Myoma Case Study

H O L Y A N G E L U N I V E R S I T YCollege of Nursing

In Partial Fulfilment of Requirements for RLE 104

“ U T E R I N E L E I O M Y O M A ”

A Case Study

Presented To:

Leonor S. Lumanlan MAN, RN

Submitted By:

Joven, Michelle Anne L.

Lacsamana, Claire D.

Laquindanum, Philein S.

Liwanag, Ma. Kristina T.

Lopez, Ruchia D.

Magcamit, Cindy F.

Maniulit, Joe Anne Mae A.

GROUP 3 of N-404

September 20, 2010

Uterine Leiomyoma: A Case Study 2

“All things are possible with God…”

In completing this case study, the members of this group encountered many individuals who helped by offering their time, knowledge, and skills.

Before the formal beginning, the group would like to give thanks and acknowledge those individuals who made this study complete.

We would like to first give thanks to the patient, and her family, in being more than hospitable in providing necessary information in completing the family history and allowing the physical assessment to be done completely.

We would like to thank the staff of St. Raphael Foundation Medical Center, who helped clarify many things from the chart and also help give information concerning the patient and his treatments.

We would also like to give a special thank you to our clinical instructor, Ms. Leonor S. Lumanlan for giving their advice based on case studies presented in previous rotations, so that ours may be strengthened somehow.

And last but not least, To the God Almighty, for although this case study was made and passed at such a turbulent time (with preliminary examinations underway with concurrent data collection from our own individual thesis), it was through God’s will that it had been completed, and completed whole-heartedly with much eagerness and passion.

The Members of Group 3 St. Raphael rotation September 20, 2010

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TABLE OF CONTENTS

INTRODUCTION

BRIEF DESCRIPTION OF THE DISEASE 4

NURSE-CENTRED OBJECTIVES 6

NURSING HISTORY

PERSONAL HISTORY 7

FAMILY HEALTH-ILLNESS HISTORY 8

HISTORY OF PAST ILLNESS 9

DIAGNOSTIC & LABRATORY PROCEDURES 10

PHYSICAL ASSESSMENT 16

ANATOMY & PHYSIOLOGY 34

PATHOPHYSIOLOGY

BOOK-BASED 44

CLIENT-CENTERED 50

MEDICAL MANAGEMENT 53

SURGICAL MANAGEMENT 60

NURSING CARE PLAN 69

DISCHARGE PLANNING 71

LEARNING DERRIVED 72

REFERENCES

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“We learn more by looking for the answer to a question

and not finding it than we do from learning the answer itself.”

~Lloyd Alexander, American Author, 1924

In the field of nursing, one encounters a wide-array of various diseases and conditions. In

order to give adequate and holistic care to individuals, it is necessary that nurses be equipped

with the proper knowledge and skills for dealing with different health states. It is only through

continuous learning that nurses acquire the necessary skill. A case study is a means of continuing

such learning. In doing a case study, the students delve into the question, “what is this disease

condition?” Student nurses learn actively and will be able to handle patients and experience what

it means to care for a patient with that particular condition. They learn, from continuous

interaction with the patients along side with inquires into books and informative journals of the

disease process, it symptoms, and corresponding treatments.

Myomas are one of the conditions which student-nurses encounter during their exposure

at the clinical setting. The disease comprises of complexities of the anatomical concepts that

surveys a thorough description to understand its manifestations and formulate interventions. It is

interesting on our part to learn its definition, causes, and proper management. The student-

nurses chose the case to be able to have an insight about the condition.

Brief Description

Myoma is a condition where there is a benign growth or tumor of smooth muscle in the

wall of the uterus. The said growth is made up of fibrous tissue; hence it is often called a fibroid

tumor. Uterine fibroids can be present and be in apparent. Fibroids vary in size and number, and

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are most often slow-growing and usually cause no symptoms. It may grow as a single nodule or

in clusters, and may range in size from 1 mm to more than 20 cm in diameter. Myomas are the

most frequently diagnosed tumor of the female pelvis, and the most common reason for

hysterectomy. Although they are often referred to as tumors, they are not cancerous.

Most myomas develop in women during their reproductive years. Myomas do not

develop before the body begins producing estrogens. Myomas tend to grow very quickly during

pregnancy when the body is producing extra estrogen. Once menopause as begun, the myoma

generally stops growing and may begin to shrink due to the loss of estrogen. Fibroids may be

removed if they cause discomforts or if they are associated with uterine bleeding. Approximately

25% of myomas will cause symptoms and need medical treatment.

Statistics

Approximately 25 % of the myomas will cause symptoms and need medical treatment.

Myomas that that do not produce symptoms, do not need to be treated. The said 25 % of women

cause significant morbidity, including prolonged or heavy menstrual bleeding, pelvic pressure or

pain, and in rare cases, reproductive dysfunction. In the Philippines, the estimated number of

women is 86,241,697 squared, and the 4,312,084 had been affected of Myoma.

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STUDENT NURSE-CENTRED OBJECTIVES

G E N E R A L O B J E C T I V E S

After 2 days of interaction with the patient and completing the case study, the student nurses will

be able to:

Know and understand the disease process and concept of Uterine Leiomyoma

S P E C I F I C O B J E C T I V E S

After 2 days of duty at St. Raphael Foundation Medical Center, the student nurses will be able

to:

Cognitive

Review the proper physical assessment (IPPA) and how to do them efficiently. Understand the disease process: the causes, effects, management, treatment, and possible

preventions. Determine the pathophysiology of the condition with their rationale for occurrence of each

manifestation. Determine why certain management and medications are given and provided for the condition. Understand how and why certain diagnostic tests are done for the condition. Review the concepts about the anatomy and physiology with regards to the condition.

Psychomotor

Perform efficiently physical assessment (IPPA) to the patient. Perform thorough health history from patient and significant others. Participate in the course of care of patient. Provide health teachings to the patient about certain interventions in the maintenance of health

care.

Affective

Establish rapport and therapeutic interaction with the patient and significant others to obtain necessary information and positive compliance to care being provided.

Provide care and health teachings necessary for the betterment of the condition of the patient. Share the learning acquired to co-student-nurses to increase awareness and help them if ever they

will encounter patient with the same condition.

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NURSING HISTORY

PERSONAL HISTORY

Ms. Myoma, a 57-year old female, stands as a mother of 6 children. She is widowed for

11 years since her husband had passed away because of Liver Complications. She lives in Davao

City. His nationality is Filipino and was born in Davao City on the 7th of June, 1949. She was

admitted in a private hospital in Mabalacat on September 10, 2010 at (time) with the initial

diagnosis of Submucous Myoma and chief complaint of Vaginal Bleeding.

Ms. Myoma graduated at a public high school and she didn’t continue his college level

due to financial problem. The one who support their family is her daughter who is a wife of a

retired U.S. Navy. Ms. Myoma was raised as a Catholic, where she learned about religious

values. She believes in super natural forces and superstitious beliefs. The client seeks medical

help from a physician for a serious health condition although she admits to seek help from the

“Hoax doctor” or the local “albolaryo” who would prescribe alternative medicine to relieve mild

signs and symptoms and other bodily discomfort.

Ms. Myoma resided at Davao City and occupies a simple house together with her son Mr.

Boy, but due to her illness, her children brought her to live with them in Mabalacat so that they

could watch her health carefully. Ms. Myoma did not report problems regarding her environment

that could interfere with her condition but instead states that he forsake his diet by consuming 4

big cups of black coffee a day. She said that she doesn’t exercise before but now she said that

walking is her exercise. Ms. Myoma would usually wake up at 5:00 in the morning and then she

would drink her coffee. She would clean the house afterwards. She takes her breakfast at 7:00 in

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the morning. He takes his lunch at 11:30 in the morning and his dinner at 7:00 in the evening. He

usually sleeps at 8:30 in the evening.

FAMILY HEALTH-ILLNESS HISTORY

Hereditary disease in the family is Uterine Myoma and Hypertension which her mother, 1

sister and the patient had herself possessed. This shows that Uterine Myoma and Hypertension

are evident in their family and are hereditary.

GENOGRAM

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HISTORY OF PAST AND PRESENT ILLNESS

Besides being hospitalized for her surgery, Ms. Myoma did not have any previous

hospital stays. She had only consulted a doctor two years ago, because she noticed that she often

had headaches. Upon the assessment with her doctor in Davao, they found that Ms. Myoma had

hypertension. To treat this, Ms. Myoma took aspirin and an anti-hyper medication to which she

could not recall the name of.

In regards to her current illness, Ms. Myoma had noticed that she had begun having

vaginal bleeding for about a year. She asked neighbors and friends about this, and because they

had told her it was a normal occurrence which may happen as a result of menopause, she sought

no further treatment. The bleeding, she explained to student nurses, was not painful, so she

believed that it was not really a concern. After telling her children about her condition, her

daughter kept insisting that she seek medical advice, however, she refused because of the high

costs which comes from hospitalization. After sometime, the bleeding began to increase, and the

patient finally listened to the advice of her children. She left for Mabalacat from Davao about a

week prior to her hospitalization, in which he doctor referred her to Dr. Flores of St. Raphael

Medical Center. After obtaining a necessary cardiopulmonary clearance as well as a pelvic

ultrasound (September 9, 2010), the patient was immediately booked for a total hysterectomy

which was done on September 11, 2010.

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DIAGNOSTIC & LABRATORY PROCEDURES

COMPLETE BLOOD COUNT

Diagnostic Procedure

Indications or Purpose

Date Ordered & Released

Results Normal Values

Analysis and interpretation

HGB (g/dL) To measure the hemoglobin

Sept 10, 2010 140 120-160 g/dl

Normal. Patient was

able to compensate

with decreased of

oxygen carrying

capacity and availability of

oxygen increased.

HCT (%) To aid diagnosis of

abnormal states of hydration, polycythemia

and anemia and aids in

calculation of erythrocyte

indices

Sept 10, 2010 43.1 36.0 – 47.0

Normal. The ratio of solid particles in the blood of the patient is in proportion to the liquid part of the

blood signifying

that the blood is neither too diluted nor

too concentrated.

Platelet Count

(x10 9/L)

To evaluate platelet

production

Sept 10, 2010 246 150 – 400 Normal. It means that

the coagulation capacity and

clotting factor of the patient is functioning

well.

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WBC (x10 9/L)

To determine for presence of for further tests such as WBC differential

infection and also for

determination count

Sept 10, 2010 9.1 4.8 – 10.8 Normal count. It

means the patient’s immune

function is intact and

functioning in its optimum. Proximity of

the WBC count to the high limit

score means the body is

trying to fight present

developing infection or

there is presence of bleeding in

some parts of the body.

Differential Count:

Segmenters (%)

To provide a numeric estimate of the client’s immune status.

Sept 10, 2010 40 55-65% The result is below normal

range indicating the

possible presence of a

viral infection.

Lymphocytes (%)

To check for immune

responses

Sept 10, 2010 48 25-35% The result is above normal

range indicating infection.

Eosinophils (%)

To determine presence of

multicellular


range indicating the

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parasites and certain

infections

presence of a parasitic infection.

Monocytes (%) To determine presence of

Chronic inflammatory

disease, Parasitic

infection, Viral infection


range. It means

macrophages are activated.

COMPLETE BLOOD COUNT

NURSING RESPONSIBILITIES BEFORE, DURING, AND AFTER PROCEDURE

Before the Procedure

Explain the procedure to the pt. and why it is indicated

Inform the patient that fluid and food restriction is not required

Inform the patient that a blood sample will be taken.

Tell the patient that he may experience transient discomfort from the needle puncture

Fill up laboratory request form properly and send it to the laboratory technician during

the collection of sample/specimen.

During the Procedure

Inform the patient that pain may be felt through prick in the needle

Instruct the patient to calm down to avoid uneasiness.

After the Procedure

Apply brief pressure to prevent bleeding

Apply warm compress if Hematoma will develop at the venipuncture site.

PELVIC ULTRASOUND

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http://www.diagnose-me.com/cond/C590185.html#G873

http://www.diagnose-me.com/cond/C590185.html#G144

http://en.wikipedia.org/wiki/Infection

http://en.wikipedia.org/wiki/Parasite





Results Analysis and interpretation

Pelvic Ultrasound

Visualization of the organs of

the pelvis, including the

uterus, fallopian tubes,

and ovaries. This study is done to detect any masses or obstructions in the region of the pelvis.

September 9, 2010

Uterus: Size 6.1 x 4.9 x 5.9 cm, Anteverted, homogenous, No intermual/ subserous myomatous growth

Cervix: Size: 2.6 cm x 2.5 cm. Abnormalities: No Focal lesions

Endometrium: Endometrium is not delineated. There is a round hyperechoic mass noted measuring 3.2 x 3.8 3.9 cm suggesting endo metrial polyp vs. Submucous myoma

Ovaries (Right) 1.7 x 2.4 x 2.4 cm lateral(Left) 2.1 x 2.0 x 2.6 cmAbnormalities: No pathologic ovarian lesion noted

Central mass (3.2 x 3.8 x 3.9 cm) suggestive of endometrial polyp v. Submucous myoma.

PELVIC ULTRASOUND

NURSING RESPONSIBILITIES BEFORE, DURING, AND AFTER PROCEDUREBefore the Procedure

Explain the procedure to the pt. and why it is indicated Instruct the patient to be placed on NPO for 8-12 hours post midnight Acquire a confirmed and informed consent prior to the procedure. Inform patient that the gel and the apparatus to be used may feel cold and uncomfortable

as it will be placed on the skin to visualize the organs.During the Procedure

Provide privacy Advise patient to remain still while the procedure is being informed

After the Procedure

Document that the procedure has been performed Inform physician when findings are available.

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BLOOD CHEMISTRY




Results Normal Values

Analysis and interpretation

Glucose ; RBS To measure the amount of

glucose in the blood right at

the time of sample

collection

Sept 10, 2010 101 <140 mg/dl

Normal count. It means the amount of

glucose in the blood is

sufficient for energy

production and also not

excessive to cause

hyperglycemia. Indicated insulin

(pancreatic) function is

functioning to its optimum.

Creatinine To evaluate kidney

function.

Sept 10, 2010 0.8 0.4-1.4 mg/dl

Normal. It means toxic substances in the body are

maintained in normal amount and signifies

the kidneys are functioning

normally with accordance to its filtration

and excretion of toxic

substances. Result also

indicate normal pH of

blood is maintained.

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Potassium To detect concentrations

that are too high

(hyperkalemia) or too low

(hypokalemia).

Sept 10, 2010 3.82 3.4 - 5.3 mmol/l

Normal / within normal range. It means

electrolyte supply in the

body is sufficient to

meet hydration needs.

BLOOD CHEMISTRY

NURSING RESPONSIBILITIES BEFORE, DURING, AND AFTER PROCEDURE


Explain the procedure to the pt. and why it is indicated

Inform the patient that fluid and food restriction is not required

Inform the patient that a blood sample will be taken.

Tell the patient that he may experience transient discomfort from the needle puncture

Fill up laboratory request form properly and send it to the laboratory technician during

the collection of sample/specimen.


Inform the patient that pain may be felt through prick in the needle

Instruct the patient to calm down to avoid uneasiness.

After the Procedure

Apply brief pressure to prevent bleeding

Apply warm compress if Hematoma will develop at the venipuncture site.

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http://www.labtestsonline.org/understanding/analytes/potassium/test.html

http://www.labtestsonline.org/understanding/analytes/potassium/test.html


PHYSICAL EXAMINATION & ASSESSMENT

Upon Admission, Lifted From the Chart: Assessed on September 9, 2010 8:15AM

Chief Complaint: Vaginal Bleeding

Complete History:

1 wk PTA (+)Vaginal bleeding

•Consulted physician and advised for surgery, hence admitted.

Past History

(-) HPN

(-) DM

(-) Heart Disease

(-) Asthma

(-) Allergies

Non-Smoker, Non-Alcoholic Beverage Drinker

G6P6

Family History

(-) HPN

(-) DM

Present History

Menopause at 53 years.

Start of Menses age 12.

Physical Examination:

VS: BP- 110/70, PR – 76, BR – 26, Temp – 36

Pink Conjunctiva, Anicteric Sclerae

NRRR, (-) Murmurs, CBS, (-) Rales, (-) Wheezes

Globular, NABS, (-) Non Tender

Impression: G6P6 Submucous Myoma

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PHYSICAL EXAMINATION & ASSESSMENT (Cephalocaudal Assessment)

The patient was first met lying in bed with no contraptions such as IV or foley catheter.

She is a 57 year old woman, wearing a set of white pajamas and was watching TV with her

daughter and her husband. The patient is alert, and coherent, giving full and detailed responses to

all of the questions asked. She is 5’4 with black hair slightly turning grey at the roots. She

informed the student nurses that she would be discharged either by today or tomorrow depending

upon the doctor’s next visit and orders. Vital Signs were taken and Recorded as follows:

Vital Signs for 6:00pm

T- 36.1 ‘C

P- 80 bpm

R- 16 cpm

BP – 140/90 mmHg

First Nurse Patient Interaction: September 13, 2010 6:30PM

Skin, Hair, and Nails

o Inspection

Skin

Skin is dark brown in color and even in distribution.

Skin is smooth without lesions or scars; no visible masses or evidence of

ecchymosis.

Fine scaling of dry skin on lower inferior portion of legs and on outer

portion of arms.

Presence of fissuring of skin on inferior portion of the feet

Hair and Scalp

Hair is black, fine, and even in distribution

Scalp is clean and dry

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Nails

Nails are pale pink in color

No presence of nail clubbing

o Palpation

Skin

Skin is smooth and even, except for at the base of the feet

Presence of calluses on the base of feet

With a Skin turgor of 3 seconds

Skin is dry and cool to touch.

Skin is wrinkled and mobile in most areas except in areas of skin folds

Hair and scalp

Smooth with no presence of masses or lesions

Scalp is dry to touch.

Hair is thin and fine; Black and grey in color

Nails

Nails are smooth and firm. Nail plate is firmly attached to nail bed.

With a capillary refill of 3 seconds.

Head and Neck

o Inspection

Head

Head is round, symmetric, erect, proportional, and midline to the client’s

body; no presence of visible lesions

Head is held still and upright

Face is symmetric with an oval appearance.

Neck

Neck is symmetric with head centered and without bulging masses.

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Thyroid cartilages move symmetrically as the client swallows.

Neck movement is smooth and controlled

o Palpation

Head

No swelling, tenderness or crepitations with movement of the jaw.

Jaw can move laterally 1 to 2 cm in each direction.

Neck

Trachea is midline

Thyroid gland is not palpable

No swelling or tenderness of the lymph nodes; lymph nodes are not

enlarged.

Eyes and Ears

o Inspection

Eyes

White sclera is seen around the iris

Cornea is transparent with no opacities. Oblique view shows a moist

overall surface.

With a thin arcus senilis around the iris.

Pupils are equally rounded and respond to light and accommodation.

The upper and lower eyelids close easily and meet completely when

closed.

Eyes are able to move smoothly in an asterisk shape.

The lower eyelids are upright

No inward or outward turning eyes

No presence of swelling, redness, or lesions of the eye.

Upper and lower palpebral conjunctiva are free of swelling or lesions.

Eyes have a sunken appearance.

Iris is round, flat, and evenly colored.

Ears

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Ears are equal in size bilaterally. The auricle aligns with the corner of each

eye.

Earlobes are attached.

Skin is smooth with no lesions; color is evenly distributed and consistent

with facial color.

Small amount of brown flaky cerumen present.

Canal walls are pink and smooth and without nodules.

o Palpation

Eyes

No drainage noted from the puncta upon palpation of the nasolacrimal

duct.

No palpable masses

Ears

No tenderness upon palpation of the auricle and mastoid process.

No palpable masses along the pinna

Mouth, Nose, and Sinuses

o Inspection

Mouth

Lips are cracked and dark brown in color.

Teeth have a yellowish discoloration

No presence of dental carries

Presence of cracking of the crowns of the wisdom teeth

Gums are pink in color

With moist pale-pink buccal mucosa.

Frenulum is midline

Tonsils and uvula show no presence of swelling.

Throat is pink in color

Nose

Color is the same as the rest of the face

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Nasal structure is both smooth and symmetric

Client is able to sniff through each nostril while the other is occluded

Nasal mucosa is pink, moist, and free of exudates

Sinuses

Sinuses do not appear enlarged or swollen

o Palpation

Mouth

No lesions, ulcerations, or nodules upon palpation

Sinuses

Frontal and maxillary sinuses are non tender to palpation and no crepition

is evident.

o Percussion

Sinuses

Sinuses are not tender upon percussion.

Thoracic and Lung

o Inspection

Skin is even in color

Chest moves symmetrically with breathing

with a respiratory rate of 16 breaths per minute

o Palpation

Skin surface and lesions are free of masses

Equal tactile fremitus noted

o Percussion

Resonance is heard throughout all lung fields.

o Auscultation

Clear breath sounds noted

Heart and Neck Vessels

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o Inspection

Jugular venous pulse is not normally visible when the client sits upright,

Apical impulses are not visible.

o Palpation

Carotid artery pulses are equally strong.

Radial and apical pulses are identical.

No pulsations or vibrations are palpated at the apex and the base of the

heart.

o Auscultation

With a BP of 140/90 mmHg

With a pulse rate of 80 beats per minute.

No murmurs or extra heart sounds are heard.

S1 and S2 sounds are clearly heard.

Peripheral and Vascular

o Inspection

Arms are bilaterally symmetric with minimal variation in size and shape.

No edema of the hands or prominent venous patterning throughout all

extremities

Veins are flat and barely seen under the surface of the skin.

Consistent with skin color on the rest of the body.

Legs have equal distribution of hair

The skin tone of the legs are consistent with those of the rest of the body

Legs are free of lesions and ulcerations

Presence of bipedal edema

o Palpation

Skin is cool to touch

With a skin turgor of 3 seconds


Radial pulses have equal strength bilaterally

Brachial pulses have equal strength bilaterally

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Skin of the feet and toes are cold to touch.

No presence of enlarged lymph nodes upon palpation

Negative Homan’s sign

Abdominal

o Inspection

With the presence of bandage below umbilicus

Bandage is clean and free of drainage

Color is consistent with the color of the rest of the body

No visible veins of the abdomen are present upon inspection

No presence of ulcerations

No presence of rashes

Skin tone of umbilicus is similar with that of abdominal skin tone.

Umbilicus is located on midline of the abdomen

Abdomen has a protruded contour and is round in shape.

Abdomen is symmetric

o Auscultation

Soft gurgles are heard at a rate of five seconds per sound.

o Percussion

Tympany is percussed over the abdomen.

o Palpation

No palpable masses

No signs of swelling of the umbilicus; no bulges, or masses.

Musculoskeletal

o Inspection

Client is able to stand on heals and toes

Toes point straight point forward and lie flat, aligned with the lower leg.

Client is able to move without limitation

Cervical and lumbar spines are concave; thoracic spine is convex. The

spine is straight when observed from behind

Joints are symmetric without signs of redness.

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Client has full range of motion without limitation.

Hands are symmetric in size; fingers lie in a straight line.

Iliac crests are symmetric in height

o Palpation

Presence of bipedal edema on lower extremities (ankles)

No presence of joint swelling or tenderness on other areas of the body

Hands and fingers are symmetric, non-tender, and without nodules.

Hips are non tender.

No heat, swelling or nodules noted on the fingers and toes.

REVIEW OF SYSTEMS

Integumentary

o For her hair, the client takes baths at least once or twice a day. She uses any

available shampoo her daughter at home also uses, and this typically includes

Sunsilk, Vaseline, or Palmolive.

o Cleans nails at least once a week using cuticle remover.

o Client does not make use of styling products for the hair.

o Client says she has no history of other skin problems such as lesions, drainage or

swelling.

o Does not feel pain upon light or deep palpation.

o The client and his family have no history of skin allergies or skin cancer.

o Does not have any birthmarks or tattoos.

o No problems with perspiration or odor.

o Has not current history of excessive hair loss, infestations, or change and

appearance in the hair (such as excessive dryness or brittleness).

o Client does not sunbathe, and is not constantly exposed to chemicals which may

harm the skin such as paint, weed killers, insect repellents, and bleach.

Musculoskeletal

o No previous history of problems with joints, muscles, and bones.

o No family history of gout, arthritis, or osteoporosis.

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o Does not experience back pain or pain in the joints during movement.

o On a typical day, she usually spends 4-6 hours in the sunlight.

o Client does not experience neck pain.

o Client experiences headaches every once in a while. The headache usually begins

on the nape of the neck and she describes it as an aching pain. The headache

usually lasts no more than 5-10 minutes and subsides when the client becomes

busy (he forgets the pain) or when he rests.

o Client does not feel any facial pain.

o No difficulty with moving the head and the neck.

o No history of lumps or lesions of the neck.

o Has not experienced dizziness, light-headedness, or a spinning sensation.

o Has not experienced loss of consciousness.

o No history of head or neck problems such as trauma, injury or falls.

Hearing, Vision, Sinuses

o The client has no problems with vision.

o The client has no problems with hearing.

o No past history of ear infection, ringing of the ears (tinnitus), or drainage from

ears.

o Cleans ears regularly once every two days, usually after he bathes.

o No problems with sinuses

o At times, experiences colds, especially during the rainy season.

Respiratory

o The client has no history of smoking

o No past history of PTB or other lung related problems.

o She has no history of lung cancer and has no family history of lung cancer,

asthma, or PTB.

Lymphatic

o No familial history of breast cancer.

o No history of problems concerning the lymphatic system.

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Circulatory

o Does not have any past history of heart problems.

o Has been taking anti-hypertensive medication (which she cannot recall the name

of) and aspirin for two years.

o Skin is often dry, however, she does not use any forms of moisturizer as it further

irritates the skin.

o Does not experience any pain or cramping in the legs.

o She does not have any sores or open wounds on his leg and foot.

o Household chores and working in the “bukid” are her daily forms of exercise.

Gastrointestinal

o Does not currently experience nausea and vomiting.

o Diet includes “ulam” and about one cup of rice. Usually the main dish includes

mainly vegetables and fish. The client does not like to eat meats because they are

“difficult to chew.”

o Drinks an average of three coffee tall coffee glasses a day, made from pure

freshly grounded coffee.

Genitourinary

o Had menarch at age twelve

o Client’s mother was also believed to have a myoma, because she had also been

experiencing the same symptoms of hypermenorrhagia.

o Menopause at 53 years old.

o Client states that he has no recent changes in urinary elimination pattern.

o Urinates every one or two hours at least once.

o Has no history of difficulty of urination.

Neurological

o Does not experience numbness or tingling.

o No history of seizures.

o Patient, at times, has may experience a headache, but it is usually relieved with

diversional activities, rest, or medication such as paracetamol.

o Has no current problem with the sense of smell.

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o No difficulty in speaking or swallowing.

o Does not experience muscle weakness or tremors.

o No problems with memory loss.

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PHYSICAL EXAMINATION & ASSESSMENT (Cephalocaudal Assessment)

Second Nurse Patient Interaction: September 14, 2010 4:00PM

Received patient sitting on bed, awake, alert, and coherent with no current IV or

contraptions. Patient’s wound has been cleaned by the doctor earlier during the day and is free

from discharge or purulent drainage. The patient was wearing wearing a plain white t-shirt and

light blue pajamas. Vital Signs were taken and recorded as follows: (at 4:00pm)

T – 36.1 ‘C

P – 80 bpm

R – 20 cpm

BP – 120/80 mmHg

Skin, Hair, and Nails

o Inspection

Skin

Skin is dark brown in color and even in distribution.

Skin is smooth without lesions or scars; no visible masses or evidence of

ecchymosis.

Fine scaling of dry skin on lower inferior portion of legs and on outer

portion of arms.

Presence of fissuring of skin on inferior portion of the feet

Hair and Scalp

Hair is black, fine, and even in distribution

Scalp is clean and dry

Nails

Nails are pale pink in color

No presence of nail clubbing

o Palpation

Skin

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Skin is smooth and even, except for at the base of the feet

Presence of calluses on the base of feet

With a Skin turgor of 2 seconds

Skin is dry and cool to touch.

Skin is wrinkled and mobile in most areas except in areas of skin folds

Hair and scalp

Smooth with no presence of masses or lesions

Scalp is dry to touch.

Hair is thin and fine; Black and grey in color

Nails

Nails are smooth and firm. Nail plate is firmly attached to nail bed.


Head and Neck

o Inspection

Head

Head is round, symmetric, erect, proportional, and midline to the client’s

body; no presence of visible lesions

Head is held still and upright

Face is symmetric with an oval appearance.

Neck

Neck is symmetric with head centered and without bulging masses.

Thyroid cartilages move symmetrically as the client swallows.

Neck movement is smooth and controlled

o Palpation

Head

No swelling, tenderness or crepitations with movement of the jaw.

Jaw can move laterally 1 to 2 cm in each direction.

Neck

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Trachea is midline

Thyroid gland is not palpable

No swelling or tenderness of the lymph nodes; lymph nodes are not

enlarged.

Eyes and Ears

o Inspection

Eyes

White sclera is seen around the iris

Cornea is transparent with no opacities. Oblique view shows a moist

overall surface.

With a thin arcus senilis around the iris.

Pupils are equally rounded and respond to light and accommodation.

The upper and lower eyelids close easily and meet completely when

closed.

Eyes are able to move smoothly in an asterisk shape.

The lower eyelids are upright

No inward or outward turning eyes

No presence of swelling, redness, or lesions of the eye.

Upper and lower palpebral conjunctiva are free of swelling or lesions.

Eyes have a sunken appearance.

Iris is round, flat, and evenly colored.

Ears

Ears are equal in size bilaterally. The auricle aligns with the corner of each

eye.

Earlobes are attached.

Skin is smooth with no lesions; color is evenly distributed and consistent

with facial color.

Small amount of brown flaky cerumen present.

Canal walls are pink and smooth and without nodules.

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o Palpation

Eyes

No drainage noted from the puncta upon palpation of the nasolacrimal

duct.

No palpable masses

Ears

No tenderness upon palpation of the auricle and mastoid process.

No palpable masses along the pinna

Mouth, Nose, and Sinuses

o Inspection

Mouth

Lips are cracked and dark brown in color.

Teeth have a yellowish discoloration

No presence of dental carries

Presence of cracking of the crowns of the wisdom teeth

Gums are pink in color

With moist pale-pink buccal mucosa.

Frenulum is midline

Tonsils and uvula show no presence of swelling.

Throat is pink in color

Nose

Color is the same as the rest of the face

Nasal structure is both smooth and symmetric

Client is able to sniff through each nostril while the other is occluded

Nasal mucosa is pink, moist, and free of exudates

Sinuses

Sinuses do not appear enlarged or swollen

o Palpation

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Mouth

No lesions, ulcerations, or nodules upon palpation

Sinuses

Frontal and maxillary sinuses are non tender to palpation and no crepition

is evident.

o Percussion

Sinuses

Sinuses are not tender upon percussion.

Thoracic and Lung

o Inspection

Skin is even in color

Chest moves symmetrically with breathing

with a respiratory rate of 20 breaths per minute

o Palpation

Skin surface and lesions are free of masses

Equal tactile fremitus noted

o Percussion

Resonance is heard throughout all lung fields.

o Auscultation

Clear breath sounds noted

Heart and Neck Vessels

o Inspection

Jugular venous pulse is not normally visible when the client sits upright,

Apical impulses are not visible.

o Palpation

Carotid artery pulses are equally strong.

Radial and apical pulses are identical.

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No pulsations or vibrations are palpated at the apex and the base of the

heart.

o Auscultation

With a BP of 120/80 mmHg

With a pulse rate of 80 beats per minute.

No murmurs or extra heart sounds are heard.

S1 and S2 sounds are clearly heard.

Peripheral and Vascular

o Inspection

Arms are bilaterally symmetric with minimal variation in size and shape.

No edema of the hands or prominent venous patterning throughout all

extremities

Veins are flat and barely seen under the surface of the skin.

Consistent with skin color on the rest of the body.

Legs have equal distribution of hair

The skin tone of the legs are consistent with those of the rest of the body

Legs are free of lesions and ulcerations

Presence of bipedal edema

o Palpation

Skin is cool to touch

With a skin turgor of 2 seconds


Radial pulses have equal strength bilaterally

Brachial pulses have equal strength bilaterally

Skin of the feet and toes are cold to touch.

No presence of enlarged lymph nodes upon palpation

Negative Homan’s sign

Abdominal

o Inspection

With the presence of bandage below umbilicus

Bandage is clean and free of drainage

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Color is consistent with the color of the rest of the body

No visible veins of the abdomen are present upon inspection

No presence of ulcerations

No presence of rashes

Skin tone of umbilicus is similar with that of abdominal skin tone.

Umbilicus is located on midline of the abdomen

Abdomen has a protruded contour and is round in shape.

Abdomen is symmetric

o Auscultation

Soft gurgles are heard at a rate of five seconds per sound.

o Percussion

Tympany is percussed over the abdomen.

o Palpation

No palpable masses

No signs of swelling of the umbilicus; no bulges, or masses.

Musculoskeletal

o Inspection

Client is able to stand on heals and toes

Toes point straight point forward and lie flat, aligned with the lower leg.

Client is able to move without limitation

Cervical and lumbar spines are concave; thoracic spine is convex. The

spine is straight when observed from behind

Joints are symmetric without signs of redness.

Client has full range of motion without limitation.

Hands are symmetric in size; fingers lie in a straight line.

Iliac crests are symmetric in height

o Palpation

Presence of bipedal edema on lower extremities (ankles)

No heat, swelling or nodules noted on the fingers and toes.

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ANATOMY & PHYSIOLOGY

The female reproductive system

consists of the ovaries, uterine

tubes (or fallopian tubes), uterus,

vagina, external genitalia, and

mammary glands. The internal

reproductive organs of the

female are located within the

pelvis, between the urinary

bladder and the rectum. The

uterus and the vagina are in the midline , with an ovary to each side of the organ. The internal

reproductive organs are held in place within the pelvis with ligaments. The most conspicuous is

the brad ligament, which spreads out on both sides of the uterus and to which the ovaries and the

uterine tubes attach.

Ovaries

The two ovaries are small organs suspended in the pelvic

cavity by ligaments. The suspensory ligament extends

from each ovary to the lateral body wall, and the ovarian

ligament attaches the ovary to the superior margin of the

uterus. In addition, the ovaries are attached to the posterior

surface of the broad ligament by folds of the peritoneum called the mesovarium. The ovarian

arteries, veins, and nerves transverse the suspensory ligament and enter the ovary through the

mesovarium.

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A layer of visceral peritoneum covers the surface of the ovary. The outer part of the ovary is

made up of dense connective tissue and contains the ovarian follicles. Each of the ovarian

follicles contains an oocyte, the female sex cell. Loose connective tissue makes up the inner part

of the ovary, where blood vessels, lymphatic vessels, and nerves are located.

Uterine Tubes

A uterine tube, fallopian tube, or oviduct (named after the italian anatomist, Gabriele Fallopio) is

associated with each ovary. The uterine tubes extend from the area of the ovaries to the uterus.

The open directly into the peritoneal cavity near each ovary and receive an oocyte. The opening

of each uterine tube is surrounded by long, thin processes called fimbriae.

The fimbriae nearly surround the surface of the ovary. As a result, as soon as the oocyte is

ovulated, it comes into contact with the surface of the fimbriae. Cilia on the fimbriae surface

sweep the oocyte into the uterine tube. Fertilization usually occurs in the part of the uterine tube

near the ovary known as the ampulla.

Uterus

The uterus is as big as the size of a medium-sized pear. It is oriented in the pelvic cavity with the

larger, rounded portion directed superiorly. The part of the uterus superior to the entrance of the

fallopian tubes is called the fundus. The main part of the uterus is called the body, and the

narrower part is termed the cervix and is directed inferiorly. Internally, the uterine cavity in the

fundus and uterine body continues through the cervix as the cervical canal, which opens into the

vagina. The cervical canal is lined by mucous glands.

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The Uterine wall is composed of three layers: a serous layer or perimetrium of the uterus,

consists of smooth muscle is quite thick and accounts for the bulk of the uterine wall. The inner

most layer of the uterus is called the endometrium. The endometrium consists of simple

columnar epithelium tissues with an underlying connective tissue layer. Simple tubular glands,

called enometrial glands, are formed by folds of the endometrium. The superficial part os the

endometrium is sloughed off during menstruation.

The uterus is supported by the broad ligament and the round ligament. In addition to these

ligaments that support the uterus, much support is provided inferiourly to the uterus by skeletal

muscles of the pelvic floor. If ligaments that suppor the uterus or the muscles of the pelvic floor

are weakened such as in childbirth, the uterus can extend inferiorly into the vagina, a condition

termed as a prolapsed uterus. Severe cases require surgical correction.

Vagina

The vagina is the female organ of copulation and functions to receive the penis during

intercourse. It also allows menstrual flow and childbirth. The vagina extends from the uterus to

outside the body. The superior portion of the vagina is attached to the sides of the cervix so that a

part of the cervix extends into the vagina.

The wall of the vagina consists of an outer muscular layer and an inner mucous layer. The

muscular layer is smooth muscle and contains many elastic fibers. Thus the vagina can increase

in size to accommodate the penis during intercourse, and it can stretch greatly during childbirth.

The mucous membrane is moist stratified squamous epitheliam that forms a protective surface

layer. Lubricating fluid passes through the vaginal epithelium into the vagina.

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In young females, the vaginal opening is covered by a thin mucous membrane known as the

hymen. The hymen can completely close the vaginal oriface in which case it must be removed to

allow menstrual flow. More commonly, the hymen is perforated by one or several holes. The

openings of the hymen are usually greatly enlarged during the first sexual intercourse. The

hymen can also be perforated during a variety of activities including strenuous exercise. The

condition of the hymen is therefore not a reliable indicator of virginity.

The External Genitalia

The external female genitalia, also called the vulva, or pudendum, consists of the vestibule and

its surrounding structures. The vestibule is the space into which the vagina and urethra open. The

urethra opens just anterior to the vagina. The vestibule is bordered by a pair of thin, longitudinal

skin folds called the labia minora. A small erectile structure called the clitoris is located in the

anterior margin of the vestibule. The two labia minora unite over the clitoris to form a fold of

skin known as the prepuce.

The clitoris consists of a shaft and a distal glans. Like the glans penis, the clitoris is well supplied

with sensory receptors, and it is made up of erectile tissue. An additional erectile tissue is

located on either side of the vaginal opening.

On each side of the vestibule, between the vaginal opening and the labia minora, are openings of

the greater vestibular glands. These glands produce a lubricating fluid that helps maintin the

moistness of the vestibule.

Lateral to the labia minor are two prominent rounded folds of skin called the labia majora. The

two labia majora unite anteriorly at the elevation of tissue over thepubic symphysis calle dthe

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mons pubis. The lateral surfaces of the labia majora and the surface of the mons pubis are

covered with coarse hair. The medial surfaces of the labia minora are covered with numerous

sebaceous and sweat glands. The space between the labia minor is called the pudendal cleft.

Most of the time, the labia minora are in contact with each other across the midline , closing the

pudendal cleft and covering the deeper structures within the vestibule.

The region between the vagina and the anus is the clinical perineum. The skin and muscle of this

region can tear during childbirth. To preven such tearing, an incision called an episiotomy is

sometimes made in the clinical perineum. Traditionally, this clean, straight incision is thought to

result in less injury, and less trouble in healing, and less pain. However, many studies indicate

that there is less injury and pain when no episiotomy is performed.

Mammary Glands

Mammary glands are located inside the breasts of sexually mature female body. They are in

actuality modified sweat glands which are in fact comprised of secretory mammary alveoli and

the appropriate ducts. Mammary glands are considered to be part of the integumentary system

rather than the reproductive system. The glands are associated with the female reproductive

system in part due to their assistance in attracting a mate as well as their role in nourishing a

baby. Size and shape of the female breast are different for every human body and factors such as

race, age, body fat, and pregnancy can make a large difference in these variations.

The release of estrogen during puberty releases hormones that stimulate the growth of the breasts

and the functions of the mammary glands. Pregnant women as well as nursing women

experience hypotrophy of the breasts while it is not uncommon for atrophy of the breasts to

occur after menopause.

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Breasts are situated over ribs 2 through 6 and overlap the pectoral muscle as well as some

portions of the oblique muscles. The lateral margin of the sternum creates an unintentional

margin for the edge of each breast. Each breast also follows the anterior margin of the respective

axilla. Coming within very close proximity to the Axillary vessels, the breasts upward and

laterally toward the axilla, which contributes to the high incidence of breast cancer due to the

axillary process’ lymphatic drainage.

15 to 20 lobes compose the mammary gland, and each lobe is equipped with its own duct to the

outside of the body. Adipose tissue in varying amounts segregates each lobe. While this tissue

controls the size and shape that the breast takes, there is no determination by this tissue when it

comes to the woman’s ability to suckle her young. Lobules are subdivisions of each lobe. These

subdivisions contain mammary alveoli. The milk of a lactating female are produced within the

mammary alveoli. Suspensory ligaments support the breasts which are attached between the

lobules and run deep into the fascia which overlap the pectoral muscles. Breast milk is secreted

into a network of mammary ducts which receive the milk from the clusters of mammary alveoli.

These mammary ducts converge to form lactiferous ducts. Near the nipple, each lactiferous duct

expands into the lumen to allow for outward flow of milk. The lactiferous sinuses store the milk

before the suckling action, or additional pressure, releases it from the body. The milk leaves the

body from the tip of the nipple.

The nipple contains some erectile tissue that protrudes into a cylindrical projection. The circular

area around the nipple that contrasts in color is the areola. Sebaceous areola glands create a

bumpy surface around the areola which reside just under the surface of the areola’s skin. These

glands secrete fluids during lactation as well as when a woman is not lactating, which keep the

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nipple supple. The complexion of the areola is based on the complexion of the skin that covers

the rest of the body, varying in pigments and tints. During gestation most areola surfaces darken.

It also becomes larger in most cases. This is thought to be more obvious for a nursing infant to

find.

Branches of the internal thoracic artery are responsible for supplying blood flow to the nipple as

well as the rest of the breast and mammary glands. Between the second, third, and forth

intercoastal spaces these braches of the thoracic artery enter the mammary glands. These spaces

are positioned laterally to the sternum and offer entry to the mammary artery, which only

supplies supportive blood. The return veins run alongside the initial arteries which supply the

blood. During pregnancy and lactation, and sometimes during other periods, a superficial venous

plexus can be seen through the surface of the skin.

The fourth, fifth, and sixth thoracic nerves innervate the breast principally through sensory

somatic neurons. These neurons are derivative of the anterior and lateral branches of the thoracic

nerves. The release of milk is dependant upon the sensory innervations as stimulus is the only

natural release an infant can provide to be nourished.

Menstrual Cycle

Menstruation is the shedding of the lining of the uterus (endometrium) accompanied by bleeding.

It occurs in approximately monthly cycles throughout a woman's reproductive life, except during

pregnancy. Menstruation starts during puberty (at menarche) and stops permanently at

menopause.

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By definition, the menstrual cycle begins with the first day of bleeding, which is counted as day

1. The cycle ends just before the next menstrual period. Menstrual cycles normally range from

about 25 to 36 days. Only 10 to 15% of women have cycles that are exactly 28 days. Usually, the

cycles vary the most and the intervals between periods are longest in the years immediately after

menarche and before menopause.

Menstrual bleeding lasts 3 to 7 days, averaging 5 days. Blood loss during a cycle usually ranges

from ½ to 2½ ounces. A sanitary pad or tampon, depending on the type, can hold up to an ounce

of blood. Menstrual blood, unlike blood resulting from an injury, usually does not clot unless the

bleeding is very heavy.

The menstrual cycle is regulated by hormones. Luteinizing hormone and follicle-stimulating

hormone, which are produced by the pituitary gland, promote ovulation and stimulate the ovaries

to produce estrogen and progesterone stimulate the uterus and breasts to prepare for possible

fertilization. The cycle has three phases: follicular (before release of the egg), ovulatory (egg

release), and luteal (after egg release).

Menopause

When a woman is 40-50 years old, the menstrual cycles become less regular and ovulation does

not consistently occur during each cycle. Eventually, the cycles stop completely. The cessation

of menstrual cycles is called menopause, and the whole time period from the onset of irregular

cycles to their complete cessation is called the female climacteric.

The major cause of menopause is age-related changes in the ovaries. The number of follicles

remaining in the ovaries of menopausal women is small. In addition to this, the follicles that

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remain become less sensitive to the stimulation of FSH and LH. As the ovaries become less

responsive to stimulation by FSH and LH, fewer mature follicles and copora lutea are produced.

Gradual changes occur in women in response to the reduced amount of estrogen and

progesterone produced by ovaries.

During the climacteric, some women experience “hot flashes,” irritability, fatigue, anxiety,

temporary decrease in libido, and occasionally severe emotional disturbances. Many of these

symptoms can be treated successfully with hormone replacement therapy, which usually consists

of small amounts of estrogen or progesterone. A potential side effect of HRT is a slightly

increased possibility of the development of breast cancer, uterine cancer, heart attacks, strokes,

and blood clots. HRT does slow the decrease in bone density that can become sever in some

women after menopause, and decreases the risk of developing colorectal cancer.

HORMONES AND FEMALE CYCLES

The ovarian cycle is

hormonally regulated in two phases.

The follicle secretes estrogen before

the ovulation; the corpus luteum

secretes both estrogen and

progesterone after ovulation.

Hormones from the hypothalamus and

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anterior pituitary control the ovarian cycle. The ovarian cycle covers events in the ovary; the

menstrual cycle occurs in the uterus.

Menstrual cycles vary from between 15 and 31 days. The first day of the cycle is the

first day of blood flow (day 0) known as menstruation. During menstruation, the uterine lining is

broken down and shed as menstrual flow. FSH and LH are secreted on day 0, beginning both the

menstrual cycle and the ovarian cycle. Both FSH and LH stimulate the maturation of a single

follicle in one of the ovaries and the secretion of estrogen. Rising levels of estrogen in the blood

trigger secretion of LH, which stimulates follicle maturation and ovulation (day 14, or mid

cycle). LH stimulates the remaining follicle cells to form the corpus luteum, which produces both

estrogen and progesterone.

Estrogen and progesterone stimulate the development of the endometrium and

preparation of the uterine lining for implantation of a zygote. If pregnancy does not occur, the

drop in FSH and LH causes the corpus luteum to disintegrate. The drop in hormones also causes

the sloughing off of the inner lining of the uterus by a series of muscle contractions of the uterus.

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BOOK-BASED PATHOPHYSIOLOGY

Schematic Diagram

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Predisposing Factors:

-Age

-Race

-Heredity

-Early Menarche

-Nulliparity


-Age

-Race

-Heredity

-Early Menarche

-Nulliparity

Precipitating Factors:

-High fat diet

-Obesity

-Anxiety/Stress

-Oral Contraceptives or

-Hormone replacement therapy

-Luteal Insufficiency

-Coffee/ Caffeine intake


-High fat diet

-Obesity

-Anxiety/Stress

-Oral Contraceptives or

-Hormone replacement therapy

-Luteal Insufficiency


Etiology:Unknown

Estrogen Dominance or increase in Estrogen production


Proliferation of cells in uterus*

Proliferation of cells in uterus*

Overgrowth the endometrial lining


Myoma: Development of uterine fibroid


Interference in the vascular supply


Degeneration of the interior part of

fibroid


fibroid

S/sx:

-Swelling of breasts

-Depression

-Loss of sex Drive

-Dysmenorrhea

S/sx:

-hypermenorrhea

-Abnormal bleeding

Uterine Cavity begins to stretch or increase in size


S/sx:

-Pain

-Increased pelvic Pressure

* Classified according to area of growth: intramural, submucous, & subserous


BO O K - B A S E D : SY N T H E S I S O F T H E D I S E A S E

Definition of the Disease

Uterine Leiomyomas are the

most common pelvic tumors of

reproductive-age women (Ling

& Duff, 2009). They occur in

up to 50 % of patients in

autopsy series, and are more

common in African-American

women. They are composed of

smooth muscle cells within a

fibrous tissue matrix and are

unicellular in origin. The

growth of these benign tumor

tends to be promoted by estrogen and other growth factors.

Uterine fibroids are leiomyomata of the uterine smooth muscle. They may vary in size and

location. Leiomyomas may be submucous, subserous, intraligamentous, peduncultated or

parasitic (Ling & Duff, 2009) As other leiomyomata, they are benign, but may lead to excessive

menstrual bleeding (menorrhagia), often cause anemia and may lead to infertility. Enucleation is

removal of fibroids without removing the uterus (hysterectomy), which is also commonly

performed. Laser surgery (called myolysis) is increasingly used, and provides a viable alternative

to traditional surgeries. Oral contraceptive pills can be used to decrease excessive menstrual

bleeding and pain associated with uterine fibroids.

Uterine leiomyomas originate in the myometrium and are classified by location:

Submucosal – lie just beneath the endometrium.

Intramural – lie within the uterine wall.

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Subserosal – lie at the serosal surface of the uterus or may bulge out from the

myometrium and can become pedunculated.

The tumors become malignant in less that 0.1 % of patients, which should serve as comfort to

women concerned with the possibility of uterine malignancy in association with a fibroid.

(McCann & Holmes, 2003)

The actual cause of uterine myomas/ leiomyomas are unknown, however, they are seen to be

increased with the presence of the following factors.

The incidence is higher on women during the reproductive years where estrogens and other

hormones are actively produced by the body. Many women opt to use oral contraceptives as a

birth control method. Oral contraceptives promote estrogen dominance and eventually influence

the growth of the cells in the uterus. High-fat diet is also considered a source of estrogen where

as diets rich in fiber and low in fat decreases estrogen reabsorption. Leimyoma formation is also

possible because of hyperestrogenism due to progesterone deficiency that is caused by luteal

insufficiency. Apart from estrogen stimulation, heredity is a factor in the occurrence of

leimyomas. Fibroids formation is 4.2 times more common in first-degree relatives than with

fibroids without genetic influence.

Estrogen is vital in the regulation the menstrual cycle. Presence of this hormone during the first

phase influences the proliferation of smooth muscle cells in the uterine walls. Overstimulation

increases the size of the uterine lining and further develops into a fibroid. During menstruation,

the excessively thickened endometrium does not desquamate (shed its lining) easily (or even

completely) at the end of the cycle, resulting in prolonged and/or excessive menstrual bleedings.

Following the degeneration of the interior part of the fibroid, are the degenerative changes that

eventually replace smooth muscle cells by fibrous connective tissue. The fibroid continually

grows and its size puts pressure on the adjacent organs, the bladder and rectosigmoid. Urinary

frequency and constipation, respectively, are the results of the compression of these organs.

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Predisposing Factors

1. Age is a risk factor in the disease process of uterine leiomyoma. This is due to the differences

of estrogen and progesterone levels in females as they get older and undergo the processes of

menopause.

2. Race – Although an actual connection between the disease process and race have yet to been

validated and affirmed, many studies have shown that particular races such as American and

African Americans are more susceptible to tumor growth in the endometrial lining among

premenopausal women (Marshall, 1997).

3. Heredity – Women who’s mothers have had myoma themselves are more susceptible to

getting the disease than those who have no family history of the disease. (Faerstein, 1997)

4. Early Menarche and Nulliparity – Studies have suggested that an early start of menarche

(less than the average age of 13) and nulliparity contribute to the development of a uterine

leiomyoma, however, how this connection or relationship between the risk factor and the

disease processes are still unknown (Faerstein, 2001). It is believed that these factors are

precipitated because of the estrogen and progesterone levels in the body.

Precipitating Factors

1. High Fat Diet & Obesity – is also considered a source of estrogen where as diets rich in fiber

and low in fat decreases estrogen reabsorption. Fat has an enzyme that converts adrenal

steroids to estrogen. The higher the fat intake, the higher the conversion of fat to estrogen.

Overeating is the norm in developed countries. A population from such countries, especially

in the Western hemisphere where a large part of the dietary calorie is derived from fat, has a

much higher incidence of menopausal symptoms. Studies have shown that estrogen and

progesterone levels fell in women who switched from a typical high-fat, refined-carbohydrate

diet to a low-fat, high-fiber and plant-based diet even though they did not adjust their total

calorie intake. Plants contain over 5,000 known sterols that have progestogenic effects.

2. Anxiety/ Stress – The stress levels of the individuals can influence the production of estrogen

and progesterone in the body. Stress causes adrenal gland exhaustion as well as reduced

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progesterone levels. This tilts the estrogen to progesterone ratios in favor of estrogen.

Excessive estrogen in turn causes insomnia and anxiety, which further taxes the adrenal

glands. This leads to a further reduction in progesterone output and even more estrogen

dominance. After a few years in this type of vicious cycle, the adrenal glands become

exhausted. This dysfunction leads to blood sugar imbalance, hormonal imbalances, and

chronic fatigue.

3. Oral Contraceptives or HRT - Oral contraceptives promote estrogen dominance and

eventually influence the growth of the cells in the uterus. This increases the level of estrogen

in the body. Premarin, an estrogen-only drug commonly used in the past 40 years, is the

mainstay of estrogen replacement therapy (ERT). It is a patented, chemicalized hormonal

substitute that is different than the natural estrogen in your body. It contains 48% estrone and

only a small amount of progesterone, which is insufficient to have an opposing effect. The

indiscriminate and over-prescription of Premarin to many who may not need it is the

problem. Symptoms include water retention, breast swelling, and fibrocysts in the breast,

depression, headache, gallbladder problems, and heavy periods. The excessive estrogen from

ERT also lead to increased chances of DNA damage, setting a stage for endometrial and

breast cancer

4. Luteal Insufficiency - Leimyoma formation is also possible because of hyperestrogenism due

to progesterone deficiency that is caused by luteal insufficiency

5. Caffeine or Coffee intake - Increase in coffee consumption. Caffeine intake from all sources

is linked with higher estrogen levels regardless of age, body mass index (BMI), caloric

intake, smoking, alcohol, and cholesterol intake. Studies have shown that women who

consumed at least 500 milligrams of caffeine daily, the equivalent of four or five cups of

coffee, had nearly 70% more estrogen during the early follicular phase than women who

consume no more than 100 mg of caffeine daily, or less than one cup of coffee. Tea is not

much better as it contains about half the amount of caffeine compared to coffee. The

exception is herbal tea like chamomile, which contains no caffeine.

Signs & Symptoms with Rationale

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1. Swelling of breasts – Enlargement of the breast and tenderness results from a fluctuation of

the hormones progesterone and estrogen.

2. Depression – Due to imbalanced levels of estrogen in the body.

3. Loss of Sex Drive – Due to imbalanced levels of estrogen in the body.

4. Dysmenorrhea – Due to imbalanced levels of estrogen in the body.

5. Pain – Due to the stretching of the uterus and the proliferation of cells which damages the

endometrial wall.

6. Increased pelvic pressure – Due to the growth of the tumor.

7. Hypremenorrhea and Abnormal Bleeding – Due to the growth of the tumor as well as the

deterioration of the surrounding tissues which may come from the ischemia due to the

tumor’s growth.

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CLIENT-CENTERED PATHOPHYSIOLOGY

Schematic Diagram

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-Age

-Race

-Early Menarche


-Age

-Race

-Early Menarche


-High fat diet

-Obesity

-Anxiety/Stress (Working in the bukid)



-High fat diet

-Obesity

-Anxiety/Stress (Working in the bukid)


Etiology:Unknown



Proliferation of cells in uterus* (Sub mucous)

Proliferation of cells in uterus* (Sub mucous)








fibroid


fibroid

s/sx:

-Abnormal bleeding




CL I E N T - B A S E D : SY N T H E S I S O F T H E D I S E A S E

Predisposing Factors

5. Age is a risk factor in the disease process of uterine leiomyoma. The client is currently 57

years old. This is due to the differences of estrogen and progesterone levels in females as

they get older and undergo the processes of menopause.

6. Heredity – Women who’s mothers have had myoma themselves are more susceptible to

getting the disease than those who have no family history of the disease. (Faerstein, 1997).

The client’s mother was believed to also have a myoma, as the client recalls that she was

experiencing the same symptoms.

7. Early Menarche and Nulliparity – The client had her menarche at 12 years of age. Studies

have suggested that an early start of menarche (less than the average age of 13) and

nulliparity contribute to the development of a uterine leiomyoma, however, how this

connection or relationship between the risk factor and the disease processes are still unknown

(Faerstein, 2001). It is believed that these factors are precipitated because of the estrogen and

progesterone levels in the body.

Precipitating Factors

1. High Fat Diet & Obesity – is also considered a source of estrogen where as diets rich in fiber

and low in fat decreases estrogen reabsorption. Fat has an enzyme that converts adrenal

steroids to estrogen. The higher the fat intake, the higher the conversion of fat to estrogen.

Overeating is the norm in developed countries. A population from such countries, especially

in the Western hemisphere where a large part of the dietary calorie is derived from fat, has a

much higher incidence of menopausal symptoms. Studies have shown that estrogen and

progesterone levels fell in women who switched from a typical high-fat, refined-carbohydrate

diet to a low-fat, high-fiber and plant-based diet even though they did not adjust their total

calorie intake. Plants contain over 5,000 known sterols that have progestogenic effects.

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2. Anxiety/ Stress – The stress levels of the individuals can influence the production of estrogen

and progesterone in the body. Stress causes adrenal gland exhaustion as well as reduced

progesterone levels. This tilts the estrogen to progesterone ratios in favor of estrogen.

Excessive estrogen in turn causes insomnia and anxiety, which further taxes the adrenal

glands. This leads to a further reduction in progesterone output and even more estrogen

dominance. After a few years in this type of vicious cycle, the adrenal glands become

exhausted. This dysfunction leads to blood sugar imbalance, hormonal imbalances, and

chronic fatigue.

3. Caffeine or Coffee intake - The client has an average consumption of at least three (tall) cups

of coffee a day. Increase in coffee consumption. Caffeine intake from all sources is linked

with higher estrogen levels regardless of age, body mass index (BMI), caloric intake,

smoking, alcohol, and cholesterol intake. Studies have shown that women who consumed at

least 500 milligrams of caffeine daily, the equivalent of four or five cups of coffee, had

nearly 70% more estrogen during the early follicular phase than women who consume no

more than 100 mg of caffeine daily, or less than one cup of coffee. Tea is not much better as

it contains about half the amount of caffeine compared to coffee. The exception is herbal tea

like chamomile, which contains no caffeine.

Signs & Symptoms with Rationale

1. Hypremenorrhea and Abnormal Bleeding – Due to the growth of the tumor as well as the

deterioration of the surrounding tissues which may come from the ischemia due to the

tumor’s growth. This was only assessed upon admission of the client as the client was seen

by the student nurses after her surgery. (September 9, 2010)

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1. MEDICAL MANAGEMENT

In t r a v e n o u s Th e r a p y

INTRAVENOUS FLUID THERAPY

Medical Management

Date Ordered General Description

Indication or Purposes

Clients Response to Treatment

5% Dextrose in Lactated Ringer’s Solution

(30gtts/min)

DO: Sept 10, 2010

DC: Sept 13, 2010

Hypertonic Solution

A solution containing sodium chloride, potassium chloride, calcium chloride and sodium lactated in distilled water, referred to Lactated Ringer’s solution calories from dextrose

To replace fluids and electrolytes loss

To increase vascular/ plasma volume necessary during bleeding or blood loss

To replenish fluid loss of the body, maintain nutritional intake when patient is unable to tolerate feedings, also serves as medium for administration of medications.

No adverse reactions or IV complications noted

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INTRAVENOUS THERAPY

NURSING RESPONSIBILITIES BEFORE, DURING, AND AFTER Before the Procedure

Check the doctor’s order regarding to what type of IVF to be used and also its volume and rate.

Explain the procedure to the patient.

Gather all materials needed for the insertion of IVF to save time and not to waste time for looking for other

materials.

Wash hands before and after the procedure to prevent contamination from insertion site.


Place patient in a comfortable position to facilitate easy insertion of IV line and to decrease patient’s fear

about the procedure.

Make sure that we give the proper IV fluid and drop rate accurately because patient may experience fluid

overload or dehydration.

Check for its patency by observing the backflow of blood upon insertion.

After the Procedure

Press the site where the needle was inserted and secure it with micropore.

Check the site of hand where the needle is inserted if bulging is not visible. If so, reinsertion is to be

undertaken.

Advice patient to avoid scratching the site less movement of the hand where the needle was inserted to

keep it in place.

Instruct patient and significant others to inform the nurse on duty if bulging of the site is visible, if there is

back flow of blood of if IVF is not infusing well.

Observe the IV site at least every hour for signs of infiltration or other complications fluid or electrolyte

overload and air embolism.

IVF regulation should be checked and monitored upon receiving patient.

Always check the doctor’s order for new orders regarding the IVF supplement of the patient.

Always check if the IVF is infusing well and intact.

Monitor the patient’s skin integrity.

Provide comfort for the patient.

Remove and dispose used items.

Report and record as appropriate.

Place IV tag

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Ph a r m a c o l o g i c a l , Ma n a g e m e n t

Drug Name

Generic Name (Brand Name)

General ActionIndication or

PurposesDates


Brand Name:

Ancef

Generic Name:

Cefazolin Sodium

Date ordered:

09/11/10

Date performed:

09/11/10

1g/IV q 8

ANST x 1 more dose

First generation cephalosporin anti-infective drug that inhibits cell-wall synthesis, promoting osmotic instability; usually bactericidal.

The patient verbalizes understanding of taking this medication

Brand Name:

Nubain

Generic Name:

Nalbuphine Hydrochloride

Date ordered:

09/11/10

Date performed:

09/11/10

10 mg / amp PRN

Opioid analgesics. Binds with opiate

Receptors in the CNS, altering perception of and emotional response to pain.

The patient

verbalizes relief from pain

Brand Name:

Amlodipine Besylate

Date ordered:

09/12/10

Antianginals. Inhibits calcium ion influx acriss cardiac and smooth- muscle


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Generic Name:

Norvasc

Date performed:

09/12/10

5 mg / tab OD cells, dilates coronary arteries and arterioles, and decreases blood pressure and myocardial oxygen demand.

Brand Name:

Voltaren

Generic Name:

Diclofenac Sodium

Date ordered:

09/12/10

Date performed:

09/12/10

75 mg/deep IM ANST

(-)

Nonsteroidal anti-inflammatory drug, may inhibit prostaglandin synthesis, to produce anti-inflmmatory, analgesic and anti-pyretic effects.


Nursing Responsibilities for All Drugs

Before the administration of drug:

Verify Doctor’s order

Remember the 10R’s of Drug administration

During the administration of drug:

Verify patient’s identification

Inform the patient with regards to drug administration

Clean the IV port prior to administration of the drug

After the administration of drug:

Monitor patient for adverse effects

Inform patient that easy bruising may occur

Caution patient not to stop taking drug abruptly without first consulting prescriber

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Di e t & Ac t i v i t y Ma n a g e m e n t

LOW SALT, LOW FAT DIET

Type of DietGeneral

DescriptionIndication or

PurposesDate Ordered


Low Salt, Low Fat diet.

Reduced sodium and cholesterol content of food

To prevent risk for other complications which may arise from hypertension.

Sept 10, 2010

Upon admission

Client has been complying with the diet and was able to maintain blood pressure within normal limits for most days.

LOW SALT, LOW FAT DIABETIC DIET

NURSING RESPONSIBILITIES BEFORE, DURING, AND AFTER


Check the doctor’s order.

Check the right client.

Be sure that the diet is properly instructed.


Monitor if the client complies with the given diet.

Be sure patient is taking or eating food he can tolerate

After the Procedure

Assess for patient’s condition; how he responds to the diet

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Active and Passive Range of Motion Exercises

Type of ActivityGeneral




Active and Passive Range of Motion Exercises

Range of motion (ROM) exercises are ones in which a nurse or patient move each joint through as full a range as is possible without causing pain.

To prevent any aggravations of complications of immobility such as thrombus formation.

Sept. 11, 2010

After Surgery

The client was able to comply with the activity; therefore thrombus formation had been prevented.

ACTIVE AND PASSIVE RANGE OF MOTION EXERCISES





Be sure that the activity is properly instructed.

Ensure that the patient understands why this type of activity is being prescribed.


Monitor if the client complies with the given activity


After the Procedure

Assess for patient’s condition; how he responds to the activity

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Turning, Coughing, And Deep Breathing

Type of ActivityGeneral




Turning, Coughing, And Deep Breathing

A type of exercise which is educated prior to the surgery and implemented soon after the effects of anesthesia have worn off which includes activities such as coughing and deep breathing with the use of a splint.

To assist in loosening and expectoration of mucous

Sept. 11, 2010

After Surgery

The client was able to comply with the activity as evidenced by clear breath sounds.

TURNING, COUGHING, AND DEEP BREATHING





Be sure that the activity is properly instructed.

Ensure that the patient understands why this type of activity is being prescribed.


Monitor if the client complies with the given activity


After the Procedure

Assess for patient’s condition; how he responds to the activity

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Su r g i c a l Ma n a g e m e n t

TOTAL ABDOMINAL HYSTERECTOMY

Total abdominal hysterectomy is utilized for benign and malignant disease where removal of the internal genitalia is indicated. The operation can be performed with the preservation or removal of the ovaries on one or both sides. In benign disease, the possibility of bilateral and unilateral oophorectomy should be thoroughly discussed with the patient. Frequently, in malignant disease, no choice exists but to remove the tubes and ovaries, since they are frequent sites of micrometastases.

In general, the modified Richardson technique of intrafascial hysterectomy is used.

The purpose of the operation is to remove the uterus through the abdomen, with or without removing the tube and ovaries.

Physiologic Changes. The predominant physiologic change from removal of the uterus is the elimination of the uterine disease and the menstrual flow. If the ovaries are removed with the specimen, the predominant physiologic change noted is loss of the ovarian steroid sex hormone production.

Points of Caution. The predominant point of caution in performing abdominal hysterectomy is to ensure that there is no damage to the bladder, ureters, or rectosigmoid colon.

Mobilization of the bladder with a combination of sharp and blunt dissection frees the bladder from the lower uterine segment and upper vagina. This reduces the incidence of damage to the bladder.

By exercising extreme care in management of the uterine artery pedicle, the surgeon may minimize the risk of injury to the ureter. The same is true of the management of the cardinal and uetrosacral ligament pedicles.

If the vaginal cuff is left open with the edges sutured, the incidence of postoperative pelvic abscess is dramatically reduced.

Instruments Used:- Self-retaining retractors- Moist Gauze packs- 0 synthetic absorbable suture- Clamps-Straight Ochsner Clamp-Curved Ochsner clamps-Metzenbaum Scissors-Scalpel

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The patient is placed in the dorsal lithotomy position, and an adequate pelvic examination is performed with the patient under general anesthesia. This is extremely important because it allows the surgeon to become acquainted with the anatomy of the internal genitalia. This is frequently impossible when the patient is examined in the gynecologic clinic. The patient is then put in approximately a 15° Trendelenburg position. A Foley catheter is left in the bladder and connected to straight drainage. In general, midline incisions are preferred for malignant disease, since they allow accurate staging and exposure to the upper abdomen and aortic lymph nodes. If investigation of the upper abdomen and aortic lymph nodes is needed, the midline incision should be extended around and above the umbilicus for appropriate exposure.

For benign disease, the Pfannenstiel incision is an adequate alternative to the midline incision.

After the abdomen is entered, it should be thoroughly explored; including the liver, gallbladder, stomach, kidneys, and aortic lymph nodes.

Self-retaining retractors are placed in the abdominal incision, and the bowel is packed off with warm, moist gauze packs. A 0 synthetic absorbable suture is placed in the fundus of the uterus and used for uterine traction. The uterus is deviated to the patient's right. The left round ligament is placed on stretch and incised between clamps.

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The distal stump of the round ligament is ligated with 0 synthetic absorbable suture. The proximal stump is held with a straight Ochsner clamp. At this point the leaves of the broad ligament are opened both anteriorly and posteriorly. This is performed by delicate dissection with the Metzenbaum scissors.

While retracting the uterus cephalad, the surgeon opens the anterior lead of the broad ligament to the vesicouterine fold. Steps 2-4 are carried out on the opposite side.

The vesicoperitoneal fold is elevated, and the fine filmy attachments of the bladder to the pubovesical

If the ovaries are to be preserved, the uterus is retracted toward the pubic symphysis and deviated

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cervical fascia are visible. The bladder can be dissected off the lower uterine segment of the uterus and cervix by either blunt or sharp dissection. If there has been extensive lower segment disease, previous cesarean sections, or pelvic irradiation, blunt dissection of the bladder off the cervix is dangerous, and a sharp dissection technique should be performed.

to one side with the infundibulopelvic ligament, tube, and ovary on tension. A finger should be inserted through the peritoneum of the posterior leaf of the broad ligament under the suspensory ligament of the ovary and Fallopian tube. The tube and suspensory ligament are doubly clamped, incised, and tied with 0 synthetic absorbable suture. The distal stump of this structure is best doubly tied, first with a single tie of 0 synthetic absorbable suture and then with a ligature of 0 synthetic absorbable suture. The same procedure is carried out on the opposite side.

The uterus is then retracted cephalad and deviated to one side of the pelvis with the lower broad ligament on stretch. The filmy tissue surrounding the uterine vessels is skeletonized by elevating the round ligament and dissecting the tissue away from the uterine vessels. Three curved Ochsner clamps are placed at the junction of the lower uterine segment on the uterine vessels. This is best performed by placing the tips of the curved Ochsner clamps onto the uterus and allowing them to slide off the body of the uterus, thus ensuring complete clamping of the uterine vessels. An incision is made between the upper Ochsner clamp and the two lower Ochsner clamps. This is suture-ligated with two 0 synthetic absorbable sutures, placing the first suture at the tip of the lower Ochsner clamp and tying the suture behind the base of the clamp. The middle Ochsner clamp is left in place and is similarly

The uterus is held in traction in the cephalad position, and the handle of the knife is used to dissect the pubovesical cervical fascia inferiorly. This step mobilizes the ureter laterally and caudally.

Group 3 N-404


suture-ligated by a second ligature placed at the tip of the Ochsner clamp and tied behind the base of the clamp. No attempt is made to place a suture in the middle of the pedicle, since it contains blood vessels and a pedicle hematoma can be created.

The same procedure is carried out on the opposite side.

A delicate, transverse, curved incision is made in the pubovesical cervical fascia overlying the lower uterine segment. The separation of the pubovesical cervical fascia from the underlying cervical stroma is facilitated by placing traction on the uterus in the cephalad position.

Two straight Ochsner clamps are applied to the cardinal ligament for a distance of approximately 2 cm. The cardinal ligament is incised between the two clamps, and the distal stump is ligated with 0 synthetic absorbable suture. The suture is tied at the base of the clamp; no attempt is made to place this suture within the body of the pedicle because vessels can be torn and hematomas created.

The same procedure is carried out on the opposite

The posterior leaf of the broad ligament is incised down to the uterosacral ligaments and across the posterior lower uterine segment between the rectum and cervix.

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cardinal ligament.

The uterosacral ligaments on both sides are clamped between straight Ochsner clamps, incised, and ligated with 0 synthetic absorbable suture.

The uterus is placed on traction cephalad, and the lower uterine segment and upper vagina are palpated between the thumb and first finger of the surgeon's hand to ensure that the ligaments have been completely incised. The vagina is entered by a stab wound with a scalpel and is cut across with either a scalpel or scissors. The uterus is removed. The edges of the vagina are picked up with straight Ochsner clamps in a north, south, east, and west direction.

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a. The vaginal cuff is never closed in our clinic. This alone has accounted for a radical decrease in postoperative febrile morbidity and abscess formation. The edges of the vaginal mucosa are sutured with a running locking 0 synthetic absorbable suture starting at the midpoint of the vagina underneath the bladder and carried around to the stumps of the cardinal and uterosacral ligaments, which are sutured into the angle of the vagina.

b. The running locking suture is carried around the posterior wall of the vagina ensuring that the rectovaginal space is obliterated.

c. The cardinal and uterosacral ligaments of the opposite side have been included in the running locking 0 synthetic absorbable suture, and the reefing process has been completed to the midpoint of the anterior vaginal wall. At this point, meticulous care should be taken to ensure that the lateral angle of the vagina is adequately secured and that hemostasis is complete between the lateral angle of the vagina and the stumps of the cardinal and uterosacral ligaments. This can be a site of hemorrhage.

At this point, the pelvis is thoroughly washed with sterile saline solution. Meticulous care is taken to

The pelvis is reperitonealized with running 2-0 synthetic absorbable suture from the anterior to the posterior leaf of the broad ligament. The stumps of the tubo-ovarian round, suspensory ligament of the ovary, and the cardinal and uterosacral ligaments are buried retroperitoneally.

Group 3 N-404


ensure that hemostasis is present throughout the dissected area.

Drains are rarely needed. If they are indicated, they are placed through the open vaginal cuff and carried along the lateral pelvic wall retroperitoneally.

If the tube and ovary are to be removed, they are removed at Step 6 in the operation. Instead of placing a finger underneath the tube and suspensory ligament of the ovary, a finger is placed under the infundilbulopelvic ligament on that side. Care is taken to ensure that the ureter is not included. In various forms of pelvic disease (endometriosis, pelvic inflammatory disease, etc.), the ureter can be deviated close to the infundibulopelvic ligament.

The infundibulopelvic ligament is doubly clamped and incised, and the distal stump of the ligament is doubly ligated with a tie of 0 synthetic absorbable suture plus a ligature of 0 synthetic absorbable suture.

For a bilateral salpingo-oophorectomy, the same procedure is carried out on the opposite infundibulopelvic ligament.

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The tube and ovary have been mobilized medially with the uterine specimens. The remainder of the operation is carried out as described in Steps 7-13.

The peritoneum of the pelvis has been reestablished with the tube and ovary removed. The stump of the infundibulopelvic ligament is buried retroperitoneally.

Postoperatively, no vaginal packing is left in the vagina, and no Foley catheter drainage of the bladder is indicated.

The open vaginal cuff closes without difficulty. Rarely, a small bit of granulation tissue is noted in the upper vagina and is adequately treated by application of silver nitrate 4 weeks postoperatively in the clinic or office. The patient is allowed to resume sexual intercourse 4 weeks after examination in the clinic and is allowed to resume work 5 weeks postoperatively.

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Chronic Obstructive Pulmonary Disease: A Case Study 70

NURSING CARE PLAN

DECREASED CARDIAC OUTPUT

CuesNursing

DiagnosisScientific

ExplanationObjectives

Nursing Interventions

Rationale Evaluation

S: -

O: with a BP of 140/80

Decreased Cardiac Output related to increased afterload as evidenced by a BP of 140/80

A surgery is a type of stress upon the body. After a surgery, the patient is left with a scar from the incision, which pay cause pain. This pain may cause an increase in the blood pressure of the client. This prolonged increase in blood pressure in time decreases the tissue perfusion and the blood out put of the heart.

After 4 hours of nursing interventions, the patient BP will decrease to less than 140/80 but not lower than 100/70

Monitored and recorded vital signs

Promote adequate rest

Encourage relaxation techniques such as listening to music

Provide psychological support

Encourage ambulation as tolerated

Encourage changing position slowly

- To establish a base line data

- To promote healing of the patient and to lower heart rate.

-To lessen anxiety from pain which may cause an increase in BP

-To lessen anxiety

-To promote proper perfusion of blood to tissues to promote healing.

- To prevent orthostatic hypotension which may result from prolonged immobilization.

After 4 hours of nursing interventions, the BP of the patient lowered to 120/80


ACTIVITY INTOLERANCE

CuesNursing

DiagnosisScientific

ExplanationObjectives

Nursing Interventions

Rationale Evaluation

S: “Di pa masyadong makagalaw,ang hirap.”

O: with facial grimace, appears weak, with verbal reports of discomforts

Activity intolerance related to generalized weakness as manifested by discomforts, weakness and facial grimace.

Because stress and pain is an inevitable factor post most surgical procedures, the client avoids movement in order to lessen the aggravation of this pain. They become immobile, not wanting to move as a result of this pain. Because of this, the immobilization can cause complications, such as thrombus formation.

After 2 hours of nursing interventions, the patient and SO will identify techniques to enhance activity tolerance of the patient.

Provide positive atmosphere

Promote comfort measures like fixing the bedside

Provide adequate rest periods

Instructed SO to reposition the patient every 2 hours with proper assistance

Instructed SO to use side rails, overhead and pillows in changing the position of the patient

-To Enhance learning

-To promote a positive atmosphere conducive to learning.

-To promote healing.

-To promote adequate tissue perfusion all throughout the body.

-To provide safety

After 2 hours of NPI, the patient and SO identified techniques to enhance activity tolerance


DISCHARGE PLANNING

Topic: Exercises, Medication, and Diet post Hysterectomy

Time allotment: 1 Hour

Venue: Room

Objectives Content Time allotmentTeaching Strategies

Evaluation

After 1 hour of health teaching the patient & significant others (SOs) should be able to:

A. Demonstrate and understand the importance of active and passive range of motion exercises

B. Carry out deep breathing exercises and understand the rationale for this

C. Adhere to a low salt and Low Fat diet as well as lessen the intake of caffeine.

D. Following the Medications ordered after discharge

A. Demonstration and education of passive and active range of motion exercises.A.1 The Effects of Mobilization

B. Demonstation of turning coughing and deep breathing with the use of Splint. B.1 Prevention of post operative pneumonia.B.2 Adequate oxygenation to promote perfusion to tissues.

C. Samples of Low Salt and Low fat foodsC.1 Vegetables over red meatsC.2 Types of meats which are healthier alternatives.C.3 Avoidance of saucesC.4 Monitoring of BPC.5 Effects of caffeine.

D. Medications given and their uses

15 minutes

30 minutes

15 minutes

Discussion-Demonstration



The patient was able to identify and demonstrate the exercises which must be implemented as well as the diet she should maintain to manage her hypertension.


LEARNING DERRIVED

For almost 2 weeks of duty, we have encountered several constraints with regards to the

implementation of interventions. It was not that easy especially we are dealing with people who

have different health problem, problem through which if jeopardized, can either put us in an

obnoxious situation or be blameworthy for any complications.

For almost three weeks of multi-tasking and time management, the SRFMC exposure has

taught us how to appropriately deal with people. The idea of caring for them is not too easy.

Slightly hard, because some of the patient’s has very serious illness which can put us to danger,

that is why we are there to care for them properly with tender loving care.

We have learned to thoroughly assess our patient to comply with the requisites. Also, we

have acquainted ourselves with regards to establishing rapport with our patient to have a trusting

relationship. We have learned how to be patient; to respect and accept their beliefs and values

without judging them; to communicate with them therapeutically. Basically, it’s the feeling of

confidence you have in yourself that will facilitate accomplishment and error-free

implementation of nursing care. The nurse has a lot of responsibilities to take in, thus, confidence

is a very important factor.

The exposure wasn’t centered mainly to rendering care. It was also focused to building

and developing intrapersonal and interpersonal relationships. To adjust and adapt with the

environment is a humongous task! It’s not that easy. But mingling with those patients helps you

identify your strength and weaknesses, and it aids in modifying what is somehow negative in our

attitudes. To sum this all up, it was a SUCCESS! Thanks be to GOD.

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REFERENCES

Black, J.M., Hawks, J. H. (2009). Medical-surgical nursing: clinical management for

positive outcomes. Vol.2. New York. Saunders.

Blanchard, R., Loeb, S. (2004) Blanchard & Loeb publishers nurse’s drug handbook.

Michigan. Blanchard & Loeb.

Fischbach, F.T., Dunning, M.B. (2008). A manual of laboratory and diagnostic tests.

Springhouse, PA. Lippincott, Williams, & Wilkins.

Gutierrez, K. J., Peterson, P.G. (2007). Saunders sursing survival guide pathophysiology.

2nd Edition. New Orleans Louisiana. Saunders & Elsevier.

Hole, J.W. (1993). Human anatomy and physiology. 6th edition. Dubuque, IA. Wm C.

Brown Publishers, inc

Huether, S.E., McCance, K.L. (2000). Understanding pathophysiology.2nd edition.

Singapore: Elsevier Science.

Karch, A. M. (2000). Lippincott’s nursing drug guide 2000. University of Michigan.

Lippincott, Williams, & Wilkins.

Keogh, J. (2009). Nursing laboratory and diagnostic tests demystified. Boston. McGraw-

Hill Professional.

McCann, J. A., Holmes, H. N., Robinson, J.M., et al. (2003). Professional guide to

pathophysiology. Springhouse, PA. Lippincott, Williams, & Wilkins.

Nicoll, D., McPhee, S.J., Pignone, M., Chuanyi, M.L. (2007). Pocket guide to diagnostic

tests: Lange clinical science series. Springhouse, PA. McGraw-Hill.

Porth, Carol M., (2005). Pathophysiology: Concepts of altered health states. 7th Edition.

Boston: Lippincott, Williams, & Wilkins.

Stockley, R. A. (2007). Chronic obstructive pulmonary disease. Chicago, IL. Wiley-

Blackwell.

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Spratto, G.R., Woods, A.L. (2004). PDR nurse’s drug handbook. Springfield, IL.

Cengage Learning, inc.

Wallach, J.B. (2007). Interpretation of diagnostic tests: Doody’s all reviewed collection.

Springhouse, PA. Lippincott, Williams, & Wilkins.

Weber, J., Kelley, J. (2007). Health assessment in nursing. 2nd edition. Boston.

Lippincott, Williams & Wilkins.

Marshall, L., Spiegelman D., Barbieri R., Goldman M.B., Manson, J., Colditz, GA,

Willet, W.C., Hunter, D. (1997) Variation in the incidence of uterine leiomyoma

among premenopausal women by age and race. United States National Library of

Medicine, National Institutes of Health. Vol. 90, Issue. 6. Pg: 967-73

Faerstein, E., Szklo, M., Rosenshein, N., (1997) Risk factors for uterine leiomyoma: a

practice-based control study. American Journal of Epidemiology. Vol. 153, Issue

1: pg 1-10.

Lam, M., (2010) Estrogen Dominance: The silent epidemic. The Authority on Natural

Healing. http://www.drlam.com/articles/Estrogen_Dominance.asp. Accessed on

September 14, 2010

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Myoma Case Study

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Transcript of Myoma Case Study