Myoma Final Power Point

A case presentationOf a Patient with

UTERINE MYOMA

IRISH C. EDOMBINGOBSN III-A

OBJECTIVES OF THE CASE PRESENTATION:

GENERAL OBJECTIVEAt the end of my case presentation, the

listeners would be able to gain knowledge and understand the case of a patient with Myoma Uterine, also to enhance skills in differentiating the difference of uterine myoma and also to improve their attitude towards patients with the same case as mine and in caring for the patients with this kind of case.

SPECIFIC OBJECTIVES:At the end of my case study presentation of Uterine myoma, the listeners

will be able to: Identify and understand my patient’s case. Know the clinical manifestations of the illness. Determine the different treatment for this case. Identify the diagnostic test to be done. Differentiate the normal from abnormal findings in my patients

laboratory results. Know the care plans for patients with this case. Trace and understand the Pathophysiology. Review the Anatomy and Physiology of the Reproductive System

OVERVIEW

Uterine fibroid tumors or leiomyomas are among the most common tumors among women. In fact, it is apparent in 25-50% of women. Uterine fibroid tumors are typically non-cancerous.

Patient’s Profile

Name: Patient “x”Age: 41 y/oSex: FemaleCivil Status: SingleAddress: Alano extension, Pagadian

CityOccupation: NoneDate of birth: May 18, 1968

Place of birth: Davao del SurReligion: Roman CatholicFather’s name: Juanito PantullanaMother’s name: Remedios PantullanaAdmission date: February 28, 2010Admission time: 10:40 amRoom/Ward: OB-WARDChief complain:

Hypogastric painADMISSION DIAGNOSIS: Uterine Myoma

Attending Physician: Dr. Chandra SalvadorHistory of Past illness:

The patient was never been hospitalized before and had not experienced any kind of diseases. She only had mild illness such as cough, fever and headache. She also experienced dysmenorrhea in the 1st – 2nd day of her menstruation

History of Present illness:3 years prior to admission, the patient

noticed a mass on hypogastric area of her abdomen. She thought that it was only due to her loaded works and stress and so, she only consulted a “hilot”. She didn’t mind to have a consultation on a doctor because of lack of financial budget.

1 year prior to admission, the patient had undergone free medical check up from the company where she was working with and so, the UTZ’s result found out that she had an enlarged uterus with intramural myoma uterine.

PHYSICAL ASSESSMENT

GENERAL SURVEY:Received lying on bed conscious and coherent

without IVF. Patient is conscious and coherent, and also responsive to certain questions and instructions given to her. Tension and increased alertness was noted on the patient upon receiving her.

VITAL SIGNS: T = 36.3oC P = 70 bpm R = 26 cpm BP = 120/70 mmHg

SKIN warm to touch on upper extremities like in the palm of her hands cold temperature on the sole of the client Fair skin and brown in color Has a good skin turgor upon palpation Presence of scars on both upper and lower extremities HAIR Equally distributed hair Black with some white hair in color Slightly coarse No nodules, lumps and tenderness noted upon palpation Absence of lice and dandruff NAILS Nail beds are pinkish in color Smooth texture short nails with dirt noted good capillary refill, less than 2 seconds

EYES symmetrical pupils are equally round and reactive to light accommodation pupils are black in color sclera is white eyebrows and eyelashes are equally distributed eyelashes are slightly curve pupils constricts symmetrically when lighted with a penlight Blurred vision on her both eyes

EARS no deformities symmetrical no cerumen and dirt noted uniform in color no discharges noted mobile, firm, and not tender upon palpation helix of ears are in line with the outer canthus of the eye

NOSE AND SINUSES nose is located in the midline of the face symmetrical proportionate to the face absence of discharges no nasal flaring uniform in color no skin breakdown nasal septum intact nasal hairs are evenly distributed no tenderness and pain upon palpation on facial sinuses MOUTH dry lips pinkish colored gums uvula is located at the midline of the soft palate teeth are yellowish in color with dental caries on his upper teeth hard palate is light pink in color tonsils are not inflamed buccal cavity is pinkish in color restricted tongue movement

NECK AND THROAT neck muscles are equal in size absence of swollen lymph nodes trachea is centrally aligned no tenderness noted no thyroid gland enlargement noted thyroid gland ascends during swallowing equal strength during the assessment for his muscle strength ANTERIOR AND POSTERIOR CHEST quiet respiration no palpitations, no deformities symmetrical in shape absence of adventitious breath sound upon auscultation vesicular breath sound was present heart is not enlarged spine is vertically aligned absence of masses right and left shoulders are at same height full and symmetric chest expansion percussion notes resonate except over the scapula no visible pulsations on anterior and posterior areas of thorax from observing them to the side

AXILLApresence of axillary hairskin is intact little perspiration notedno nodules and tenderness notedABDOMENhas an enlarge mass noted on hypogastric areauniform in colorno skin problemsabsence of bruits on all 4 quadrantsno evidence of enlargement of liver and spleen liver is not palpable as well as the bladder

MUSCULOSKELETAL has 10 fingernails and toenails uniform in color presence of scar in his calf and elbow presence of dirt in the fingernails and toenails no contractures noted Absence of tremors Has good muscle gait NEUROLOGIC Able to talk with sense Oriented Able to remember past events in life Coordinated and verbally responsive

GENOGRAM

USUAL APPRAISALINITIAL APPRAISAL 03-01-10

ONGOING APPRAISAL1-03-02-10

ONGOING APPRAISAL 01-03-10

1.) Health Perception- health Management

Before Hospitalization:

Patient has not been pregnant since before

Experienced cold in ē past year. She eats varieties of healthy

foods such as fruits and vegetables and does not smoke and take alcoholic beverage to keep healthy

The patient is aware that she has a myoma

Family initially seeks the help of a doctor and uses herbal meds and also takes OTC meds

Pt., experiences dysmenorrhea everytime she has menstruation

Patient follows the doctor’s advices and takes the meds given

Patient was confined because she will be operated and be free from myoma.

Patient is complaining of pain because she has dysmenorrhea today of her first day of menstruation.

She feels a little bit of tense for her operation to be done tomorrow.

This is the day of her operation

Patient still confined in bed taking rest after her operation with catheter

Patient is crying because of happiness that she is now free from her problem which was havingUterine myoma.

Patient still continues to receive her Post op. meds such as Cefuroxime, Ranitidine, Ketorolac

Patient is still confined in bed without catheter.

Patient is experiencing pain with a pain scale of 7 out of 10.

Gordon’s 11 Functional Health Pattern







Nutritional – Metabolic Pattern

Eat vegetables, rice, dried fish and fish as daily food intake.

Water is her typical daily fluid intake.

She does not gain weight according to her.

She usually has no appetite in foods and does not crave for any foods.

3.) Elimination Pattern

She urinates 5-6 times daily at about ½ glasses per urination and states that there is a urine that stays after urination.

Sensation of fullness even when finish urinating

She perspire more often whenever she has a lot of works.

She doesn’t have any odor problems.

She is in soft diet “ tea and crackers”And NPO at post midnight.She had undergone Soap suds enema for her preparation for tomorrow’s operation.

Does urinate thrice in the day.She perspires a little

She is NPO for this day.Patient has ongoing IVF of D5LR

She has a catheter attached because she undergone operation with a urine output of 150 cc.She perspire more

She is now allowed to eat soft foods like lugaw and adviced to drink fluids.

Patient has ongoing IVF of D5LR

Patient urinates 3x on the day.

She perspire a little

No odor problem




Activity – exercise pattern

Patient’s daily activity includes cleaning the house, washing clothes, grooming, cooking, home maintainance, does not do household chores when the labor started.

Sleep – rest patternUsually sleeps at 9-10pm and wakes up at 5am.Has no nightmaresSleeps during siestas

Patient can no longer do usual activities for she is confined and she needs rest but she is able to do grooming, go to bathroom alone.

She has didn’t really sleep at night because of new environment in the hospital.She has no nightmares.She feels quite tense for the operation.

She is most dependent on her SO for doing things.

Patient sleeps most of the time after her operation

Her condition is progressing but still more dependent on her SO.

Patient has adequate sleep and rest whole day and nightShe has no nightmareSleep during siestas




Cognitive – perception patternHas no hearing difficultiesPatient has nearsightedness but does not wears eyeglassesNo memory gapShe manages pain by applying or taking medicines 7.) Self – perception / self conceptPatient does not feels good about herself knowing she has a myoma which is burden to her.Patient is maintains to be calm and does not easily gets angry.

Has no hearing difficultyHe receives medications Patient has nearsightedness but does not wears eyeglasses, able to read or writeNo memory gapShe continues to receive meds

Patient is worried about her operation.She is not taken a bath yet

Hearing acuity is goodNo memory gapPatient says that she does not feel pain now because there is still the effect of anesthesia. She continues to receive meds Patient feels happy after her successful operation.She is not taken a bath and has odorShe is comfortable with her visitors.

hearing acuity is goodNo memory gapPatient says that her pain scale is 7 out of 10. She continues to receive meds Patient feels happy about herself.She has not taken her bath yetShe feels good with the support coming from her family.

USUAL APPRAISAL

INITIAL APPRAISAL 03-01-10



8.) Role – relationship patternPatient lives with her parents and nieces; extended familyThey have a good relationship with her family.Income is sufficient for their daily needs.

9.) Sexually Reproductive patternMenstruation started when she was 16 years old. Menstruation last 6-7 days with heavy bleeding in 1st to 2nd day; 7pads on first 2nd day.She is single and has no plan for marriage.She is not active in sexual life.

Her niece took all her hospital expenses.Her niece is with her as her SO

She is single and has no plan for marriage.She had 3 boyfriends on her past but all got married with another women.She said that she is still a virgin.

Her family is concerned about her condition. Her sister is with her the whole night.Family always come to visit her. She is contented with her life. She feels the care from her family.

The patient cried after seing the person who took all her hospital expenses.She has a good relationship with her relatives who visited her. Her mother and sister vited her and shows care and love to her.




10.) Coping – stress tolerance patternPatient doesn’t always get tensed; she only gets stressed, angry when someone irritated her. Whenever she has a problem, she consulted and talk with her sister to relieve it. 11.) Value – belief patternPatient does not always go to church and pray.Religion is Roman catholic.Patient has a believes in both hospitalization when gets sick, consult doctor and also “hilot.

Patient is relaxed and sleeping which helps her cope up with the stress.Her niece is her SO and takes the responsibilities. Patient often pray and seek for help from God..Patient follows the instruction of the doctor and receives her duely meds at right time.

Patient sleeps and relax in bed as her way of relieving from the operation because she is weak.All her family give support and her niece is always with her, serves as her SO. Patient does not forget to pray for the successful operation.Receives meds as ordered by the doctor and trusted the care given by the hospital.

Patient talks with her mother the things she experienced during her operation.She is able to show smile. Patient pray and seek help from God. Has choose hospitalization and trusted it.

Date & Time Order

2-28-1011:OO AM

Pls. admit TPR every 4H Soft diet Labs: CBC FBSECGCXR for TAH once cleared refer to Dr. Uy for CP clearance Secure unit of FWB properly Start Bisacodyl @ HS Metronidazole 500mg 1 tab TID Seen and axamined History reviewed No previous admission BP: 100/60 HR= 76 RR= 16

DOCTOR’S ORDER

Date & Time Order

3-01-108:00AM

Soft diet Tea and crackers for lunch and dinner NPO post midnight For elective TAH Secure Consent Inform anesthesia on care OR personel Start IVF D5LR @ 30gtts @6H Cefuroxime 750mg IVTT every 8H ANST Bisacodyl suppository II/ rectum @ 6pm SS enema @ 9pm or 6 Cleaning enema @ 5am until rectum is clear All prep FF up blood for standby Continue V/S monitoring

Date & Time Order

3-01-101:00pm

– NPO post midnight -check vital signs prior to O.R. -Normal hygiene Prior O.R -Ranitidine 50 mg

IVTT -Metoclopramide 10 mg IVTT -Continue pre-meds needed -IVF / IVTT meds Refer to O.R the following: spinal needle G 25 #1 2)Midazolam 3)Butyphenol

Date & Time Order

03-02-1010:40 AM

10:40am - to PACU- O2 inhalation 2 L/min- NPO temporarily- flat in bed x 8 hours then may

turn to sides.- Monitor V/S q 15 min x 2 hours then q 30 min until

stable. Monitor I & O

- Regulate IVF at 30 gtts/min- IVF to ff. the following

D5LR 1L D5W x 8 hours D5LR 1L

- Continue Cefuroxime 750mg q 8hr IVTT- Ranitidine 50 mg, 8hr IVTT- Nalbuphine HCl 5mg IVTT q 6hr x 4 doses

only -Ketorolac 30 mg q 8 hrs IVTT x 2 days for pain

- repeat hemoglobin 6hrs post-op.- refer to Dr. Chandra Salvador for further

order.- Refer accordingly.

Diagnostic Test

Ultrasound Report Date: 04-13-09Examination Performed: Pelvic ultrasoundImpression: Enlarge uterus w/ intramural

myoma

Electrocardiogram Report2-28-10Analysis: 801 sinus rhythm, 401 short P-R

internal

Laboratory Result:Hematology Date: 02-25-10WBC- 3, 250 cu/mmHemoglobin- 13.4 gms %Differential countSegmented neutrophils- 74%Lymphocytes- 20 %Eosinophils- .6 %Hematology Date: 03-02-10

Hemoglobin- 12.4 gms %

DRUG STUDY

Doctor’s Order: Metronidazole 500mg 1tab q 8 hrs P.O. Generic Name: Metronidazole Brand name: Metrocream, MetroGel, Vaginal, Metrolotion, Noritate Classification: Anti-infectives. Antiprotozoals, Anti-ulcer Indication: Inflammatory papules and pustules of acne rosacea, bacterial

vaginosis Mechanism of action: Unknown. May cause bacterial effect by interacting

with bacterial DNA Dosage: 500mg P.O. Adverse Effects: dizziness, headache, cramps,pain, nausea, diarrhea,

constipation, rash Contraindication: Contraindicated in patients hypersensitivity to the drug. Nursing Responsibilities: Take full course of drug therapy; take the drug with food if GI upset occurs. Do not drink alcohol Your urine may appear dark; this is expected.

Doctor’s Order: Cefuroxime 750mg q 8hrs ANST(-)Generic Name: Cefuroxime sodiumBrand name: Kefurox, zinacefClassification: antibiotic, second generation cephalosporinIndication: pharyngitis, tonsillitis, infection of urinary and

lower respiratory tractMechanism of action: hinders and kills susceptible bacteriaAdverse Effects: dizziness, headache, malaise, diarrhea,

nauseaContraindication: hypersensitivity to cephalosporinNursing Responsibilities:Asssess pt’s infection before therapy and regularly thereafterBe alert for adverse reactions and drug interactions

Total Abdominal Hysterectomy Surgical Procedure

removal of uterus through an incision in the lower abdomen.

This operation involves removing both the body of the uterus and the cervix, which is the lower part of the uterus.

can sometimes be done through the vagina (vaginal hysterectomy);

Generic Name: Ranitidine Brand Name: Zantac Classification: Histamine 2 antagonist Mode of Action: Competitively inhibits the action of histamine at the H2

receptors of the parietal cells f the stomach, inhibiting basal gastric acid secretion and gastric acid secretion that is stimulated by food, insulin, histamine, cholinergic agonist, gastrin, and pentagastrin.

Dosage: Ranitidine 50mg q8 IVTT Indication: Post surgery antacid to prevent ulcer formation Contraindication: Hypersensitivity to ranitidine, lactation. Adverse Effects: malaise, insomnia, somnolence, urticaria, tachycardia,

bradycardia, leukopenia, pancytopenia, thrombocytopenia, gynecomastia, impotence, hepatitis

Nursing Responsibilities: Instruct patient to take his meal if nausea or vomiting occurs.

metoclopramide Apo-Metoclop (CAN), Maxeran (CAN), Maxolon, Nu-Metoclopramide (CAN), Drug classes: GI stimulant, Antiemetic, Dopaminergic-blocking agent Therapeutic actions Stimulates motility of upper GI tract without stimulating gastric, biliary, or pancreatic

secretions; Indications Relief of symptoms of acute and recurrent diabetic gastroparesis Short-term therapy (4–12 wk) for adults with symptomatic gastroesophageal reflux who fail to

respond to conventional therapy Parenteral: Prevention of nausea and vomiting associated with emetogenic cancer chemotherapy Prophylaxis of postoperative nausea and vomiting when nasogastric suction is undesirable Contraindications: Contraindicated with allergy to metoclopramide; GI hemorrhage,

mechanical obstruction or perforation; pheochromocytoma Adverse effects CNS: Restlessness, drowsiness, fatigue, lassitude, insomnia, extrapyramidal reactions,

parkinsonism-like reactions, akathisia, dystonia, myoclonus, dizziness, anxiety CV: Transient hypertension GI: Nausea, diarrhea Nursing considerations Take this drug exactly as prescribed. Do not use alcohol, sleep remedies, sedatives; serious sedation could occur.

GENERIC NAME: BISACODYLBRAND NAME(S): Dulcolax, Fleet Bisacodyl, Magic BulletClassification: stimulant laxativeAction: It acts by irritating the digestive tract and stimulates

intestinal activityIndication: . It is used to treat constipation or to clean out the

intestinal tract before bowel examinations or bowel surgeryAdverse Effects: stomach ache, cramping, weakness,

sweating, irritation of the rectal area, diarrhea, or dizzinessContraindication: hypersensitivity to the drugNursing Responsibilities:If the patient is under 6 years of age, consult child's doctor

before using this medication.

http://www.medicinenet.com/script/main/art.asp?articlekey=331


Generic Name: Ketorolac tromethamine Brand Name: Toradol Classification: NSAID, Nonopioid analgesic Mode of Action: Reduces the production of prostaglandins, chemicals that cells of

the immune system make that cause the redness, fever, and pain of inflammation and that also are believed to be important in the production of non-inflammatory pain. It blocks the enzymes that cells use to make prostaglandins (cyclooxygenase 1 and 2). As a result, pain as well as inflammation and its signs and symptoms - redness, swelling, fever, and pain - are reduced.

Dosage: Ketorolac 30mg q8 IVTT Indication: For short-term management (up to 5 days) of moderately severe acute

pain that otherwise would require narcotics. It most often is used after surgery. Contraindication: Hypersensitivity to ketorolac, renal Impariment, aspirin allergy Adverse Effects: gastric or duodenal ulcer, renal impairment, liver failure, dysuria,

bleeding, platelet inhibition, neutropenia, leukopenia, pancytopenia, thrombocytopenia, bone marrow depression

Nursing Responsibilities: Infuse slowly as a bolus over no less than 15 seconds


NALBUPHINE HYDROCHLORIDE NUBAINE Drug Class: Narcotic agonist-antagonist analgesic Therapeutic Actions:Nalbuphine acts as an agonist at specific opioid

receptors in the CNS to produce analgesia, sedation but also acts to cause hallucinations and is an antagonist at µ receptors

Indications: Relief of moderate to severe pain. Preoperative analgesia, as a supplement to surgical anesthesia, and for obstetric analgesia during labor and delivery.

Contraindications/cautions: Contraindications: hypersensitivity to nalbuphine, sulfites; lactation.

Adverse Effects: Sedation. Clamminess, sweating headache, nervousness,

restlessness, depression, crying, confusion, faintness, hostility, unusual dreams, hallucinations, euphoria, dysphoria, unreality.

ANATOMY AND PHYSIOLOGY

The uterus is a hollow muscular organ located in the female pelvis between the bladder and rectum.

The ovaries produce the eggs that travel through the fallopian tubes. Once the egg has left the ovary it can be fertilized and implant itself in the lining of the uterus. The main function of the uterus is to nourish the developing fetus prior to birth.

Kinds of Fibroids/myoma depends on their orientation in the uterine

wall

PATHOPHYSIOLOGY

CUES AND EVIDENCES

NURSING DX OUTCOME CRITERIA NURSING INTERVETION

RATIONALE

SUBLECTIVE DATA:

“Nakulbaan man ko, hadlok ang akong pamati nga operahan ko unya dapit.” as verbalized by the patient.OBJECTIVE DATA:v/s = T = 36.3oC

P = 70 bpm R = 26 cpm BP = 120/70 mmHg- increased respiratory rate- increased perspiration- increase alertness

Fear related to

impending surgery

secondary to Total

Abdominal Histerecto

my.

After my 8 hours of care, the patient will be able to:1. Demonstrate

understanding through use of effective coping behaviors and resources.

2. Display appropriate range of feelings and lessened fear.

3. Verbalize knowledge of safety about the surgery.

4. Acknowledge and discuss fears, recognizing healthy benefits than unhealthy fears.

1. Explain the procedure detailedly to the patient.

2. Help her acknowledge that her fear of surgery is normal.

3. Provide opportunity for questions and answer honestly.

4. Manage environmental factors such as loud noises, harsh lighting.

- To reduce fear and help patient to be calm and relax

- Helps to enhance her self-esteem

- Enhances sense of trust and nurse-patient relationship

- Which can cause stress to the patient.

NURSING INTERVETION RATIONALE EVALUATION

1. Take and monitor vital signs.

2. Stay with the patient or make arrangements to have someone else be with her.

3. Discuss patient’s perceptions of feelings. Listen to patient’s concerns.

4. Provide information in verbal form and speak in simple sentences and concrete terms.

5. Promote patient control and help patient identify and accept things over which control is not possible.

- To reduce fear and help patient to be calm and relax

- Helps to enhance her self-esteem

- To identify physical responses associated with both medical and emotional conditions.

- Providing patient with usual support persons can diminish feelings of fear.

- Promotes atmosphere of caring and permits correction of misperceptions.

- Facilitates understanding and retention of information.

- Strengthens internal locus of control.

Verbalized accurate knowledge of safety about the surgery.Acknowledged and discussed fears, recognized healthy benefits than unhealthy fears.“Magpa- opera na lang ko kay gikinahanglan na jud na ko Para ko maayo.” As verbalized by the patient.

CUES AND EVIDENCES

NURSING DX OUTCOME CRITERIA NURSING INTERVETION

RATIONALE

Subjective:Sakit akong tahi” as verbalized by the patient.Objectives: Restlessness noted Facial Grimace

Noted Pain scale 7 out of

1010- highest pain

1. No pain Fatigue Weak Undergone TAHVital Signs:T- 37.1°cPR- 66 bpmRR- 19 cpmBP- 110/80 mmHg

Altered Comfort: Pain Related to Surgical incision secondary to Post surgery.

At the end of my Care my patient will manifest decrease pain as evidence by: Verbalized pain is

tolerated Absence of facial

grimace Pain scale <7 out of

10 Absence of fatigue Absence of body

weakness

1. Perform a comprehensive assessment

2. Note location of surgical incision

3. Assess client’s perception

4. Perform pain assessment each time pain occurs

1. To assess precipitating factors

2. To know the presence of pain complication

3. To evaluate pain that relate to client

4. To role out worsening of underlying condition

NURSING INTERVETION RATIONALE EVALUATION

1. Accept clients description of pain

2. Monitor vital sign3. Work with client to

prevent pain4. Provide quiet

environment and calm activities.

5. Administer analgesic as prescribed

6. Encourage adequate rest period

1. To identify pain subject to patients experience

2. Usually altered pain3. To assist to explore

method that controls pain

4. To alleviate pain

5. As a pain medication

6. To prevent fatigue

After my nursing intervention the patient has been manifested decreased pain as evidenced by: Verbalized pain is tolerated(mas dili na kaayu sakit akong tahi” as verbalized by the patient. Absence of facial grimacePain scale 5 out of 10 Absence of fatigue Absence of body weakness

CUES AND EVIDENCES

NURSING DX

OUTCOME CRITERIA

NURSING INTERVETION

RATIONALE EVALUATION

Subjective:“ pamati nako mura kog ge hilantan, bag-o raba ko ge operahan” as verbalized by the patient.Objectives: Lack of

knowledge regarding causative factors

Unable to identify preventive measures

Weak febrile Surgical inscision

at hypogastric region

Undergone TAHVital Signs:T- 37.6°CPR- 69bpmRR- 20 cpmBP- 130/80 mmHG

Risk for Infection Related to surgical Incision secondary to surgical operation.

At the end of my care, the patient will manifest free from infection as evidence by: Verbalize

understanding

Of causative factors

Identify interventions to prevent infection

Absence of body weakness

Afebrile

1. Note risk factors for occurrence of infection

2. To assess skin condition around incision

3. Stress proper hand washing technique by all care givers to the client

4. Cleans incision daily and prn with providione iodine or other appropriate solution

5. Change dressing as needed

6. Encourage early ambulation, deep breathing, coughing and position change.

7. Administer or monitor medication regimen

1. To assist contributing factors

2. To assess presence of infection

3. To reduce existing risk factor

4. To prevent infection

5. To reduce infection

6. For mobilization of respiratory secretions

7. To prevent infection

After my nursing intervention my patient has been manifested free from infection as evidence by: “ ako paning paning kamotan nga dili mainfection akong tahi” as verbalized by the patient.Performed intervention to prevent infectionAbsence of weaknessAfebriledT = 36.6 degree C

Documents

Myoma Final Power Point