Arellano UniversityJose Abad Santos Campus

College of Nursing

A Case Study

Ovarian New Growth (Mucinous Cystadenomacarcinoma)

Presented by:

BSN III BLOCK 6

INTRODUCTION:

The ovary is a pair of reproductive glands in women that are located in the pelvis, one on each side of the uterus. Each ovary is about the size and shape of an almond. The ovaries produce eggs (ova) and female hormones.

Ovarian cysts are closed, sac-like structures within an ovary that contain a liquid, gaseous, or semisolid substance.

Types of Ovarian Cyst

Follicular

Corpus Luteum

Hemorrhagic

Dermoid

Endometriosis

Polycystic ovarian syndrome

Cystadenoma

o A malignant cystic or semisolid tumor most often occurring in the ovary.

I. BIOGRAPHIC DATA

Name: Patient X Age: 50 y/oSex: FemaleAddress: Soro soro Ilaya, Batangas CityNationality: FilipinoMarital Status: Married with 4 childrenOccupation: HousewifeReligion: Roman CatholicAdmission date/ time: October 03, 2010/ 6:39 am

II. NURSING HEALTH HISTORY(Upon Admission)

CHIEF COMPLAINT Abdominal Enlargement : 36 inches abdominal girth

REASON FOR VISIT “Lumaki ang tiyan ko.” as verbalized by the client.

HISTORY OF THE PRESENT ILLNESSPatient noticed enlarging abdomen and it was accompanied by weight loss and difficulty of

eating. Consulted a Gynecologist and was diagnosed of having a cyst on her left ovary through UTZ on September 8, 2010. Her UTZ result showed 10 cm in diameter specimen of ovarian mass. Consulted to Mary Mediatrix Medical Center hence admitted. She had undergone a laparotomy on October 4, 2010.

PAST HISTORYBefore the end of August 2010, the client experience influenza for 1 week. The client has not undergone any operations and hospitalizations. She also has no allergies and injuries.

FAMILY HISTORY OF ILLNESS

Legend:

HPN, stroke Gallbladder

dse.

Ovarian cyst

III. PATTERNS OF FUNCTIONING

Gordon’s Functional Pattern

Health Perception – Health Management PatternThe patient does not smoke and not an alcohol drinker. She does not feel any symptoms until she noticed enlargement of her abdomen followed by weight loss and that is the time she decided to consult it with the Gynecologist and undergone different laboratory exams and was advised to undergo laparotomy.

Nutrition – Metabolic PatternBefore admission, the patient eats more on vegetables, meat and fruits. After the operation, the patient was placed NPO for 1 day then take general fluids with crackers as diet. IVF of D5NSS 1L x 60cc/hour and hooked for the second bottle.

Mother, 78

deceased

Mother, 78

deceased

Father, 80

Deceased

Father, 80

Deceased

Patient, 50

EliminationWhen the patient is not diagnosed with ovarian cyst, she eliminates 2-3 times a day. She drinks 6 glasses of water everyday and urinates regularly. When she was hospitalized, she has indwelling Foley catheter with 30 cc/hour dark yellow urine and she does not defecate even once for 3 days.

Activity – Exercise PatternShe spends her time taking care of her grandchildren and their piggery business as a form of exercise. After the operation, she was advised to have complete bed rest.

Sleep – Rest PatternWhen the patient was not diagnosed with ovarian cyst, she sleeps 6 hours a day. She has a good quantity of sleep, but when she was hospitalized she sleeps irregularly because of the pain on the incision site and also because of fever.

Cognitive – Perceptual Pattern Our patient is very cooperative and answers all the questions asked to her without any confusion.

Self- Perception and Self Concept PatternShe still manages to smile and have a strong determination to cope up with her condition. She gets all the support from her family.

Coping- Stress Tolerance PatternWhen patient encounters big problems she handles it by talking things over to her husband. She also has determination to solve any problems.

Role Relationship PatternOur patient is with her husband and 4 children. She is 50 years old and a housewife focusing on their piggery. Her family was extended and very close to their neighbors.

Sexuality – Reproductive PatternOur patient is not sexually active anymore because of her age and condition. She is still menstruating and her last menstrual period was October 1, 2010. She has an irregular menstrual cycle. At the age of 11 years old, she began menstruating. Obstetric history G4 P4.

Value Belief PatternShe is Roman Catholic and attends mass every Sunday. She also believes in “medico” or “albularios”. Before she consulted a Gynecologist, she went first to medico and she was advised to take “pito-pito” as a medication.

IV. PHYSICAL ASSESSMENT

General Survey: As of oct 5, 2010

Vital signs are: body temperature of 38 C; pulse rate 82 beats per minute with regular rhythm upon palpation; respiratory rate of 22 cycles per minute with regular rhythm; with equal expansion of the chest; blood pressure of systolic 110 and diastolic of 70 mmHg. Patient is conscious and coherent. Conversant and well oriented. Client is responsive to questions both verbally and physically.

Post-Op Findings: October 05, 2010Part to be

examined

Method Findings

Skin Inspection, Palpation Brown skin complexion. Hypertrophic scar which is approximately 4.5 inches long noted on the lower abdomen. Skin onthe right arm is punctured due to intravenous fluid infusion but with no notedswelling, reddening, heat and pain. Body hair is fine and thinly distributed. Skin iswarm to touch, with good skin turgor, and with adequate moisture upon palpation.

Head Inspection, Palpation Head is symmetrical upon inspection. Short, fine, black &

white hair noted in thin distribution. No masses noted

upon palpation. The client doesn’t complain of dizziness,

vertigo and headache upon the interview. She has no

family history of mental disorders noted upon assessment

of her/his family background.

Ears Inspection, Palpation

Ears are symmetrical upon inspection. Pinna and external auditory canalsare intact upon inspection. She reported no history of ear pain, ringing in the ear, or ear infections. She does not use hearing aids to facilitate hearing.

Eyes Inspection, Palpation

Eyes are symmetrical upon inspection. Patient has brownish black eyes. Eyelashes and eyebrows are equally but finely distributed on both sides of the face.

Pupils are equal, round, reactive to light. No unusual discharges from the lacrimal ducts noted upon palpation. She reported use of correctional eyeglasses because she is farsighted.

Nose Inspection,Palpation

Nose is symmetrical with good septal deviation noted upon inspection. No lesions and scars noted. Nasal mucosa is red with adequate nasal hair andaccumulated mucus secretions noted upon inspection. Patient is able to breathe without difficulties. Patient is able to smell pleasant and foul odors suggestinggood olfaction.

Neck Inspection, palpation

Neck muscles are symmetrical upon inspection. Skin on the neck is intact with good integrity. Carotid pulse is palpable. Voice is clear and well modulated.

Breast and Axilla Inspection, palpation

Symmetrical breast with round, brown and reverted nipples noted upon inspection. No unusual discharges upon palpation of the nipples. She has no family history of breast carcinomas on both father and mother sides.

Chest and lungs inspection Respiratory rate of 22 cycles per minute, regular in rhythm.

Genito – urinary Inspection Patient has IFC with an average Urine Output of 30 cc per hour. Monitoring of urine output every hour and recorded every shift.

Extremities:Upper Extremities:Right Upper:

Left Lower:

Lower Extremities

Inspection, Palpation

She has limited motion due to muscle weakness.

With normal movement upon doing ROM, no weakness noted.

She can move both lower extremities. She uses support leggings to prevent edema.

V. LABORATORY/ DIAGNOSTICS TEST

Specimen: Urine Date: 10/01/2010

TEST Normal Findings Actual Finding InterpretationColor Pale Yellow Yellow Excess sweating, not drinking enough

liquid

Transparency Transparent Turbid Symptom of a bacterial infection

Specimen: Serum 10/01/2010

Test Normal Findings Actual Finding Interpretation

Hemoglobin F (12-16) 11.2 Minimal Iron deficiency

Hematocrit F(38-47) 36.3 Minimal decrease on Fluid volume concentration

WBC

Test Normal Findings Actual Finding Interpretation

Creatinine 61.88 – 106.88 mmol/L 44.20 Decreased muscle mass

Test Normal Findings

Actual Finding Interpretation

Differential Count 55-62 53.6% Normal

Neutrophils 20-40 34.8% Normal

Lymphocytes 4-10 8.7% Normal

Eosinophils 0-1 0.1% Normal

VI. Medications, IV infusions, Blood Transfusions, Treatments Given

Blood typing “A”

Rh typing Positive(+)

Drugs Mechanism of Action

Indication Contra-indication

SideEffects

Nursing Implications

Generic Name:Morphine Sulfate

Brand Name:Avinza

Class:Narcotic

Drugs that act to decrease pain by binding with the opiate receptors of the brain, thus inhibiting transmission of pain impulses.

Treatment of moderate to severe pain by stimulating opiate receptors in CNS

Heart failure secondary to chronic lung disease; cardiac arrhythmias; brain tumour; acute alcoholism; convulsive states (eg, status epileptics, tetanus, strychnine poisoning).

Sedation, dizziness, light-headedness, constipation, urinary retention, hypersensitivity, respiratory depression, euphoria leading to excessive use or abuse

-Watch out for depression of vital signs.-check for pupil changes and reaction (pinpoint pupils indicate overdose).-Monitor I&O (input and Output) and bowel movements.-Avoid other CNS depressants.-have antidote (naloxone) already.-watch out for possible tolerance and dependence.

Drug Mechanismof

Action

Indication Contra-indication

SideEffects

Nursing Implication

GenericName:

Act to reduce symptoms of

Treatment of mild to moderate pain

Known alcohol intolerance

Gastrointestinal irritation and

-Assess for history of

Ketorolac

Brand Name: Toradol

Class:Nonsteroidal Anti-inflammatory Drugs (NSAID)

inflammation by inhibiting COX enzymes which is needed for biosynthesis of prostaglandin

caused by inflammatory conditions; symptomatic relief of arthritic conditions.

Use cautiously in:1) History of GI bleeding2) Renal impairment (dosage reduction may be required)3)Cardiovascular disease

ulceration, bleeding, dizziness, bowel changes, allergy, headache, ringing in the ears, impaired hearing and vision, palpitations, nausea and vomiting, lethargy, hyperventilation.

gastric upset, bleeding.-take with food or antacid or w/ plenty of fluids to decrease gastrointestinal distress.-monitor blood counts.-watch for gastrointestinal bleeding, like hematochezia and melena.- Instruct client to avoidalcoholand maintainadequate hydration (2-3L/day of fluids) unlessinstructed to restrict fluid intake.-Instruct client to avoidtaking ketorolac withaspirin or other NSAIDssuch as ibuprofen.

Drugs Mechanism of Action

Indication Contra-indication

Side Effect

Nursing Intervention

Generic Name:Fortifer

Anti-anemic preparations that provide adequate

Prevention & treatment of Fe

Contraindicated to patient with stomach upset.

Gastrointestinal irritation

-May be taken w/ meals to reduce GI discomfort.

Brand Name:

Class:Vitamins & Minerals Antianemic

amounts of iron and B-complex vitamins to prevent and treat anemia. Iron is essential in the formation of blood, transport and storage of oxygen and acts as cofactor for proper functioning of cells.

deficiency & nutritional anemia and folate deficiency.

VII. REVIEW OF SYSTEMS

EENT: [X] impaired vision: farsightedness[ ] pain [ ] gums [ ] hard of hearing [ ] deaf [ ] edema [ ] lesion[ ] teeth Assess eyes, ears, nose throat for abnormalities. [ ] no problem RESPIRATORY: [ ] asymmetric [ ] tachypnea [ ] apnea [ ] rales [ ] cough [ ] barrel chest [ ] bradypnea [ ] shallow [ ] rhonchi [ ] sputum [ ] diminished [ ] dyspnea

[ ] orthopnea [ ] labored [ ] wheezing [ ] pain [ ] cyanotic [ x] no problem

CARDIOVASCULAR: [ ] arrhythmia [ ] tachypnea [ ] numbness [ ] diminished pulses [ ] edema [ ] fatigue [ ] irregular [ ] bradycardia [ ] murmur [ ] tingling [ ] absent pulses [ ] pain Assess heart sound, rate, rhythm, pulse, blood pressure.circulation, fluid retention, comfort [X] no problem GASTROINTESTINAL TRACT:

[ ] obese [ ] distention [ ] mass [ ] dysphagia [ ] rigidity [X] pain Assess abdomen, bowel habits, swallowing bowel sounds, comfort. [x ] no problem GENITO-URINARY AND GYNE: [ ] pain [Dark yellow] urine color [ ] vaginal bleeding [ ] hematuria [ ] discharge [ ] nocturia assess urine frequency, control, color, odor, comfort, gyne bleeding, discharge [x] no problem NEURO: [ ] paralysis [ ] stuporous [ ] unsteady [ ] seizures [ ] lethargic [ ] comatose

[ ] vertigo [ ] tremors [ ] confused [X] vision : farsightedness[ ] grip assess motor, function, sensation, LOC, strength grip, gait, coordination, speech [ ] no problem MUSCULOSKELETAL AND SKIN: [ ] poor turgor [ ] cool [ ] deformity [X] wound : along the incision site, with intact and clean dressing and abdominal binder[ ] rash [ ] skin color [ ] flushed [x] pain:with a pain rate of 6/10 from a scale of: 0=no pain, 1-3=mild, 4-7=moderate, 8-

10=severe[ ] ecchymosis [ ] diaphoretic [ ] moistassess mobility, motion, gait, alignment, joint functionskin color, texture, turgor, integrity[ ] no problem

VIII. ANATOMY AND PHYSIOLOGY

FEMALE REPRODUCTIVE ORGANS

Organ Functions

1. Vagina a. Passageway of menstrual flowb. Female organ for coitus; receives male penisc. Passageway for the fetus during birth

2. Uterusa. Houses and nourishes fetus until sufficiently mature to function outside the mother’s bodyb. Uterine muscles propels fetus outside.

3. Fallopian Tube a. Provides passageway for ovum as it travels from ovary to uterus.b. Site of Fertilization.

4. Ovariesa. Endocrine glands that secrete estrogen and progesterone.b. Contain ova within follicles for maturation during the woman’s reproductive life.

Hormonal Regulation

PARTS OF THE

OVARY

IX. PATHOPHYSIOLOGY

Leuteinizing Hormone Leuteinizing Hormone

Hormonal Imbalance

Hormonal Imbalance

Abnormal Proliferation of Follicle

Abnormal Proliferation of Follicle

Follicles Fail to Ovulate and Fail to Undergo Atresia

Follicles Fail to Ovulate and Fail to Undergo Atresia

Continue to GrowContinue to Grow

Menstrual Irregularities

Cyst Grow in size up to 15 cm in Diameter

Cyst Grow in size up to 15 cm in Diameter

Abdominal distention

PREDISPOSING FACTOR

Race – North America & Western

EuropeLeast in Asia

Hyperstimulation of Ovaries Hyperstimulation of Ovaries

HCG Estrogen

InfectionInfection

Fatigue and Sense of

Heaviness in the Pelvis

PRECIPITATINGIrregular menstrual cycle

Early menstruation

Mucinous Cystadenocarcinoma: A malignant cystic or semisolid tumor most often occurring in the ovary. Rarely, one is solid. This tumor may develop from a mucinous cystadenoma, or it may be malignant at the onset. The cysts are lined with tall columnar epithelial cells; in others, the epithelium consists of many layers of cells that have lost normal structure entirely. In the more undifferentiated tumors, one may see sheets and nests of tumor cells that have very little resemblance to the parent structure.

X. LIST OF PRIORITIZED NURSING PROBLEMS (Based on Gordon’s Functional Health Pattern)

Nursing Diagnosis Reason for Prioritizationi. Pain related to post-op

procedureBecause Nursing care focus first on pain management

ii. Hyperthermia related to medication

Second priority in GFHP and signifies that there is something wrong from within.

iii. Constipation related to abdominal muscle weakness

Third priority in GFHP

iv. Altered Sleeping Pattern related to environmental changes

Fifth priority in GFHP. An individual needs adequate sleep pattern in order to renew her strength.

XI. NURSING CARE PLAN

DEATHDEATH

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION EVALUATION

S:”Mainit ang pakiramdam ko” as verbalized by the patient

Hyperthermia related to medication

Within the shift:Goal: The patient’s body temperature will decrease from 38◦C to 37◦ C

Independent:Intervention 1:Monitor Vital SignRationale: To provide baseline data

Intervention 2:Perform Tepid Sponge BathRationale: to provide and to decrease body temperature

Dependent: Intervention1:Administer antipyretic drug as ordered.Rationale: To reduce body temperature

The patient was able to cooperate during vital sign monitoring.

The patient was able to verbalize comfortable feeling after TSB.

The patient was able to comply with medication schedule.

Goal was met as evidenced by the patient’s body temperature of 37◦ C from 38◦C.

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION EVALUATION

S:

“Hindi pa ako nakakadumi” as verbalized by

Constipation related to abdominal muscle weakness

Within the shift:

Goal: The patient will establish normal

Goal was met. The patient was able to establish normal pattern of bowel

the client.

O:

Irritable

pattern of bowel function

Independent:Intervention 1:Maintain adequate fluid intake Rationale: To promote passage of soft stool.

Intervention 2:Encourage a diet of balanced fiber and bulk.Rationale: To improve consistency of stool & facilitate passage through colon.

Dependent:Intervention 1:Administer medications as prescribed.

The patient was able to intake adequate fluid.

The patient was able to verbalized change in bowel pattern and character of stool.

The patient shows compliance on drug intake.

movement.

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION EVALUATIONS:“hindi ako makatulog ng maayos maya’t maya ako nagigising” as verbalized by the patient

O: Dark circle around the eyes

Altered sleeping pattern related to environmental changes.

Within the shift:Goal 1:able to report satisfactory of sleep

Independent:

Intervention 1:Maintain slightly dark,

Patient was able to relax on a slightly dark,

Goal was met. The patient was able to report satisfactory of sleep.

Decrease attention span Frequent yawning

Restless in appearance

quite and well ventilated environmentRationale:Sleep is difficult without relaxation the unfamiliar hospital environment can hinder relaxation

Intervention 2:Prepare patient for necessary anticipated interruption to her sleepRationale:In order to feel rested, the patient usually must complete an entire sleep cycle

Intervention 3:Assist client in a comfortable position

Dependent:

Intervention 1:Administer medication as ordered by the attending physicianRationale:to prevent further

quite and well ventilated environment

Patient was able to anticipate interruption to her sleep

Patient was able to demonstrate comfortable position.

Patient complied religiously to medications and treatments as ordered.

aggravation and occurrence of complication.

Collaborative:

Intervention 1:Increase physical activitiesRationale:To promote ROM

Patient was able to do physical activities as to increase her ROM.

XII. DISCHARGE PLAN

Nursing care has a significant impact on the patient’s body recover. Often, many body systems are impaired as a result of a laparotomy and conscientious care and timely interventions can prevent debilitating complications. Nursing interventions focus on the whole person.

Medication a) Instruct the family members how to administer such medication prescribed. b) Teach client what to do to lessen the side effects of the drugs. c) Describe the importance of regularly taking of prescribed medications d) Instruct the family to continue with follow up medical care e) Advise the family not to miss the intake of medications given by the patient’s

physician upon discharge.

Environmental & Exercise Maintain a quiet, pleasant, environment to promote relaxation.(Provide clean and

comfortable environment.) Encourage client to continue deep breathing exercises. Provide splint such as

pillow to secure the incision site. This is to promote circulation of blood,

relaxation also. Avoid strenuous exercise heavy lifting, and sexual intercourse.

Treatment Continue home medications. For the follow-up check-up repeat, Encourage the family to let the patient to take multivitamins for immunity.

Hygiene Teach the patient or the family member on how and how often to clean the

incision site Encourage also family to maintain clean surroundings.

Others

Encourage family for regular diagnostic examination Advised to consult physician if there are any problems or complications

encountered.

Diet Diets as tolerated as much as possible, unless contraindicated Increase intake of high fiber diet to avoid constipation. Increase fluid intake

Sexual and Spiritual supporting religious practices assisting clients with prayer referring client for spiritual counseling no sexual intercourse up to the time of the next follow-up check up.

In addition to providing physical care, we should encourage patient to verbalize any questions pertinent to condition for further evaluation and follow up of the disease.