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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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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
Goal Objectives Interventions Rationale Evaluation
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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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
Goal Objectives Interventions Rationale Evaluation
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.