CHAPTER I INTRODUCTION

Dermatofibroma is a common cutaneous nodule of unknown etiology that occurs more often in women. Dermatofibroma frequently develops on the extremities (mostly the lower legs) and is usually asymptomatic, although pruritus and tenderness are not uncommon. The latter feature is seen in a sufficient number of patients to make dermatofibroma the most prevalent of all painful skin tumors. A number of well-described, histologic subtypes of dermatofibroma have been reported. Removal of the tumor is not necessary unless diagnostic uncertainty exists or particularly troubling symptoms are present. Excisional biopsy is the recommended method of treatment. Skin grafting is a type of graft surgery involving the transplantation of skin. The transplanted tissue is called a skin graft. Skin grafting is often used to treat extensive wounding or trauma, burns, areas of extensive skin loss due to infection such as necrotizing fasciitis or purpura fulminans. Specific surgeries that may require skin grafts for healing to occur - most commonly removal of skin cancers. Skin grafts are often employed after serious injuries when some of the body's skin is damaged. Surgical removal (excision or debridement) of the damaged skin is followed by skin grafting. The grafting serves two purposes: reduce the course of treatment needed (and time in the hospital), and improve the function and appearance of the area of the body which receives the skin graft.

A. RATIONALE FOR CHOOSING THE CASE

All over the world, dermatofibromas incidence is probably similar to United States which is relatively common. Its frequency appears to be similar in all races. Females are the more commonly affected than males having male to female ratio of 1:4. It occurs in patients of any age, but it usually develops in young adulthood. Approximately 20% of the lesions occur before age 17 years. We have chosen this case, Dermatofibroma because its our first time to handle such case. We were curious and interested on how it was developed from being a simple mole to a tumor that can turn to a cancerous one. Also, observing its surgical procedure which is skin grafting, give us cues and knowledge about its method of treatment.

B. LEARNING OBJECTIVES

General Objectives The main goal of our group is to be able to state and present the case study of our chosen client that would provide a clear discussion of the pathological mechanism of the disease to gain significant knowledge, skills and attitude in caring for the patient post operatively who has Dermatofibroma. Specific Objectives Cognitive To describe Dermatofibroma as a health problem. To identify risk factors for Dermatofibroma To identify the possible nursing problems of patient post operatively with Dermatofibroma To know, analyze and understand the pathophysiology of Dermatofibroma Psychomotor To establish rapport with the patient and significant others To assess the patient who had removal of Dermatofibroma To use nursing process as a framework for care post operatively To make a patient centered and comprehensive nursing care plan To impart health teachings to the patient and significant others To evaluate the effectiveness of nursing care rendered to patient Behavioral To respect clients beliefs and practices To sympathize the client with her current condition.

CHAPTER II CLINICAL SUMMARY

A. GENERAL DATA Name : Gender : Unit Assigned : Age : Birthday : Birthplace : Religion : Address : Civil Status : Occupation : Educational Attainment : Date Admitted : Time Admitted : Admitting Physician : Admitting Diagnosis : Operation Performed : Mrs. Y.A.R. Female Operating Room 44 yrs. old February 06, 1967 Naujan, Or. Mindoro Roman Catholic Naujan, Or. Mindoro Married Housewife Elementary Graduate December 08, 2011 1:28 pm Dr. Matthew M. Rico Dermatofibroma skin excision with possible skin grafting

B. CHIEF COMPLAINT The patient was admitted at New Oriental Mindoro Provincial Hospital with chief complaint of right shoulder mass. C. HISTORY OF PRESENT ILLNESS The client is a 44 year old housewife who has a right shoulder mass which has a gradual swelling. Since April 2010, the mass in the patients shoulder starts to enlarge in size. The mass begun from a simple mole which has irregular border and dark black appearance. The right shoulder mass has a gradual swelling and brings discomfort and body weakness. A day prior to hospitalization, the patient complained of pain and progressive weakness of her right upper extremity.

D. PAST MEDICAL HISTORY The patient stated that she had measles and chickenpox when she was in elementary.

The patient doesnt have any food or medication allergy. She had her menarche when she was 13 years old with the duration of 4 days. Her menstrual cycle length is 30 days. The patient delivered her 4 children on their home by a hilot. E. FAMILIAL HISTORY

LEGEND: Patient The familial history of the patient clearly shows that the patients parents has both hypertension and the father has heart disease. Among her siblings, 2 of her sisters have hypertension. The patient has 4 children. All her children are alive and well.

Male (Alive, Well)

Female (Alive, Well)

70Hypertension and heart

63Hypertens

Dermatofibr

Hypertens

Hypertens

33

44

42

38

36

32

28

26

23

21

9

F. PHYSICAL ASSESSMENT 7months 8 6 GENERAL APPEARANCE

Received patient lying on the bed of recovery room, wearing green printed hospital uniform and has an IV fluid of PNSS @ 250cc level on her left metacarpal vein infusing well @ 30gtts/min. VITAL SIGNS December 13, 2011 10:30 am 36.7 C 79 bpm 21 cpm 110/80 mmHg 3/15

Temperature Pulse Rate Respiratory Rate Blood Pressure Glasgow Coma Scale

Area Assessed

Technique Used

Normal Findings Rounded normocephalic, No lumps, No abrasions, Symmetrical Evenly distributed silky resilient black hair, no infection or infestation Symmetric facial features and facial movements, no lesions Symmetric and straight, no discharge or flaring, uniform color, not tender, no lesions, air moves freely as the client breaths through the nares, pink mucosa

Significant Findings

Analysis

Head Cranium

Palpation

Inspection Hair

Face

Inspection

Facial Grimace

Due to pain sensation

Nose

Inspection

Mouth Medium red, appears smooth at the margins and rough at the center No swelling, redness, bacterial or viral patches complete set of teeth, no bad odor No palpable lymph nodes, presence of carotid pulse, trachea in midline Muscle equal in size, head centered coordinated, smooth movement with no discomfort

Inspection Tongue

Throat

Inspection

Teeth

Inspection

Palpation

Neck Inspection

Thorax Lungs

Auscultation

No abnormal sounds Level of shoulder is equal, No signs of respiratory distress

Inspection Chest

Inspection Breast Palpation

Symmetrical No lesion No discharges

No masses

Inspection

Uniform in color, rounded in shape w/ symmetric contour No bowel sounds No dullness Non tender

Auscultation Percussion Palpation Upper Extremities Arms Hands

Abdomen

Inspection

Symmetrical Skin no lesions, No abnormal color No nodules and enlargement of bones Symmetrical, no abnormal color Capillary refill Hypersensiti vity to the drug >Active intravascular clotting

Side effects

Nursing Management >Observ e area of surgery for bleeding. >advise patient to inform physician or other health provider of any changes in vision. >Caution patient to avoid taking other meds w/o doctors prescripti on.

>dizziness

Name Generic Name: Ketorolac Brand name: Toradol Classificatio n: Nonsteroidal antiinflammatory agents, nonopioid analagesics

Dosage/ Frequency / Route 30mg IV every 6 hrs x 3 doses

Action - Inhibits prostaglan din synthesis, producing peripherall y mediated algesia

Contraindication >Hypersensitivity >Cross-sensitivity with other NSAIDs may exist Pre- or perioperative use > Known alcohol intolerance Use cautiously in: 1) History of GI bleeding 2) Renal impair-ment (dosage reduction may be required) 3) Cardiovascular disease

Side Effects >dizziness >headache

Nursing Management >Assess for pain (note type, location, and intensity) prior to and 1-2 hr following administration. >Instructed patient on how and when to ask for pain medications. >Instructed patient to avoid double dosing.

Name

Dosage/ Frequency/ Route 100 g IV every 6 hours x 4 doses

Indicatio ns Treatment of moderate to moderatel y severe pain.

Action

Contraindica tion >Hypersensiti vity to Tramadol. >Acute alcohol intoxication >opiod dependence >Pregnancy and lactation

Side Effects >dizziness >Headach e

Nursing Management >Assess type, location and intensity of pain prior to and 2-3 hr following administration. >assess BP and RR before and periodically during administration

Generic: Tramadol Brand Name: Ultram Classific ation: CNS Analgesic

>Binds to mu-opiod receptors. >Inhibits reuptake of serotonin and norepinep hrine in the CNS >decrease s pain perception

Name Generic Name: Glibenclami de Classificat ion: Antidiabetic

Dosage/ Frequenc y/ Route 5 mg 1 tab OD

Indication

Action >Inhibits ATP-

Contraindi cation >Severe hyperglyce mia >severe liver or renal failure >type 1 DM > DKA

Side Effects

Nursing Managem ent >Monitor the Blood sugar. >encourag e patient to follow prescribed diet, medication and exercise regimen.

>Type 2 DM

sensitive potassium channels in pancreatic beta cells

Name Generic Name: Atropine Sulfate

Dosage/ Frequenc y/ Route Single dose

Indication >Given preoperativel y to decrease oral and respiratory secretions

Action >Inhibits action of acetylcholin e

Contraindica tion >Hypersensiti vity to drug >Narrow angle glaucoma > Acute hemorrhage >Tachycardia

Side Effects >dry mouth >drowsi ness

Nursing Management >Assess signs vital

Classificatio n: Anticholinerg ic

Drug

Dosage and Frequenc y Single dose IV after induction of anesthesia

Action

Indicatio n

Contraindica tion

Side Effects/Adv erse Effects > muscle fasciculation

Nursing Responsibi lities Assess respirat ory status continuo usly Monitor neurom uscular respons e of drug Monitor HR and BP

Generic Name: Succinylc holine

Classifica tion: Neuromus cular blocking agent

>prevents neuromusc ular transmissi on by blocking the effect of acetylcholi ne at MNJ >Skeletal muscle paralysis

>Used after induction of anesthesi a to produce skeletal muscle paralysis

>hypersensiti vity > Children and neonates

CHAPTER IV NURSING PROCESS A. Problem List

Date of Onset

Diagnosis

Date Identified

Date Resolved

December 13, 2011

Acute Pain related to Surgical wound

December 13, 2011

December 13, 2011

December 13, 2011

Risk for infection related to Surgical wound

December 13, 2011

December 13, 2011

December 13, 2011

Activity Intolerance related to pain

December 13, 2011

December 13, 2011

B. NURSING CARE PLAN Assessme nt Backgrou nd Knowled ge The patient experienc ed unpleasan t sensory and emotional experienc e arising from actual tissue damage. Nursing Diagnosis Planning Intervention Rationale Evaluation

Subjective: Masakit ang sugat ko at ung opera ko >PRS: 10/10 Objective: >presence of gauze in the right posterior shoulder >presence of gauze in her right anterior thigh >facial grimace >with restraints on her both arms and legs >GCS: 13/15 E- 3 M-5 V-5

Acute Pain related to Surgical wound

After 30 minutes of nursing intervention, patient will report control of pain.

1.Established rapport. 2.Monitored vital signs.

1. To gain trust. 2. To have baseline data. 3.Obtained 3.To rule patients out assessment of worsening pain to of include: underlying a. locati condition/ developm on ent of b. char complicati acter ons. istics c. onse t/dur ation d. frequ ency e. quali ty 4.Pain is a f. inten subjective sity experienc e and 4.Accepted cannot be patients by description of felt others. pain. 5.A quiet environ ment promotes 5. Provided restful calm and quiet environment. atmospher e. 6.To promote 6.Provided noncomfort measures like pharmacol

Partially met, having the PRS of 7 out of 10.

giving ogical pain emotional managem support, use of ent. therapeutic touch.

Assessme nt

Backgrou nd Knowled ge

Nursing Diagnosis

Planning

Intervention

Rationale

Evaluation

Subjective: Inoperaha n ang aking likod at may sugat pa ko sa binti Objective: >presence of gauze in the right posterior shoulder >presence of gauze in her right anterior thigh >GCS: 13/15 E- 3 M-5 V-5

The patient is at risk for being invaded by pathogeni c organism.

Risk for infection related to Surgical wound

After 30 minutes of nursing intervention, patient will demonstrate and verbalize understandin g on how to prevent spread of infection.

1.Established rapport. 2.Monitored vital signs.

1.To gain trust. 2. To have baseline data. 3. Assessed 3. To and assess documented causative/ skin conditions contributin noting g factors. inflammation. 4. Observed 4.To for localized detect and signs of have early infection at prevention surgical of wound. infection. 5.Done health teaching such as: a. the importance of proper wound care. b. Proper handwashing before and after wound care. c. appropriate change of wound dressing. d. Proper technique for changing or disposing contaminated materials. 5. To promote wellness and prevent spread of infection.

Goal met.

Assessme nt

Backgrou nd Knowled ge

Nursing Diagnosis

Planning

Intervention

Rationale

Evaluation

Subjective: Hindi ako makalakad nang ayos kasi masakit ang sugat sa binti ko Objective: >presence of gauze in the right posterior shoulder >presence of gauze in her right anterior thigh >GCS: 15/15 E- 4 M-6 V-5 The patient has insufficient physiologi cal energy to endure /complete desired daily activities. Activity Intolerance related to pain After 30 minutes of nursing intervention, patient will use identified techniques to enhance activity intolerance. 1.Established rapport. 2.Monitored vital signs. 3.Noted patient reports of weakness, pain, difficulty accomplishing tasks. 1. To gain trust. 2. To have baseline data. 3. Symptoms may be result of/contribu te to intoleranc e of activity. 4. To allow patient express her feelings.

Partially met,

4. Encouraged verbalization of feelings contributing to/resulting from condition. 5. Promoted comfort measures and provide for 5. To relief of pain. enhance ability to 6. Done participate health in teachings like: activities. a. Early 6. To ambulation. promote b. Regular wellness. exercise. c. Progressive increase of activity level as tolerated by patient.