General Objective:

Within 4 hours of grand case presentation,

the participants will be able to gain
knowledge about myoma, demonstrate
adequate skills in analyzing the nursing
process and appreciate the importance of
nurse’s role in providing appropriate
management for a client having the disease.
Specific Objectives:
Within 4 hours of grand case presentation
the students will be able to:
 Describe the common characteristic of
myoma.
 Present the anatomy and physiology of
myoma related with our client’s condition.
 Discuss the etiology, pathophysiology and
clinical manifestation of our client’s
condition.
 Relate the significance of laboratory results
to client’s conditions or the disease process.
 Identify the classification, indication,
mechanism of action, special
precautions, side effects, dosage and
availability and nursing responsibilities
of the drug administered to the client.
 Discuss comprehensively nursing care
plans formulated specifically based on
client’s condition.
 Discuss the medical and surgical
interventions related to the client.
 Formulate a comprehensive discharge
plan realistic to the needs and
compliance of the client.
NURSING HISTORY
I: Biographical Data

Name: L.C.
Age: 42 years old
Gender: Female
Date of Birth: March 19, 1966
Status: Married
Address: Sta. Ana, Estancia, Iloilo
Religion: Roman Catholic
Occupation: Barangay Health Worker
(Midwife)
Date and Time of Admision: Jan. 19, 2009
(1:00pm)
Chief Complaint: Menorrhagia
Diagnosis: Myoma Uterine, Abnormal Uterine
Bleeding secondary G4P3 TPAL - 3013
Attending Physician: R.D., M.D.
Name of Surgery: : Total Abdominal
Hysterectomy Bilateral Salpingo
Oophorectomy
Date of Surgery: January 21, 2009
II: History of Present Illness
Two days prior to admission, client suffers
from fever with chills and difficulty in
urinating; and she had taken Paracetamol
500mg 1 tablet without doctor’s
prescription. She decided to seek medical
check up in private clinic in Estancia. The
physician requested her for an ultrasound
in Sara and advised to have a referral in
Western Visayas Medical Center. Client
was an out patient in WVMC then was
admitted to ER and scheduled for TAHBSO
on Jan. 21, 2009.
Routine laboratory test was done such
as CBC and Urinalysis. Around 4:00pm
on the day she was admitted to ER she
was transferred to Female Surgical
Ward. Jan. 20, 2009, post midnight, Dr.
R.D. instructed her for NPO to prepare
her self for operation by the next day.
Jan. 21, 2009, D5LR 1L x 8 hours was
attached to her right metacarpal vein
to serve as the main line and PNSS 1L x
KVO attached at left metacarpal vein to
serve as the blood line; and with Foley
Catheter attached to Uro Bag. Around
9:00 am latest vital signs taken and
Uro Bag was drained about 150 cc of
yellow colored urine. Then she was
brought to OR via stretcher for TAHBSO
III: Past Medical History
According to the client she has
immunization of BCG, DPT, OPV, Hepa B
and Measles. She has a history of
chicken pox infection when she was on
grade 5. This is her second time of
hospitalization. Her first hospitalization
was last 1992 brought about by
unexpected abortion with unknown
cause. Last year she underwent
Dilatation and Curettage.
IV: Family Medical History
There is no known heredo familial
disease in her both paternal and maternal
family although her sister was diagnose with
same disease.
V: Lifestyle
Client stated that she doesn’t smoke nor drink
alcoholic beverages. She sleeps at 8:30 pm or
9:00 pm and wakes up at 4:30 am to prepare
the food for her children during weekdays. On
weekdays she does the household chores like
washing dishes, doing the laundry, sweeping
the floor, and cooking food. According to her,
she seldom eats beef or pork, and preferred to
eat vegetables and fruits such as orange,
apples, grapes, mango and banana, because
she believes these are nutritious.
Their family drinks purified water which they
buy from the market which costs 40 pesos
per gallon. They can consume 4-5 gallons
of water a month. She has a regular bowel
movement on daily basis and has
experience episodes of pain during voiding
with the pain scale of 6.
VI: Social History
She belongs to a nuclear type of family. She
has 3 children; 2 female and 1 male. Her
husband is a tricycle driver. She completed
2nd year college in Mindanao Norte Dame
Tacorong College while her husband was a
high school graduate in Leon Ganzon High
School. Their house is a bungalow type
which is made up of cement and galvanized
iron. There are 4 rooms; one for the client
and her husband; one for her 2 girls; one for
her son; one for the comfort room.
Their monthly income is 10-20 thousand
or they can earned 300-500 pesos a
day from farm production. Her
husband also earns as a tricycle
driver. They used their money for the
tuition fees of their children and for
the expenses for their foods, water,
electricity and etc. They have a good
relationship with their neighbors.
VII: Pattern of Health Care
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.
PRE- PHYSICAL ASSESSMENT
(January 20, 2009)
GENERAL SURVEY
The patient is awake, sitting up on
bed, dress appropriately, appears
calm and not pallor, and weak looking;
has slender medium body built with an
apparent flabby abdominal girth and a
height of 5’5”. Conscious, conversant,
coherent and oriented to time place
and person; has no mobility
restrictions and ambulatory. With vital
signs of T:36.8oC per axilla , PR: 91
bpm, RR: 20bpm, BP: 110/70mmhg
SKIN:
Skin is light brown in color, mole noted
on right side of the face and rashes noted
on both arms, warm to touch and with
good skin turgor.
NAILS: (Fingernails and toe
nails)
Nails are convex, pinkish in color well
trimmed and cleaned with good capillary
refill that returns to original color after 2
seconds when pressed; has angle of 160
degrees between the fingernail and nail
base, firm, strong and intact.
HEAD:
Normocephalic, symmetrical facial
features and can moved within range
of motion. Hair is black, short, thick
and evenly distributed, slightly silky
and resilient and free from infestation.
The scalp is shiny, smooth, without
lesion, lump or mass, dandruff and no
tenderness noted
EYES:
Eyebrows evenly distributed, eyelashes
curled outward, upper eyelid covers the
uppermost part of the iris and free from
nystagmus. Eyelids overlaps iris and free
from inflammation, edema or mass.
Lacrimal gland is not palpable, conjunctiva
pinkish in color and lens transparent, with
white sclera. Pupils are equally rounded,
both are reactive to light and
accommodation. Able to read newsprint
with eyeglasses at the distance of 2 feet,
eye movement symmetrical as both eyes
followed the direction of the gaze. There
NOSE AND SINUSES:
Nose is located at the midline of the face,
without swelling, bleeding, lesions or masses
noted. Each nostrils patent, septum is on
midline, with moderate amount of cilia, and
the mucosa is pinkish in color. Nasal sinuses
are non tender, no discharges noted. Sense of
smell is intact, able to identify what kind of
scent is being introduced such as alcohol and
cologne.
EARS:
Ears are symmetrical, pinna at the level
of the outer canthus of the eyes, color
is same with the facial skin, and auricle
is firm, smooth, and free from lesions
and pain. Good pinna recoil, with small
amount of wet cerumen on both ears
(yellow in color), Ear canal is pinkish.
Client can repeat whispered words
(Bluemoon) at distance of 2 feet.
MOUTH:
Lips and mucosa pinkish in color, smooth, moist,
and without inflammation or lesions noted. Gums
are pink, smooth, moist and firm, with complete
teeth properly aligned, and smooth, slightly
white and shiny. Cavities not noted. Tongue lies
at the midline, pinkish in color, moist and smooth
along lateral margins with free mobility. Palates
are concave and pink; hard palate has ridges,
soft palate is smooth. Able to taste food and can
consume meals with good appetite.
NECK:
Neck is symmetrical with head in
central position. Lymph nodes not
palpable, trachea on midline position
above the supra sternal noted. Thyroid
is smooth, soft, nontender, and not
enlarged. Movement through range of
motion without complaint of
discomfort or limitation.
POSTERIOR CHEST:
Skin is same color to all parts of the body.
Respirations are quiet, effortless and regular;
20bpm. Thorax rises and falls in unison with
respiratory cycle. Ribs slope across and down
without movement or bulging in the
intercostal spaces, free from tenderness,
lesion. Resonant sound heard over lung fields
and bronchovesicular sounds noted upon
auscultation.
ANTERIOR CHEST
Skin is same color to all parts of the body,
Thorax rises and falls in unison with respiratory
cycle, fremitus is equal on lung fields and
strongest at the level of tracheal bifurcation.
Resonant sound heard over tissue, bronchial,
bronchovesicular noted upon auscultation.

HEART
Absence or visible pulsation, heaves or
retractions, Cardiac rate of 91 beats per minute
and with regular rhythm
BREAST
Breasts are flesh colored; the areolar
areas and nipples are darker in
pigmentation. Superficial vascular
patterns are diffuse and symmetrical.
Breast on right side as the dominant arm
is larger. Nipples point upward and
laterally convex breast without flattening,
retractions or dimpling. No palpable lymph
node or no additional enlargement of
maxillary lymph nodes. No discharge
noted
ABDOMEN
Abdomen is round and symmetrical, fair
in color, no lesions noted, umbilicus is
depressed and beneath the abdominal
surface. Abdomen rises with inspirations
and falls with expirations, free from
respiratory retractions. Bowel sounds
heard upon auscultation; dullness sound
heard over the mass when percussed,
tenderness note upon palpation. mass
noted on the hypogastric area upon
palpation.
GENITALS
Skin over the mons pubis is clear
except for hair distribution. The labia
majora and minora are symmetrical,
with a smooth to wrinkled, slightly
pigmented skin surface, and free from
ecchymosis. With slight foul odor. The
anus is dark pink to brown and usually
with skin tags. Able to urinate three
times a day, with slight pain felt when
voiding with pain scale of 6.
EXTREMITIES
Upper
Equal in size on both sides of the body,
no deformities, no contractures,
swelling or tenderness, normal muscle
tone, equal strength on each side, with
range of motion within normal limits,
no edema noted. Thumbs move from
side to side, fingers, hands and wrists
are straight. Joints are smoothly
movable and is easy and has a
strength felt on grasp. Elbows is
symmetrical and movement done with
ease.
Lower
Equal size of both lower limbs of
the body, no deformities, no
contractures swelling or tenderness,
normal muscle tone, equal strength on
each side, with full range of motion,
no edema noted. Foot is aligned with
lower leg. Knees are in alignment with
each other and do not protrude
medially or laterally.
ANATOMY and PHYSIOLOGY
VULVA
- Plays a role in stimulation and
protects the body from foreign
materials.
Mons pubis/mons veneris- a
rounded pad of flesh located over the
symhpysis pubis; covered by hair
after puberty.
Labia Majora - two elongated folds of
hair covered-adipose tissue separated
by a cleft, and covered by loose
connective tissue and epithelium.
 Labia Minora- two thin hairless folds of
connective tissue between the labia majora
and vaginal opening; they divide and unite
to form the hood like prepuce of the clitoris.
And contains the Bartholin’s gland which
secretes mucus for lubrication during sexual
intercourse.
 Clitoris- an organ homologous to penis, a
small body of spongy tissue that functions
solely for sexual pleasure.
OVARIES
- Also called as the female gonads; they
produce, mature, and discharge ova.
- They also produce estrogen and
progesterone which initiates and
regulates the menstrual cycle,
influences the growth and
enlargement of the breasts and uterus
and stimulate endometrial growth.
- Secured to the lateral walls of the pelvic wall
by the suspensory ligament. They flank the
uterus laterally and anchor to it medially by
the ovarian ligaments.
- Ovarian follicles are can be seen inside which
are saclike structures. And consist of
immature eggs called the oocyte, it is
surrounded by one or more germ layers
called ovarian follicles.
Two almond-sized glands which consists
of three surface germinal
epitheliums:
 tunica albugniea- dense connective
tissue; outer layer
 stroma
 cortex- dense outer layer
 medulla- loose inner layer
FALLOPIAN TUBES
 Thin-walled tubes with serosal covering,
with a muscular layer and ciliated mucus
lining, transport the ova after
fertilization.
 It is approximately 10cm or 4 inches
long.
FIMBRIAE
 It is the distal end of the fallopian tube,
which has finger like projections and
catches the ova when it is ejected by the
ovaries.
UTERUS

 Uterine growth is the formation of a few

new muscle fibers and the stretching of
existing muscle fibers in the uterine
myometrium which is influenced by
estrogen and progesterone.
 A pear-shaped, hollow muscular organ
in the pelvic cavity ( 2-5 cm thick, 5 cm
long, 5 cm at widest point, 2 cm at
narrowest point). Provides as an
environment for implantation,
development, and delivery of fetus.
 It is suspended in the pelvis by the broad
and uterosacral ligament. the It is
composed of three layers namely:
Endometrium- inner mucosal layer,
which is the site of implantation
Myometrium- the bulky middle layer,
made of bundles of inert lacing smooth
muscles. Plays a role in delivering the
baby.
Perimetrium- the outer most serous
layer.
 It receives an ovum from the ovaries,
and provides a place for implantation
and nourishment during fetal growth
CERVIX
Lower, narrow portion of the uterus
cylindrical or conical in shape and
protrudes through the upper anterior
vaginal wall. It allows the passage of
sperm from the vaginal canal during
intercourse.
VAGINA
The canal between inferior to the
uterus and cervix, provides as a route
of entry for sexual intercourse; exit
for menstrual blood and serves as a
PATHOPHYSIOLOGY
Precipitating factor Precipitating factors
•Age: 30-50 •Hormone
•Gender ETIOLOGY: replacement therapy
•Lifestyle
Unknown •Anovulation
•Early menarche
•Nulliparity
•High-fat diet
•Obesity Stimulation of
•Faimily history
•Anxiety increase estrogen
• Race: African- 50%, production
American 25% SIGNS AND SYMPTOMS
• lifestyle •SWELLING OF
IF NOT TREATED BREAST
•DEPRESSION
•DYSMENORRHEA
•LOSS OF SEXUAL
PROLIFERATION OF DRIVE
CELLS IN THE UTERUS

OVERGROWTH OF
THE
ENDOMETRIAL
LINING
DIAGNOSTIC DEVELOPS
•PELVIC EXAM INTO UTERINE
•ULTRASOUND FIBROID

INTERFERENCE
IN THE
VASCULAR
SUPPLY

DETERIORATIO
N IN THE SIGNS AND
INTERIOR PART SYMPTOMS
OF THE HYPERAMENORRHEA
FIBROID (If untreated with
radiation)
MEDICAL-SURGICAL
INTERVENTIONS
1. Vital signs monitoring – to
continuously monitor client’s health
status
2. Nutritional Needs – on Diet As
Tolerated and was placed on Nothing
Per Orem subsequently for surgical
purposes.
3. Fluid Intake and Output – to monitor
hydration pattern of the client
whether it is too high or too low than
normal amount of hydration and to
check the function of the kidney
through urine output.
 IVFTherapy– implemented to maintain
the fluid and electrolyte balance of the
body which sustains bodily functions on
the optimum level.
D5LR – a physiological solution used for
infusion into the circulation. In addition
to essential ions it also contains
glucose.
PNSS – a way to replace water at
correct electrolyte deficits. It provides
medium for IV drug administration.
5. Foley Catheter insertion - allow drainage
of urine in certain disoreder and to empty
the bladder before abdominal operation.
6. O2 Therapy – inhalation (2L/min)
7. Medications:
 Ceftriaxone 1g IVTT q8h x3days-
antibiotic; pre-operative prophylaxis
 Celecoxib – 200mg/cap, 1 cap BID x 5
days (8am – 6pm)
 for acute pain
 anti-inflammatory
 Tramadol 50mg IVTT q6h PRN for
severe pain (6am-12nn-6pm-12mn)
Ketorlac 30mg IVTT q8h ANST (-)
analgesic, anti-inflammatory;
short term pain management
Multivitamins 1cap OD 8am
Vitamin supplement; additional
vitamin for post-op patient
Co-amoxiclav 625mg 1tab BID
antibiotic
Diagnostic Exams
 Urinalysis – analysis of the volume,
physical, chemical and microscopic
properties of urine.
 Complete Blood Count – examines
the component of blood including
RBC, WBC and platelets as a pre-
operative test to ensure adequate O2
carrying capacity of homeostatsis.
 Blood Chemistry – used to detect
electrolyte level to supplement
physical exam.
 Protothrombin Time – blood test that
measure how long it takes blood to
clot; can be used to check for bleeding
problems; also used to check whether
anticoagulant is effective.
 Ultrasound – is a noninvasive
diagnostic test that uses sound
waves to create a visual image of the
uterus as well as other pelvic organs.
 Chest X-ray Posterior Anterior View-
NORMAL
 ECG – used to measure the rate and
regularity or heartbeats as well as
the size and position of chambers,
the presence of any damage to the
heart and the effects of drugs or
devices used to regulate the heart.
Surgical Interventions
 TAHBSO (Total Abdominal
Hysterectomy Bilateral Salpingo-
Oopherectomy) – removal of the uterus
including the cervix as well as the
fallopian tubes and ovaries using an
incision in the abdomen. Intended for
obstetrical conditions of which the
normal functions of these organs
involve are compromised and
necessitate.
 Indication: Removal as the last
recourse of management; in this case,
Myoma.
 Treatment:
 Blood Typing – determines blood
compatibility.
 Blood Transfusion –indicated to make-up
for blood loss during the onset of intra-
operative phase.
 Subarachnoid Block– a type of regional
anesthesia, that averts pain sensation
from the lower extremity to the nipple
line making it the anesthesia of choice
for obstetric surgery.
Operative Technique - TAHBSO
Induction of Anesthesia
Asepsis/antiseptics/draping
Midline intra-umbilical incision done on the
skin and deepened down to the
peritoneum abdominal pack and
retractors applied. Round ligament
doubly clamped cut and suture ligated
with chromic 1 suture.

Anterior left of the broad ligament lifted

and incised done to the vesicouterine
peritoneum in collinear manner bladder
strap separated bluntly.
A window was made on the peritoneum of
the posterior left of the broad ligament
under the infundibulopelvic ligament. The
infundobulopelvic ligament was triply
clamped, cut and suture ligated with
chromic 1 suture. The same procedure
was carried out on the opposite side.
Posterior left of the broad ligament at
medically from the pelvic opening to the
posterior uterine wall toward the cardinal
ligament. Ascending to the uterus vessels
on both sides, identified and clamped near
the origin adjacent and the uterus and the
divided peclide suture ligated using
chromic suture.
Series of clamping cutting and suture
ligation done on the cardinal and
uterosacral ligaments on both sides
using chromic suture.
Amputation of the cervix at the level of
the cervical os baseline applied over
the rest up.
The angle on both sides of the vaginal
string anchored to the cardinal
ligaments using chromic suture for
homeostasis.
Bleeding inspected and ligated as
encountered.
Reperitonealization done with simple
continuous strikes using chromic sutures.
Retractor and abdominal removed abdominal
cavity covered os.
Peritoneum closed with simple continuous
suture using chromic 2-0 suture.
Fascia closed with continuous interlocking
stitches using vicryl 4-0 suture.
Subcutaneous tissue closed with simple
interrupted suture.
Skin closed subticullarly with vicryl 4-0
suture.
Betadine and abdominal dressing applied;
kept dry and intact.
NURSING CARE PLAN
Infection related to Within 3 INDEPENDENT After 3 days of
altered physiologic days of 1.Encourage oral fluid Acid ash juices have nursing
infection barrier of nursing intake of fruit juices, pH acidifier retarding intervention
the vaginal intervention especially coconut bacterial growth. goal was
environment s the client juice. partially met as
secondary to will be free 2.Increase oral fluid Frequent urination evidenced by
persistent uterine from intake of 1 to 2 liters a prevents urine pus cells in the
bleeding as infection. day to promote retention that could urine and
evidenced by urination. cause bacterial evident blood-
Objective cues: 3.Encourage perineal growth stained urine
A. urinalysis: care once a day to Reduces risk of still noted.
(pyuria) maintain acidity of the contamination or Client
Presence of pus vagina. ascending infection. verbalized
cells 0-2 with 4. Review self “hindi na gawa
increase alkalinity medication regimen of Some drugs can masakit
B. blood stained the client. alter bladder and mangihi”
urine. kidney function, like
C. introitus antidepressant(Trazod
mucosa/vaginal one Hcl) and
orifice has white anticonvulsants
discharge with (Topiramate)
slight foul odor.
Subjective cue:
Client verbalize
“masakit mangihi”
1. Review self medication Some drugs can alter
regimen of the client bladder and or kidney
function
DEPENDENT
1. Administer antibiotic kills susceptible
prescribed bacteria by inhibiting cell
 Co-amoxiclav wall synthesis
625mg 1tab PO
BID
8am-6pm
Ceftriaxone sodium kills susceptible
1 g IVTT q8h x 3 days bacteria by inhibiting cell
(8am-4pm-12mn) wall synthesis
COLLABORaTIVE
1. Refer to medical technologist
for urinalysis
To monitor progress of
medication and
intervention.
 NURSING GOAL INTERVENTION RATIONALE EVALU
DIAGNOSIS ATION

Acute pain Within 8 INDEPENDENT After 8

related to post hours of 1. Assess pain noting Useful in monitoring hours of
operative wound nursing location, effectiveness of nursing
as evidenced by: interventiocharacteristics, severity medications, progression of interven
Objective cues: n the (0-10). healing. Changes in tion goal
A.facial client will Investigate and report characteristics of pain may is fully
grimacing be able to changes in pain as indicate developing abscess/ met as
B.limited report appropriate. peritonitis, requiring prompt evidenc
movement relief from medical evaluation and ed by
C. guarding pain with intervention pain
behavior, scale of 1 2. Keep rested in semi- Relieving abdominal scale of
specially at the as the fowlers position. tension, which attenuated 1.
Right lower lowest and by supine position.
quadrant 10 as the 3. Provide supportive Keep incision site intact,
D.Moaning highest. dressing (abdominal which prevent
Subjective cues: binder), not too loose evisceration /dehiscence.
a. A pain scale of and not too tight. Relieves discomfort
7 rating 10 as 4. Splint and support Facilitates participation in
the highest chest during coughing activity without undue
Client verbalized and deep breathing discomforts.
“sakit akong exercises.
tinahian” 5. Explain the cause of It enhances client’s ability to
pain. cope pain
6. Provide therapeutic .
communication on Address the client’s
concerns and issues actual needs for pain
associated to pain. management plus
DEPENDENT reduce tension.
1. Administer analgesic Relieves pain by
and anti-inflammatory binding by opiod
drugs as prescribed: receptors and inhibiting
tramadol hCl
50mg IVTT q6H PNN for Of none epinephrine
severe pain and serotonin
6am-12nn-6pm-12mid Relieves pain and
Ketarolac inflammatory by
30mg IVTT q8H ANST inhibiting prostaglandin
8am-4pm-12mid synthesis.
Celecoxib Relieves pain and
200mg/cap inflammation in joints
1cap BID x 5 days and muscle tissue by
8am-6pm inhibiting cox-2,
decreasing
prostaglandin
synthesis.
VIDEO PRESENTATION
 LABORATORY AND
DIAGNOSTIC EXAMINATION
 Patients name: L.C.
Type of examination: Prothrombin time
Date: January 09, 2009
Definition:
it measures the time required for clotting
to occur after thromboplastin and calcium are
added to decalcified plasma.
Parameters Result Normal Value Significance
Patient 16 seconds 11-16 seconds Normal
Control 13 seconds 13-15 normal
% activity 81.25% 70-120% normal
INR 1.26% 0.9-1.3 normal

Interpretation:
clients protrombin time is within
the norrmal range.
 Patients name: L.C
Type of examination: Blood Chemistry
Date: January 09, 2009
Definition:
Used to detect electrolytes to supplement physical exam and history of client
is placed on NPO post micnight prior to laboratory exam.
Patient’s name: L. C
Type of Examination: Cross matching/Blood typing (A) Date: January 21, 2009

Parameters Result Normal Value Significance

Blood Sugar 4.2mmol/L 3.3-5.5mmol/L Normal

BUN 3.2mmol/L 2.9-8.2mmo/L Normal

Creatinine .70mg/dL .6-12mg/dL Normal

Sodium 142.6mmol/L 135-148mmol/L Normal

Potassium 4.08mmol/L 3.5-5.3mmol/L Normal

Interpretation:
clients blood chemistry result is within the
normal range
Patients name: L.C.
Type of examination: CBC
Date: January 20, 2009
Definition:
for evaluation of general health status

Parameters Results Normal Values Significance

Hemoglobin 11.9 g/dl 12.5-15.3 g/dl Below normal
White Blood Cell 8.6x109/L 4.5-6.1x109/L Above normal

Neutrophils .58 .54-.68 Normal

Segmenters [P1]
.58 .32-.62 Normal
Eusonophils .19 .01-.04 Above normal
Lymphocytes .23 .25-.33 Below normal
Hematocrit .35 vol.% .37-47 vol.% Below normal
Platelet 204x109/L 150-450x109/L Normal
Interpretation:
decreased in hemoglobin,
hematocrit and lymphocytes is related
to persistent blood loss due to
abdominal uterine bleeding. Increase in
neutrophils and eosinophils indicates
presence of infection related to urinary
tract infection.
 Patients name: L.C.
Type of examination: CT-BT
Date: January 21, 2009
Definition:
to measure the required bleeding and
clotting time, in preparation for surgery
Parameters Results Normal Significance
Value
Bleeding 1 min. and 1-6mins. Normal
Time 50 secs.

Clotting Time3mins. 2-8 mins. Normal

Interpretation:
Bleeding Time and clotting time are within
normal range .
Patient’s Name: L. C
Type of Examination: Cross matching/Blood
typing
Date: January 21, 2009
Definition:
blood typing is a laboratory test done to
determine a persons blood type. If the
person needs a blood transfusion, another
test called cross matching is done after the
blood is turned to fluid
 HEMATOLOGY

Patients Name: L.C

Type of Exam: Hemoglobin and Hematocrit
Date: January 22, 2009
Definition:
This test is ordered to aid in the detection of anemias
and determine blood loss hydration status.
Parameters Result Normal Values Significance
Hemoglobin 116 g/dl 123-153 g/dl Below normal

Hematocrit .34 vol. % .37-.47 vol. % Below normal

Interpretation:
Decrease in Hemoglobin and hematocrit indicates anemia or
hemorrhage due to pesistent blood loss related to abdominal uterine
bleeding.
Patients Name: L.C
Type of Examination: Urinalysis
Date: January 09 2009
Definition
Used in diagnosing renal disease or
Urinary Tract Infection.
Parameters Result Normal values Significance
Color Straw Straw-Pale Straw Normal

Transparency Hazy Hazy-slightly hazy Normal

Reaction 7.5 Alkaline Acidic-slightly Above normal

Acidic
Specific Gravity 1.015 1.005-1.030 Normal
Sugar Negative Negative Normal
Albumin Negative Negative Normal
Pus Cells 0-2 Negative Above normal
RBC 6-10 0-2 rbc’s Above normal
Amorphous Many 0-1 Above normal
phosphates
Round Epithelial None 0-1 normal
Cells
Squamous Few 0-2 Normal
Epithelial Cells
Renal Epithilail None negative Normal
Cells
Bacteria Few 0-1 Normal
Interpretation:
increase RBC, amorphous
phosphate and alkalinity of the urine
plus presence of pus cells indicates
infection, related to urinary tract
infection of the client.
 Urinalysis
Patients name: L.C.
Date: January 26, 2009

Parameters Result Normal Value Significance

Colour Pale straw Straw-Pale Straw Normal
Transparency Slightly hazy Hazy-slightly hazy Normal

Reaction Alkaline Acidic-slightly Acidic Above normal

Specific gravity 1.005 1.005-1.030 Normal
Sugar Negative Negative Normal
Protein Negative Negative Normal
RBC (0-3) occasional 0-2 Above normal
Pus cells (0-2) occasional negative Above normal
Amorphous phosphates Many 0-1 Above normal

Squamous ep. Cells few O-2 Normal

Round ep cells None 0-1 Normal
Bacteria few 0-1 Normal
Parasites None negative Normal
Yeast cells None negative normal
Interpretation:
increase RBC, amorphous phosphate and
alkalinity of the urine plus presence of pus cells
indicates infection, related to urinary tract infection
of the client.
 X-ray
Patients name: L.C.
Type of examination: Chest PA
Definition:
done primarily to detect bone fractures.
Impression:
-both lung field are clear in with normal
vascular markings.
-the heart is normal in configuration.
-normal roots of the great vessels.
-diaphragm and bonycage unremarkable.
Remarks:
-normal chest
 MEDICUS DIAGNOSTIC CENTER

Name: L.C
Age: 42 years old
UTZ 00-07-3239
Address: Estancia, Iloilo
Invoice no.: 8066
Physician: Dr. E.A
 Lower abdominal ultrasound
Kidneys:
Normal in size and echogenecity
Distinct corticomedullary differentiation
Good renal excursion with respiration
The central echo complex is intact
Right kidney measures
9.3cmsx4.6cmsx4.8cms (LXAPXW)
Left kidney measures
10.0cmsx4.4cmsx4.8cms (LXAPXW)
CT= 1.1 cm
Urinary bladder:
Unremarkable
Enlarged retroverted measuring
10.6cmsx8.6cmsx11.7cms (LXAPXW)
Serosal contour is smooth
a 9..0cmsx6.0cmsx8.7cms
heterogeneously hypoechoic lesion is
seen occupying the posterior 2/3 of
the corpus
endometrial strip-not delineated
Cervix:
is normal measures 2.5cmsx3.1cms
(LXH) no mass or cysts noted
Ovaries:
not delineated otherwise no adnexal
mass or cyst notd
Impression:
enlarged retroverted uterine corpus
with hug intramural fobroid
normal kidneys, cervix and H adnexal
areas ultrasonically.
DRUG STUDY
 Generic and Classification Dosage Action Indication
Brand Name

Anti- 200mg/cap 1 cap Relieves pain and Acute pain

1. Celecoxib inflammator BID x 5 days inflammation in joints
y (8am-6pm) and smooth muscle
tissue by inhibiting
COX-2 decreasing
prostaglandin
synthesis
 Precaution Contraindication Side Effects Adverse Reaction Nsg.
Responsibilities

Use cautiously Contraindicated in CNS: dizziness, CNS: Stroke - instruct patient to

in patients patients headache, CV: immediately report
with known or hypersensitive to insomnia, EENT: Hypertension, to prescriber signs
suspected drug, pharyngitis, Myocardial of GI bleeding such
history and in sulfonamides or rhiniyis, sinusitis infarction, as bloody vomitus,
patients with aspirin and in GI: diarrhea, peripheral edema blood in urine or
history of patients with dyspepsia, GI: abdominal stool
ulcers, GI severe hepatic or flatulence, pain - inform patient
bleeding renal impairment. nausea. Skin: erythema, that it may take
Also Metabolic: muliforme, several days
contraindicated forhyperchloremia, exfoliative before he feels
treating hypophosphatemi dermatitis, consistent pain
perioprative pain a stevens-johnson relief.
after coronary Musculoskeletal: syndrome, toxic Instruct patient to
artery bypass back pain epidermal take drug with
graft surgery. Respitatory: uppernecrolysis food if stomach
respiratory tract Other: accidental upset occurs
infection injury - observe 10 rights
Skin: rash in giving
medications
- perform
handwashing
before giving the
medications
2. Cetriaxone Antibiotic 1g IVTT q8h x 3 Hinders or kills susceptible Preoperative
days bacteria by inhibiting prophylaxis
(8am-6pm) cell wall synthesis,
promoting osmotic
instability; usually
bactericidal
Use cautiously in Contraindicate Dizziness, Leukopenia - instruct patient to report
patient with history d in patients fever, rash, pain at the IV site
of sensitivity to drug hypersensitive nausea and - tell patient to notify
or other to drug or othervomiting, prescriber if loose stools or
cephalosporins cephalosporins diarrhea diarrhea occur
- tell patient to promptly
report adverse reactions
and any symptoms of
superinfection
- observe 10 rights in
giving medication
- perform handwashing in
giving the medication.
3. Tramadol Analgesic 50mg IVTT q6h PRN Relieves pain by Severe pain
for severe pain centrally
(6am-12nn-6pm- acting
12mn) synthetic
analgesic
compound not
chemically
related to
opioids
receptors and
inhibit
reuptake of
norepinephrine
and serotonin.
Use Contraindicate CNS: dizziness, vertigo, CNS: - instruct patient to
cautiously in d in patients headache, somnolence, seizures check with prescriber
patients at hypersensitive CNS stimulation, Respiratory: before taking OTC
risk for to the drug or asthenia, anxiety, repiratory drug; drug interaction
seizures or any of its confusion, coordination depression can occur
respiratory components disturbance, malaise, - instruct patient to
depression and in those euphoria, nervousness, take drug only as
and patients with acute sleep disturbances prescribed and not to
with intoxication CV: vasodilation increase dosage.
increased from alcohol EENT: visual - tell patient to be
intra-cranial disturbances careful when getting
pressure or GI: nausea, out of bed and walking
head injury. constipation, vomiting, or other dangerous
dyspepsia, dry mouth, activities until drugs
diarrhea, abdominal CNS effects are known.
pain, anorexia, - observe 10 rights in
flatulance giving the medication.
GU: urine retention, - perform handwashing
urinary frequency, before giving the
menopausal symptoms medication.
Musculoskeletal:
hypertonia
Skin: pruritus, sweating,
rash
4. Co-amoxiclav Antibiotic 625mg 1 Kills
tab susceptibl
BID e bacteria
Superinfec History of nausea, diarrhea
tions penicillin skin
involving hypersensitivi rashes &
Pseudomo ty. urticaria,
nas or vaginitis,
candida. abdomin
Pregnancy al
& discomfo
lactation. rt,
flatulenc
e&
headach
e.
5. Ketorolac Analgesic and anti- 30mg IVTTq8h Relieves pain and Short-term
inflammatory ANST(-) inflammation manageme
by inhibiting nt for pain
prostaglandin
synthesis
Use cautiously in Contraindicated in CNS: drowsiness, CNS: syncope - advise patient to
patients in the patients insomnia, dizziness, CV: edema, report worsening pain.
perioperative period hypersensitive to the headache hypertension, - teach patient to
and in patients with drug or any of its GI: nausea, palpitations recognize and report
hepatic or renal components dyspepsia, diarrhea EENT: transient signs and symptoms or
impairment Hematologic: purpura stinging and GI bleeding.
Skin: sweating burning, corneal - explain that drug is
Other: pain at edema, corneal intended only for short
injection site irritation, term use.
keratitis(occular - observe 10 rights in
form) giving medication.
GI: GI pain - perform handwashing
GU: renal failure before giving the
Hematologic: medication.
eosinophilia,
anemia
6. Multivitamins Vitamins 1 cap OD Correct dietary Additional
8am imbalances vitamins
for post-
operative
patient
Use Contraindicate -observe 10 rights in
cautiously in d in patients in giving medications
pregnant patient iron -perform handwashing
women to toxicity before giving
consult their medication.
physician
before taking
any MVT.
7. Midezolam sedative 5mg 1/amp Severe pain Promotes
calmness and
sleep by
depressing
CNS at limbic
and subcortical
levels of brain
by potentiating
effects of
GABX.
Use Contraindicate CNS: CV: -Handwashing
cautiously in d in patient headache, hypotensio -Observe 10 rights
patient with hypersensitive oversedation, n, cardiac -Assess patient’s
uncompens to the drug or involuntary arrest condition before
ated acute any of its movements Respiratory therapy and regularly
illness and components CV: variations : Apnea thereafter to monitor
in and in those in blood the drug’s
debilitated with acute pressure and effectiveness.
patient. angle-closure pulse rate
-Monitor blood
glaucoma, GI: nausea and pressure, heart rate
shock, coma, vomiting
or acute and rhythm
alcohol Respiratory: respirations and
intoxication. decreased airway integrity and
respiratory rate during procedure,
especially in patients
premedicated with
opiods
Clonidine HCL Antihypertensive 150mcg/amp # Severe Lower blood
2 pain preesure and
decreases
neurogenic pain
by inhibiting
central
vasomotor
centers,
decreasing
sympathetic
outflow to heart,
kidney and
peripheral
vasculature
resulting in
decreased
vascular
resistance and
decreased
systolic and
diastolic.
Midazolam Sedative 1.5 mg/ amp # 2 preoperative promotes
sedation(to calmness and
induce sleepiness sleep by
or drowsiness depresing CNS at
and relieve limbic and sub
apprehension) cortical levels of
brain by

potentiating
effects of GABX.
Use Contraindicated CNS: CV: -Handwashing
cautiously in in patients headache, bradycardia, -Observe 10 rights
patient with hypersensitive nervousness, severe -asses patient’s blood
severe to drug. sedation, rebound pressure before
coronary Transdermal confusion hypertensio therapy and regularly
insufficiency, form is CV: n thereafter
recent MI, contraindicated Hypotension,
-Be alert for adverse
cerebrovascul in patient orthostatic
ar disease hypersentive to hypotension reactions and drug
and chronic any component GU: urine interactions
renal or of adhesive - urge patient to rise
retention,
hepatic layer. Injectable impotence, UTI slowly and avoid
impairment. form is sudden position
contraindicated GI: changes to reduce
in patient constipation, orthostatic
receiving dry mouth, hypotension.
anticoagulation nausea and -Cation patient that
therapy and vomiting drug can cause
patients with Metabolic: drowsiness, but that
bleeding transient she will develop
diathesis or glucose tolerance to this side
injection-site intolerance, effects.
infection. skin pruritus
and dermatitis
with
transdermal
patch
Use cautiously in Contraindicated CNS: headache, CV: hypotension, Hand Washing
px in px over sedation, cardiac arrest Observe 10
uncompensated hypersensitive to involuntary nights
acute & illness in the drug or any movements. Respiratory: Assess px’s
debilitated px of its components CV: APNEA condition before
& in those acute decreased therapy and
angle-closure nausea variation regularly there
glaucoma, shock, in blood pressure after to monitor
coma, or acute and pulse rate. the drugs
alcohol GI:, effectiveness
intoxication. vomiting Monitor blood
pressure, heart
rate and rhythm,
respiration &
airway intigrits
during procedure,
especially in px’s
premedicated
apioids.
Use extra caution
when teaching px
because drug will
diminish predrug
memory.
Nalbuphine HCI analgesic anti 10mg/ amp #2 adjunct in
anginal adjunct balance
to anesthesia anesthesia
use Contraindi CHS: CV: Hand
cautiously cated in headache bradycard washing
in px dizziness, ia Observe
substance hypersensdepressio respirator 10 rights.
abusers & itive to n, y: Monitor
in those drugs and restlessne respirator for angina
emotional its ss. CV: y and
inability, compone hypertensidepressio symptoms
head nts on, n, of
injury, hypotensi pulmonar constipati
increased on, y edema on.
intracrani tachycardi
Monitor
al a IENT:
pressure, blurred closely for
impaired vision GI: respirator
ventilation cramps, y
depressio
Tetracycli Antibiotic
ne HCL
Use Contraindi CNS: CNS: Give
cautiosly cated with dizziness, intracrani drug on
in px with px headache al empty
impaered hypersensEENT: hypertensistomach
kidney or itive to sore on Skin: Observe
liiver tetracyclin throat, candidal 10 rights
functions. es, glossitis, superinfecWarn px
dysphagia tion to avoid
. direct
GI: sunlight
anorexia, and
nausea, ultraviolet
vomiting light
diarrhea
DISCHARGE PLAN
NAME: L.C.
AGE: 42 years old
SEX: FEMALE
ADDRESS: Sta. Ana, Estancia
CHIEF COMPLAINT: Menorrhagia
DIAGNOSIS: UTERINE MYOMA
GENERAL OBJECTIVES:

To provide continuity of care and appropriate needs to the

client at home in the absence of a health care provider
after discharge from the health care facility.
SPECIFIC OBJECTIVES:

The patient will be able to:

i. Gain more ideas about her present illness.
ii. Know what are the do’s and don’ts activities
that may affect her illness. Either may increase or
decrease the condition of the illness.
iii. Perform proper hygiene procedures that she
must do in her daily living to prevent further more
infection that may arise.
iv. Take her medications faithfully and follow some
non-pharmacological and pharmacological
treatments for fast recovery of illness.
v. Take whatever foods she likes to eat as long as
she can tolerate it.
Do a follow up check up whenever the doctor
scheduled her or present illness re-occur or became
worst.
HEALTH TEACHINGS:

KNOWLEDGE ABOUT THE PROBLEM:

Uterine Myoma is when a benign tumor grows in the
muscles of the uterus, it is known as uterine
Myoma. These tumors can grow very large,
sometimes growing as large as a melon. The typical
Myoma, however, is around the size of an egg.
When the Myoma penetrates the entire wall of the
uterus, it is referred to as uterus myomatosus.

When the Myoma pushes on the intestines or the

bladder, it can result in constipation, pain of the
bladder, or a constant need to urinate. If the tumor
pushes on the nerves in the spinal cord, it can result
in pain of the back or the legs.
The causes of uterine Myoma are not fully
understood. Some research suggests that Uterine
Myoma is less common in women who have had at
least two children. For at least one form of uterine
Myoma, there seems to be a genetic predisposition.

Uterine Myoma often goes undetected. Ultrasounds,

CT Scans, or MRIs may be necessary to fully
diagnose uterine Myoma. If you have symptoms of
Uterine Myoma, your health care provider will help
you determine the best way to diagnose the
problem.
 Once it is diagnosed, Uterine Myoma can be
treated through hormonal and/or herbal
treatments. Hormonal treatments typically do not
cure the Uterine Myoma. Rather, they give a
temporary relief of the symptoms of Uterine
Myoma. In addition, these hormones may have
certain side effects. If these hormone treatments
do not work, surgery is typically an option.
Surgical options include the surgical removal of
the Myoma tumors (known as an enucleation) or
a complete hysterectomy. Recent advances in
laser surgery may make this an option also. If this
is the case, the surgery can become much less
invasive, and can be done laparoscopically.
ACTIVITIES OF DAILY LIVING:

Ensure Mrs. L.C. for a progressive ambulation;

ambulation promotes circulation and reduces the risk
of thrombophebitis in lower and upper extremities. It
also improves the function of bladder and bowel
elimination and decreases abdominal distention and
constipation.

Encourage patient to have adequate sleep and rest.

rest is facilitated by reducing worry and anxiety –
producing situations and promoting comfort. sleep
reduces fatigue and help gain energy.

Inform patient to avoid intercourse for 6 weeks until

healing is complete. to ensure healing and vaginal cuff
and risk of infection and vaginal hemorrhage.
 PERSONAL HYGIENE:
 Mrs. L.C should do perineal care and wound dressing daily.
Perineal care procedure as follows:
 Start from the mons pubis then to labia majora right to
labia minora left then labia majora left to labia minora right. Cleaning
of this areas should be cleaned from front to back direction using
cotton balls soaked in betadine solution or with water and mild soap.
 In wound dressing, wipe the wound with cotton balls or cotton
applicator soaked in sterile water followed by dry cotton balls or
cotton applicator. Wipe the wound with cotton balls soaked in
betadine solution or cotton applicator. Cleanse the wound using
long or circular strokes from inner to outer in single stroke only.
Apply sterile gauze on the wound and secure with plaster.
MEDICATIONS AND TREATMENT:

Folks should always facilitate the compliance

of the medications of the patient at the right time
and dosage. Advise the folks not to stop or take
medication unless ordered by the physician.

 Celecoxib 200 mg/cap 1 cap by mouth twice a day x

5 days 8 am – 6 pm
 MTV 1 cap by mouth once a day 8 am for 1 month.
 Co-amoxiclav 625 mg 1 tab by mouth twice a day 8
am – 6 pm x 7 days.
NUTRITIONAL INSTRUCTIONS:

Instruct patient to eat nutritious foods that rich in iron

such as ampalaya, chicken or pork liver and red meat
especially green leafy vegetables and take any kind of
foods as long as she can tolerate it. Instruct to drink 6-8
glasses of water daily as a normal habit to maintain
homeostasis of fluid in the body and maintain proper
function of all the organs in the body. To promote wound
healing, encourage patient to eat food rich in vitamin C
such as oranges or calamansi.
FOLLOW UP VISIT:

Instruct patient to comply continuity of follow up schedule to

monitor health status by coming back to the Out Patient
Department one week after discharge.
POST - PHYSICAL
ASSESSMENT
(JAN. 26, 2009)
GENERAL SURVEY
Client is oriented, coherent to time, place, and person.
Well-groomed, with good skin turgor, absence of body
odor, cooperative, skin springs back after 2 seconds. Vital
signs taken, BP of 110/70mmhg, temperature of 36C, PR
of 85bpm, RR of 22bpm.
SKIN
The skin is brown in color except in sun exposed areas,
moisture varies with activity, body and environmental
temperature, and humidity in skin folds and the axilla.
Texture is smooth, soft and flexible except for palms and
soles. Body hair is thin and evenly distributed no lesions,
masses and edema noted. Skin temperature is uniform
allover the body and within the range, with good skin
turgor because of absence of indentation in dependent
areas and the resilience of the skin to spring back to its
previous state after being pinched.
NAILS
Nails are convex in curvature, pinkish in color, nails
is trimmed and clean with good capillary refill
because when pressure is released firm the nail, it
promptly returns to its normal color. Has angle of
approximately 160 degree between the fingernails
and nail base; nails feels firm when palpated. Tissue
surrounding the nails is intact.
HEAD
Head is normocephalic; the hair is black, thick and
evenly distributed; lesions, mass and edema not
noted; the eyes, nose, mouth and ears are
symmetrically aligned; the face can project different
facial expressions.
EYES
Eyebrows are bilaterally symmetrical and evenly
distributed and in equal movement. Eyelashes equally
distributed and curled slightly outward. Eyelids intact
with no discharges noted. Lids close symmetrically and
free from inflammation, crusting, edema or masses. Both
eyes move in unison and are coordinated. Conjunctiva is
pink. Sclera appears white. Pupils are equally rounded,
both are reactive to light and accommodation. Blinking
reflex is present. Client has history of using reading glass
since high school student, far sighted.

EARS
The Ears are bilateral and symmetrical. Color is even with
the facial skin , no discharges observed. No tenderness,
masses or swelling noted. Auricle is firm, smooth, and
free from lesions and pain and is aligned to the outer
canthus of the eyes, cerumen not noted with mole in
right earlobe. Ear canal is pinkish and dry, and able to
hear whispered words (BLUEMOON). Do not have hearing
difficulty, able to hear sound in both ears.
NOSE
Nose symmetrical and located at the midline of
face, masses or swelling not noted with no discharges
noted. Each nostril is patent. Mucosa is pink or dull red
without swelling or polyps. Nasal septum is intact in
midline, no history of nosebleed and can distinguish
odor (scent of cologne) with clear watery discharge
and nontender nasal sinuses upon percussion

NECK
Neck is same to all parts of the body. Muscles
are symmetrical with head in central position and
with full range of motion without complaint of
discomfort and lymph nodes not palpable.
MOUTH
No halitosis noted. Mucosa and lips are slightly pink and moist without inflammation or
lesions noted. Gag reflex is present, with complete teeth, properly aligned white and shiny.
Tongue is in central position and moves freely and pink in color, moist and smooth. Uvula
is in midline, tonsils are not inflamed. Palates are red or pink in color, concave and pink:
hard palate has ridges and soft palate is smooth.

CHEST
Posterior Chest
Respirations are effortless, quiet, and regular, RR of 22bpm. Thorax rises and
falls in unison with respiratory cycle. Ribs slope across and down, without movement or
bulging in the intercostals spaces. Tenderness, lesions, and pulsations not noted upon
palpation. Fremitus is equal on both sides of thorax, strongest at the level of tracheal
bifurcation. Air filled lungs create a resonant sound and with bronchovesicular sounds.
Anterior Chest
Thorax rises and falls in unison with respiratory cycle, ribs at a 45degree angle with
sternum. Tenderness, lesions, and pulsations not noted upon palpation. Fremitus is equal
on both sides of thorax, strongest at the level of tracheal bifurcation. Resonant sound over
lung tissue upon percussion and ribs are flat. Bronchovesicular sounds heard upon
auscultation. The right breast is bigger than the left; areola is darker in color with no
discharges and masses noted upon palpation.
HEART
Absence of visible pulsation, heaves or retractions and strong pulsations thrusting
upward against the finger pads noted.
ABDOMEN
Not assessed, with abdominal binder. Pain felt by the client (pain scale of 7 rating
to 10 as the highest scale)
Anterior Chest
Thorax rises and falls in unison with respiratory cycle, ribs at a
45degree angle with sternum. Tenderness, lesions, and
pulsations not noted upon palpation. Fremitus is equal on both
sides of thorax, strongest at the level of tracheal bifurcation.
Resonant sound over lung tissue upon percussion and ribs are
flat. Bronchovesicular sounds heard upon auscultation. The right
breast is bigger than the left; areola is darker in color with no
discharges and masses noted upon palpation.
HEART
Absence of visible pulsation, heaves or retractions and
strong pulsations thrusting upward against the finger pads noted.
ABDOMEN
Not assessed, with abdominal binder. Pain felt by the client (pain
scale of 7 rating to 10 as the highest scale)
GENITALS
Genitals not assessed. Client refused and with
normal voiding pattern.

EXTREMITIES
Upper
Symmetric and equal in length and no swelling and
tenderness noted. Client has good skin turgor
because as I pinched the skin it returns back less
than 3 seconds. Skin color is same to all parts of the
body and with good capillary refill because it
returns to its normal color within 3seconds and with
full range of motion.
Lower
Symmetric and equal in length and no swelling and
tenderness noted. Skin color is same to all parts of
the body
WARD OBSERVATION
January 20, 2009
7-3 Shift
7:00 AM Awake, sitting on bed, coherent,
conversant, oriented to time, place and
person.
8:00 AM With BP= 110/70 mmHg, T=36.8
C, PR=91 beats per minute, and RR=20
breaths per minute.
8:30 AM Breakfast taken; consumed 1 cup
of rice, 1 bowl of soup, 1 fried fish and 1
glass (240cc) of orange juice.
8:55 AM Morning and bed side care done.
9:15 AM Seen every now and then.
10:00 AM Dr. D in made orders and carried out
by Staff Nurse on Duty.
Pre physical assessment done.
12:00 NN Vital signs checked; afebrile.
12:30 PM Lunch taken; with good appetite;
drink 360 cc of water.
1:00 PM Made comfortable in bed.
1:30 PM Slept at long interval.
2:30 PM Endorsed to Staff Nurse on Duty;
asleep, with style vital signs and scheduled
for Total Abdominal Hysterectomy
Bilateral Salpingo Oophorectomy (TAHBSO)
for tomorrow.
January 21, 2009
7-3 Shift
7:00 AM Awake, lying on bed, with IVF of D5LR 1L
x 8 hours at the right metacarpal vein at the
level of 800cc, with blood line of PNSS 1L x KVO
at the left metacarpal vein at the level of 850cc.
patent and infusing well. With foley catheter
attached to uro bag draining to yellow
colored urine about 150cc.
8:00 AM Vital signs check and recorded;
BP=100/80 mmHg, T= 36.8 C, PR=75 beats per
minute, RR=18 breaths per minute.
9:00 AM Latest vital signs taken; T=36 C, PR=
71 beats per minute, RR= 20 breaths per
minute, and BP=100/80 mmHg.Sedative
drugs given by staff nurse on duty
(Midazolam 1.5 mg/amp #2 IVTT) Brought to
OR via stretcher with spinal needle g25 #1,
tetracaine 2mg/amp #1, D10w amp #2,
Clonidine 150mcg/amp #1, Nalbuphine
10mg/amp #2.
January 26 2009
7-3 Shift
7:00 AM Awake, lying on bed; wound dressing
done by Dr. D.
With intact scultitus binder in the abdomen, no
bleeding noted. For removal of sutures in AM.
8:00 AM Vital signs taken and recorded;
afebrile, BP= 110/70 mmHg, PR=85 beats per
minute, RR= 22 breaths per minute.
Assess level of pain.
8:45 AM Bedside and morning care done;
made comfortable in bed.
9:05 AM Breakfast taken with good appetite.
10:00 AM Post physical assessment done.
12:00 NN Vital signs taken and recorded.
Afebrile; PR=87 beats per minute, RR=21 breaths
per minute, and BP=110/80 mmHg.
Lunch taken; 1 cup of rice, 1 cup vegetable soup
and drink 480cc of water.
1:00 PM Slept at short intervals.
2:30 PM Endorsed to Staff Nurse on Duty with may
go home order.