result Significance

ABO A

To anticipate Blood

Transfusion, should

the patient need oneRH +

Feb 13 2013


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Feb. 13, 2013

Radiology Report

Name : Maria Clara Gender: Female

Address: Tuburan, Cawayan Masbate

Age : 36 years old DOB: 12/19/1976

Conclusion:

Negative Chest Favorable

F b 13 2013 8 39 AM I l


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Feb. 13, 2013 8:39 AM Immunology

Laboratory Patients

Result

Reference

Value

Significance

CA-125 46.9 < 35 U/mL,the generally

accepted

upper limit

Elevated

Feb 123 2013 4:05 PM


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Feb. 123, 2013 4:05 PM

Ultrasound Report


Address: Tuburan, Cawayan Masbate

Age : 36 years old DOB : 12/19/1976

Case # : 13-033

Date : 2/13/13 16:05:27

Examination: Whole abdomen

LMP : November 28, 2012

Remarks:

The right kidney measures 9.6 cm x 4.3 cm.

The right renal cortex measures 1.2 cm. Mild hydro-nephrosis

The left kidney measures 9.2 cm x 5.4 cm.

The left renal cortex measures 1.7 cm

Conclusion:

Normal liver, Pancreas, GB, Spleen, Left Kidney, Ureters,

Urinary Bladder, and Uterus

Mild hydro-nephrosis in the right kidney probably due to infections. Not favorable

Feb. 14, 2013 12:33 PM


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Ultrasound Report


Address : Tuburan, Cawayan Masbate

Age : 36 years old DOB : 12/19/1976

Case # : 035

Date : 2/14/13 12:33:08

Examination: Transvaginal Ultrasound

LMP : November 28, 2012

Remarks:

Posterior to the uterus and within the right adnexa is a cystic structure measuring 59. x 6.9 x4.4 cm, thick-walled, unilocular, containing hyperechoic lines and dots.

Posterior to the uterus and within the left adnexa is a cystic structure measuring 8.2 x 5.3 x6.2 cm, thick-walled, multilocular, also containing hyperechoic lines and dots

Impression:

Normal-size anteverted uterus with intact trilaminar endometrium Favorable

Bilateral ovarian cyst, probably dermoid Not favorable

No culdesac fluid Favorable


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Human Anatomy and Physiology


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Ovaries:


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Ovaries:

- Ovaries are located close to and on both sides of the uterusin the lower abdomen. It is difficult to locate them byabdominal palpation because they are situated so low in theabdomen.

- the ovaries are approximately 4 cm long by 2 cm in diameterand approximately 1.5 cm thick, or the size and shape ofalmonds.

- they are grayish white and appear pitted, or with minuteindentations on the surface.

- the ovaries are held suspended and in close contact with theends of the Fallopian tubes by three strong supportingligaments attached to the uterus or the pelvic wall.

- the function of the two ovaries is to produce, mature anddischarge ova

- in the process, the ovaries produce estrogen andprogesterone and initiate and regulate menstrual cycles.

Pituitary Gland


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Pituitary Gland

- Pituitary Gland is a small, bean-sized organ

that is located at the base of the brain and isconnected to the hypothalamus by a stalk.

The pituitary gland secretes many essential

hormones for growth and sexual maturation.

- produces two hormones; follicle stimulating

hormone and luteinizing hormone


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the second pituitary hormone luteinizing


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- the second pituitary hormone, luteinizinghormone continues to rise in amount and actson the follicle cells of the ovary. It influencesthe follicle cells to produce lutein, a bright-yellow fluid.

- lutein is high in progesterone and contains

some estrogen. This yellow fluids fill theempty follicle , which is termed a corpusluteum

-If fertilization does not occur, the corpusluteum in the ovary begins to regress after 8to 10 days. As it regresses, the production ofprogesterone and estrogen decreases.

- every month during fertile period of a women's life,


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y g pone of the ovary's primordial follicles is activated byfollicle stimulating hormone to begin to grow andmature

- as it grows, it's cells produce a clear fluid thatcontains a high degree of estrogen and someprogesterone.

- as the follicle reaches its maximum size, it is

propelled toward the surface of the ovary. A fullmaturation the small ovum with its surroundingfollicle membrane and fluid, is termed a graafianfollicle.

- when the graafian follicle is mature,the pituitarygland releases luteinizing hormone that increasesthe prostaglandin so the graafian follicle ruptures

- the ovum is set free from the surface of the ovary, aprocess termed ovulation


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Pathophysiology


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Medical-Surgical

Management

IDEAL ACTUAL


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DIAGNOSTICS:

Urinalysis

-To identify presence ofinfection.

Transvaginal Ultrasonography

-To define cysts morphologic

characteristics.Abdominal Ultrasonography

-Allows assessment of other

intra-

abdominal structure.

CT Scan

-Best in imaging the ovarian

cysts and distinguish other intra

abdominal causes.

-Done (Feb. 13, 2013)

-Done (Feb.14,2013)

-Done (Feb.13, 2013)

-Not done.

IDEAL ACTUAL


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DIAGNOSTICS:

MRI- To identify fat and blood products

and provide idea of the organ of origin for

gynecological masses.

Hormone Test

- Evaluates hormonal balance in both

pre- and post menopausal women, using asingle blood sample.

Pregnancy Test

-To detect pregnancy

Laparascopy

- for visualization.

-Not done.

-Not done.

-Not done.

Chest X-Ray

-Use ionizing radiation to create pictures ofstructures inside the chest such as heart,

lungs and blood vessels.

-Done (Feb.13, 2013)

IDEAL ACTUAL


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IDEAL ACTUAL

LABORATORY:

Complete Blood Count

-To detect any blood

dyscrasias.

Creatinine Test

-Measures kidney

function.

Blood Typing

-To identify blood group toanticipate blood transfusion

should the patient requires.

Done (Feb. 13, 2013 and

Feb.14, 2013)

Done (Feb. 14, 2013)

Done ( Feb.13, 2013)

IDEAL ACTUAL


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MEDICATIONS:

Nonsteroidal Anti-inflammatory Drugs

(NSAIDS)-Pain reliever, mild to moderate

pain

Narcotic Analgesics

-Pain reliever, moderate to

severe pain.D5 NSS

-Hypertonic solution, for

replacement or maintenance of fluid

and electrolyte.

D5 NM

-Hypertonic solution, parenteral

maintenance of routine daily fluid and

electrolyte requirement w/ minimal

carbohydrate calories from dextrose.

Not ordered.

Not ordered.

Ordered (Feb. 13, 2013)

Done (Feb.14, 2013)

IDEAL ACTUAL


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MEDICATIONS:

Ranitidine

-Anti- reflux agent

-Ordered (Feb. 14, 2013)

Dulcolax Suppository

-Laxative-Ordered (Feb. 14,2013)

once only

Omeprazole

-Gastric Anti-secretoryagent

-Ordered (Feb.14,2013)

IDEAL ACTUAL


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MEDICATIONS:

Metoclopramide

-Anti-emetic agent


STAT

Metronidazole-antibiotic


Ciprofloxacin

-Antibiotic-Ordered (Feb. 14, 2013)

IDEAL ACTUAL


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TREATMENT:

Blood Transfusion

used to replace blood lost.

DIET :

Increase fluid intake

-fluid and electrolytereplenishing

Foods rich in Protein

-to promote tissue repair

and healing Foods rich in

Carbohydrates

-provide energy for the

body

Ordered (feb.14,2013)

DAT ( DIET AS TOLERATED)

IDEAL ACTUAL


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DIET :

Foods rich in Iron

-Manage and prevent anemia

Foods rich in Vitamin C

-To boost immune system

Foods rich in Vitamin E

-antioxidant that protects body tissue

from damage caused by substances

called free radicals

D5 NM

-Hypertonic solution, parenteral

maintenance of routine daily fluid and

electrolyte requirement w/ minimal

carbohydrate calories from dextrose.D5 NSS

-Hypertonic solution, for replacement

or maintenance of fluid and electrolyte.

Done (Feb.14, 2013)

Done (Feb.13,2013)

IDEAL ACTUAL


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SURGICAL:

Laparatomy

-to remove cyst in a largeincision.

Laparascopy

- for visualization.

TAHBSO ( Total AbdominalHysterectomy Bilateral

Salpingo Oophorectomy)

-surgical removal of the

affected ovaries and uterus

Colostomy

- provides an alternative

channel for feces to leave the

body.

Not done.


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11 KEY AREAS OF RESPONSIBILITY

A. Safe and Quality Nursing Care


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y g

Assisted patient during ambulation, upon getting up

and in lying down, and in going to the comfort room.

Obtained consent from the patient when taking vitalsigns.

Explained to patient the purpose and/or significance

of the procedure done to her present condition like

monitoring of vital signs, intake/output and

administration of medications.

Given patient enough time to rest in between

procedures.

Minimized noise to promote comforting/relaxing

environment.

Made sure nothing was cluttered on the floor

especially where patient is walking around.

A. Safe and Quality Nursing Care


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Made sure the floor was not wet and/or slippery.

Evaluated patients response to medication after 30minutes of administration.

Taught patient and significant other regarding properhygiene especially stressing on the importance ofhand washing to prevent spread of microorganismsthat may cause infection.

Stressed on patient and significant other regardingfood intake especially foods rich in protein whichpromotes tissue repair and vitamin C to boost immunesystem as well as high in fiber to manageconstipation. Avoid gas-forming foods like potatoesand sweet potatoes and carcinogenic foods like grilledand char-broiled foods.

- Discussed patients medical condition only amonghealthcare providers involved in the patients healthcare

management.

B. Management of Resources and


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g

Environment

Took patients vital signs as scheduled.

Accompanied patient to the comfort

room.

Encouraged patient to reposition every 2hours to prevent respiratory

complications.

Checked IVF patency regularly. Discarded used needles at the sharp

box/receptacles as delegated by the

nurse.

C. Health Education

T ht ti t d i ifi t th di


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Taught patient and significant other regarding proper

hygiene especially the importance of hand washing to

avoid spread of microorganisms that may cause

infection.

Reinforced to patient and significant other that patient

should eat foods that are rich in protein to promote

tissue repair, vitamin C to boost immune system and

those rich in fiber to manage constipation. (At leastsmall frequent feedings.) Avoid gas-forming foods like

potatoes and sweet potatoes.

Monitored family/clients response by letting them

verbalize what they understood about the proceduresdone to her.

Documented patients vital signs and referred to

patients baseline data at the patients chart for any

abnormalities.

D. Legal Responsibility


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g p y

Carefully identified the right patient and re-

checked data before administering medications.

Documented every intervention/procedure done

to patient like taking of vital signs and

administration of medication carefully and

correctly in the patients chart with the clinicalinstructors supervision and had it countersigned.

Referred to patients chart to check for

interventions/procedures ordered by the

physician, and done every intervention with theconsent and supervision of the clinical instructor.

E. Ethico-Moral Responsibility


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y

Provided confidentiality by discussing

patients medical condition only among

healthcare providers involved in thehealthcare team.

Respected patients religious practices.

F. Personal and Professional Development


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Done every nursing interventions/procedures

especially the administration of medications

always with the supervision of the clinicalinstructor.

Discussed with the healthcare team involved in

the patient care relevant data regarding patientscondition and suggested ideas which may be

helpful to the patient care.

Addressed patients needs and set them to

priorities based on clinical judgment. Involved patient as well as her significant other in

the plan of care management for the patient.

G. Quality Improvement


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Referred to patients chart for data regarding patients

health status to know whether she has improved with all

the interventions/procedures done. Monitored patients response after every

intervention/procedure done.

Documented carefully all data gathered after every

interventions done like taking of vital signs andadministration of medications.

Reported to the nurse-in-charge any deviances noted with

the patient like her increase in blood pressure after she

took one of her medication.

Took vital signs when patient reported that she felt dizzy

after she took one of her medications, reported the data

to the nurse-in-charge and documented it accurately on

the patients chart.

H. Research


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Discussed among healthcare team regarding

priority needs and problems of the patient.

Consulted with the clinical instructor/ nurse on

duty regularly to discuss patients health

status as well as data gathered from the

patient.

I. Records Management


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Documented accurately relevant data of

interventions done like taking of vital signs and

administration of medication on the patientschart with the supervision of the clinical

instructor.

Asked permission when using the chart.Returned the chart after using.

J. Communication


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Provided open communication with the patient and

significant other to allow them to express feelings, needs

and problems with regards to the patients condition. Readily addressed patients concerns and needs right

away.

Allowed patient to verbalize feelings and concerns after

every intervention/procedure done to her. Stayed and listened to patient, given her time to talk to

establish rapport and confidence.

Reported/relayed patients concerns regarding her

condition/care to the appropriate member of thehealthcare team. (Clinical Instructor/Nurse-in-charge)

K. Collaboration and Teamwork


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Reported to nurse-in-charge/clinical instructor any

deviances noted with the patient especially when

taking vital signs and administration of medications. Assisted nurse-in-charge whenever she performed

certain interventions/procedures to the patient like

administration of medication.

Coordinated with the nurse-in-charge and clinicalinstructor whatever interventions/procedures to be

done like monitoring of vital signs every 4 hours and

administration of medications, and reported and

documented accurately data gathered especially any

deviations noted.

Referred patient to social welfare services for

financial support.


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Discharge Planning

-Advise patient to :


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MEDICATIONS

-take medications with right dose,

frequency and route as prescribed.

-complete full course of

medications as ordered.

-properly and safely store

medications

-report/ call physician for any signs

of adverse/anaphylactic reactions.

EXERCISE

- Encourage patient to perform

progressive ambulation exercises

by gradually increasing distanceand/or duration.

-Advise patient to comply with all

laboratory examinations as


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TREATMENT

laboratory examinations as

ordered.

HEALTH TEACHING

-Advise patient to :-practice proper hygiene especially

hand washing and mouth care.

-take enough rest/sleep at least 8

hours

-observe proper perineal care,

front to back

-Avoid interacting with people

having infections

-have small frequent feeding

-Advise patient to comply with

h d l d f ll i it ith


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OUT- PATIENTscheduled follow up visits with

her primary care physician.

DIET

-Advise patient to:

-increase fluid intake at least

2,500ml daily

-Encourage patient to eat

foods rich in Vitamin C,Vitamin E, protein, Iron and

carbohydrates.

-Avoid fatty/oily and spicy

foods-Encourage patient to include

high fiber in the diet.

SPIRITUAL R t ti t li i

Documents

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