Chapter 1 Introduction The uterus or womb is a major female hormone-responsive reproductive sex organ of humans.

One end, the cervix, opens into the vagina, while the other is connected to one or both fallopian tubes. It is within the uterus that the fetus develops during gestation. The uterus consists of a body and a cervix. The cervix protrudes into the vagina. The uterus is held in position within the pelvis by condensations of endopelvic fascia, which are called ligaments. It is covered by a sheet-like fold of peritoneum, the broad ligament. The uterus is essential in sexual response by directing blood flow to the pelvis and to the external genitalia, including the ovaries, vagina, labia, and clitoris. The reproductive function of the uterus is to accept a fertilized ovum which passes through the utero-tubal junction from the fallopian tube. It implants into the endometrium and derives nourishment from blood vessels which develop exclusively for this purpose. The fertilized ovum becomes an embryo, attaches to a wall of the uterus, creates a placenta, and develops into a fetus (gestates) until childbirth. Uterine myoma is the most common tumors of the female genitalia tract. Myoma commonly called fibroid is the benign tumor of the smooth muscle in the wall of the uterus. Hysterectomy has been a common therapy in patients who have completed reproduction. Total hysterectomy plus bilateral salphingo oophorectomy TAHBSO is a recommended procedure. This procedure removes the uterus, cervix, both ovary and both fallopian tube. Fibroids can be present and be apparent. However they are clinically apparent in up to 25 % of the women. Although, myoma is generally considered to be slowly growing tumor in 20-40% of women at the age of 35 and more have uterine fibroids of significant sizes with severe clinical symptoms. Moreover, myoma can be relapse in 728% of patient after surgical treatment and in certain case it may even turn to malignant tumor. This could cause significant morbidity including prolonged or heavy menstrual bleeding, pelvic pleasure and pain and in rare cases reproductive dysfunction.

Myoma affects one of every four women, however three every four women experience no symptoms. Uterine myoma is developing on the background of hyper estrogen, progesterone, deficits in hyper gonadotrophine. The majority of the researches say that the growth of myoma depends on concentration of cystosolic receptors to the sex hormones and their interactions with the endrogen or extrogen hormones. In accordance to clinical observations, it can be admitted that both growth and regressions of myoma are estrogen-dependent. In fact, uterine myoma accounts for 20% of 650,000 hysterectomies performed annually in the U.S. Interest in the uterine preservation and organ preserving surgery through techniques minimally invasive surgery has increased the first reports of laparoscopic myomectomy. The researcher intends to use the Ten Carative Factors of Jean Watsons Theory of Caring to provide holistic and humane care to the patient with multiple uterine myoma who needs curative and supportive care. Watson defined nursing as a human science of persons and human health-illness experiences that are mediated by professional, personal, scientific, esthetic and ethical human transactions. In this connection, the nurse can offer emotional support by simply being with the patient so that the patient would feel that she is cared for, give assistance with her basic needs, and endowed with a helping-trust relationship in order for her to have a sense of self worth.

Objectives of the Study

General Objectives: After 1 hour of case presentation, the researcher aims to formulate a comprehensive case study analysis that would provide essential knowledge and skills in delivering quality health care to patient diagnosed with Multiple Uterine Myoma.

Specific Objectives: Within 1 hour of case presentation, I will be able to: Define Multiple Uterine Myoma and its related concepts. Make a comprehensive assessment of the patient using a standard maternal assessment tool. Anchor Nursing theory to the case of the patient. Formulate Nursing Care Plan to the patient based on the identified patients problem. Prioritize the identified problem according to its risk. Create drug study on the different medications of the patient. Relate the laboratory values to the case of the patient.

Theoritical-Conceptual Framework

This study is anchored on the Ten Carative Factors of Jean Watsons Theory of Caring. She adopts a view of the human being as: .. a valued person in and of him or herself to be cared for, respected, nurtured, understood and assisted; in general a philosophical view of a person as a fully functional integrated self. He, human, is viewed as greater than and different from, the sum of his or her parts (Watson, 2001). The theory of caring and nursing has existed in every society. A caring attitude is not transmitted from generation to generation. It is transmitted by the culture of the profession as a unique way of coping with the environment. Nursing is concerned with promoting health, preventing illness, caring for the sick and restoring health . It focuses on health promotion and the treatment of disease. The Theory of Caring states that holistic health care is central to the practice of caring in nursing. It defines nursing as a human science of persons and human health-illness experiences that are mediated by professional, personal, scientific, esthetic and ethical human transactions (Watson, 1997). The theory of Jean Watson has seven assumptions for the science of caring in nursing. It asserts that caring can be effectively demonstrated and practiced only interpersonally. Second, caring consists of carative factors that result in the satisfaction of certain human needs. Third, effective caring promotes health and individual or family growth. Fourth, caring responses accept the person not only as he or she is now but as what he or she may become. Fifth, a caring environment is one that offers the development of potential while allowing the person to choose the best action for himself or herself at a given point in time. Sixth, caring is more healthogenic than curing. The practice of caring integrates biophysical knowledge with knowledge of human behavior to generate or promote health and to provide ministrations to those who are ill. Lastly, the practice of caring is central to nursing. (Watson, 2001) In addition to the seven assumptions, it describes ten "Carative Factors," that characterize the nursing caring transaction occurring within a given caring moment or occasion. The ten carative factors involve 1. Forming a humanistic-altruistic system of values. 2. Enabling and sustaining faith-hope.

3. Being sensitive to self and others. 4. Developing a helping-trusting, caring relationship. 5. Promoting and accepting the expression of positive and negative feelings and emotions. 6. Engaging in creative, individualized, problem-solving caring processes. 7. Promoting transpersonal teaching-learning. 8. Attending to supportive, protective, and/ or corrective mental, physical, societal, and spiritual environments. 9. Assisting with gratification of basic human needs while preserving human dignity and wholeness. 10. Allowing for, and being open to, existential-phenomenological and spiritual dimensions of caring and healing that cannot be fully explained scientifically through modern Western medicine. Watson (1996) sees the carative factors as instrumental in reintegrating a sense of harmony and dignity into interpersonal, sociopolitical and environmental relationships. According to the theory, the nursing process contains the same steps as the scientific research process. They both try to solve a problem. Both provide a framework for decision making. The assessment phase involves observation, identification and review of the problem; and use of applicable knowledge in literature. It also includes conceptual knowledge for the formulation and conceptualization of framework. It includes the formulation of hypothesis, and defining variables that will be examined in solving the problem. In Watsons book entitled Nursing the Philosophy and Science of Caring , the second half of the book is about helping people gratify their human needs. These are classified into two; the lower order needs which include biophysical needs and psychophysical needs and the higher order needs which include psychosocial needs and intrapersonal-interpersonal needs. A need is defined generally as a prerequisite of a person to relieve distress and improve his well-being (Watson, 1999).

The lower order needs consist of the biophysical needs and the psychopyhsical needs. The biophysical needs include the need for food and fluid, elimination, and ventilation. These are also commonly called the survival needs as they are essential to sustain life. Next is the psychophysical needs. These are the need for activity-inactivity and the need for sexuality. This subdivision is also referred to as functional needs. When these needs are met, it is believed to increase the quality of living. The higher order needs consist of psychosocial needs. These are the need for achievement and affiliation, referred to as integrative needs. Reaching these needs can bring out the human potential, maturity, and satisfaction towards others. The second is intrapersonal-interpersonal needs. This is the need for self-actualization or growthseeking needs. All the higher order needs are long-term goals the nurse must attempt to reach. The planning phase helps to determine how variables would be examined or measured; it includes a conceptual approach or design for problem solving. It determines what data would be collected and how, and on whom. In the intervention phase, the use of clinical caritas processes was emphasized in the implementation of the plan. It included the collection of data. The last phase in Jean Watson's nursing process is evaluation. This is the analysis of the data as well as the examination of the effects of interventions based on the data. It includes the interpretation of the results, the degree to which a positive outcome has occurred, and whether the result can be generalized. It may also generate additional hypothesis or may even lead to the generation of a nursing theory (Watson, 2001).

Chapter 2 Finding of History and Assessment

This is a case of Mrs. L.L., female, married, 43 years old, Filipino, Roman Catholic, born last April 8, 1969 in Pulang-bato, Pit-os Talamban, Cebu City, Cebu. Patient was admitted at Vicente Sotto Memorial Medical Center (VSMMC) for the third time last August 26, 2012 at 2:56pm for complaints of abdominal pain and difficulty in breathing. Patient was brought to Ward 6 (Female Ward) on the same day and was placed in bed 26. Patient was diagnosed with Multiple Uterine Myoma SP Myemectomy 2x (2003,2007). Proposed operation was Total Abdominal Hysterectomy (TAH). Years prior to admission, patient verbalized abdominal pain and was admitted at Vicente Sotto Memorial Medical Center, diagnosed with Uterine Myoma last 2003. Myomectomy was done. Four years after the surgical procedure, patient complains abdominal pain and difficulty in breathing. She was admitted at Vicente Sotto Memorial Medical Center last 2007. Myomectomy was done. One week prior to admission, the patient was admitted again at Vicente Sotto Memorial Medical Center due to painful and rigid abdomen, difficulty in breathing especially when full. She has no known allergies to food and drugs. She is non-asthmatic and no history of cardiac illness. Biophysical Profile The patient was seen lying on bed, in supine, was awake, coherent, responsive and febrile. The patient has a bedside oxygen inhalation regulated at 2-3 liters per minute attached via nasal prong PRN with ongoing intravenous fluid at the right arm, Plain Normal Saline Solution (PNSS) 1 Liter at 30 drops per minute, is infusing well, nonphlebitic and non-infiltrated. On inspection, the patients head is normocephalic, the face is symmetric, hair color is black and dull. There are no gross structural deformities. Upon palpation, hair texture is rough and dry but resilient, with presence of moderate amounts of dandruff flakes on scalp. No presence of edema, tenderness and bruises noted on scalp and face. The eyes are symmetric, no signs of scaling. The sclera is white in color, palpebral conjuctiva is pale pink in color and moist. Pupils are equal, round, reactive to

light and accommodation. Vision is adequate, patient is neither farsighted nor nearsighted. The ears are symmetric and in line with the inner canthus of the eye. There is no presence of edema, bruises and tenderness on palpation. Hearing is adequate and the patient was able to hear a whispered voice at a distance of 2-3 feet away. On inspection, the chest is normal and symmetric in expansion. Anterolateral diameter is larger than the posterior-anterior diameter. The patients abdomen is enlarged which measures 38 inches and rigid. The apical pulse is regular in rhythm and has a rate of 80 beats per minute. Nail beds are pale, but there is no clubbing. Capillary refill time is three seconds. Prior to admission, she was on full diet at home. Oral fluid intake at home was usually eight (8) glasses per day. Her mouth and tongue are moist but oral mucous membranes are pale pink in color. Prior to her hospitalization, the patient verbalized that she had a regular dietary food intake like dried fish, sunny side up egg and rice in the morning or sometimes bread and hot chocolate. In the afternoon she had vegetables, chicken, and meat, and in the evening she usually ate the same as her lunch. The patient usually ate 2 cups of rice, 1-2 pieces of chicken or meat, and a bowl of soup. She had no restrictions or preferences with her dietary intake and she did not experience any difficulty in eating, swallowing and chewing except when full, she experienced difficulty in breathing. The volume of food that the patient normally eats could no longer be possible due to her illness. Weight loss was manifested by the patient. She had a total weight loss of three kilograms, from a weight of 58 kilograms down to 55 kilograms. The patient defecated once a day with a normal consistency of stool. The amount of stool was moderate and was brown in color. In the hospital, she defecated at least four times a week, with moderate amount of yellow to brown stool of hard consistency. The patient verbalized that she had a normal voiding pattern at home, with four to six voiding times and amounts of about one and a half cup per voiding. Urine color was from light yellow to amber and the patient did not experience any pain before, during and after urination. During her hospital stay she voided about five to six times a day. The urine color is amber without any pain upon, during and after urination.

Prior to hospitalization, the patient stated that her normal sleeping time was around nine oclock in the evening and she woke up at four oclock in the morning. The patient did not experience any difficulty falling asleep at night. However during admission, there was a change in sleeping pattern as verbalized by the patient due to environment and frequent interruptions due to therapeutic interventions. Vital signs revealed Temp= 38.4 degrees Centigrade, P= 80bpm, RR= 22 cpm, BP= 160/120 mmHg. Psychophysical Profile Prior to her diagnosis of Multiple Uterine Myoma, the patient is a fish vendor though she had underwent Myomectomy twice, she was able to take care of herself with regards to the activities of daily living. The patient together with her husband manages to run their small business of buying and selling fish. This is their familys source of income. During admission, the patient is ambulatory, she was able to perform light exercises to exercise her muscles and joints though feeling weak. The patient complained of difficulty in breathing, especially when she eats a lot or in pain. Psychosocial Profile Prior to her hospitalization, patient get to mingle their neighborhood usually because of their business. At night, she cooks for the family and ate together with her husband and son. During admission, the patient was accompanied by her son and husband and some relatives and friends used to visit her. Prior to admission, the patient used Bisaya as her spoken language. She expressed herself through speaking with gestures and so the same during her hospitalization. The patient is anxious during hospitalization because she is scheduled for an operation. Intrapersonal-Interpersonal Profile Prior to her multiple hospitalizations for the treatment of her condition, the patient described her health as fair. According to the patient, hospitalization was one way of treating illness by following the prescribed treatment. During admission, the patient

10

verbalized her health as poor. She had body malaise, weight loss, difficulty in breathing and in pain. The patient is a Roman Catholic and believes in Almighty God. She verbalized the importance of faith in God, hope, and love. During admission, the patients faith strengthened and she prayed for a successful operation and that she would be cured of her illness.

Chapter 3 Psychopathophysiology Uterus

11

Etiology: - Unknown

Predisposing Factors: - Advancing Age - Genetics - Race - Stress Precipitating Factors: Disease Process - Hyperestrogenic State - Hypertension - Nulliparity - Menopause - Contraceptives

Benign tumors originating in the smooth muscular uterine tissue, though sometimes they originate in the smooth muscle of the uterine vessels

Stress within the myometrium (Due to physical and mental means resulting from uterine contractions. Multiple fibroids)

Simple proliferation (monoclonal) of smooth muscle cells (Continuous development of group of cells from a single ancestral cell by repeated cellular replication; cell formation)

Development of Leiomyomas ( fibroid )

Fibroid Growth Increase Estrogen-dependent tumors, their growth is related to their exposure to circulating estrogens Express maximal growth during the generativeage of a female, when estrogen secretion is at its highest, and growth curve is especially slope in the decade

12

preceding menopause (probably as the consequence of anovulatory cycles with unopposed circulatory estrogen) sometimes grow during pregnancy, which is probably related to estrogen, as well as an increased blood flow in pregnancy and edema. Estrogen receptors are present in a higher concentration within myomas than in the adjacent myometrium. Hormonal therapy

Fibroid Growth Decrease decrease during menopause and other hypoestrogenic conditions

Endometrial Distention

Signs and Symptoms Abdominal fullness, gas Bleeding between periods or very prolonged bleeding with periods Increase in urinary frequency Heavy menstrual bleeding (menorrhagia), sometimes with the passage of blood clots Pelvic cramping or pain with periods Sensation of fullness or pressure in lower abdomen Sudden, severe pain due to a pedunculated fibroid

Complications Large fibroids may cause infertility by: - Impairing the uterine lining, Blocking the fallopian tubes, Distorting the shape of the uterine cavity, Altering the position of the cervix and preventing sperm from reaching the uterus Pregnancy complications and delivery risks: - Cesarean section delivery, Breech presentation, Preterm birth, Placenta previa, Postpartum hemorrhage Anemia Pressure on the ureters may cause urinary obstruction and kidney damage.

13

Pain can also develop if the blood supply is cut off from the fibroid tissue. In such cases, the cells blacken and die (a process called necrosis) from lack of oxygen - A very large fibroid outgrows its own blood supply, A pedunculated fibroid (one that grows on a stem from the uterine wall) becomes twisted, thus cutting off its blood supply, Pregnancy occurs in which the risk for fibroid cell degeneration and necrosis increases Fibroid breaks away from the uterus and develops in other locations. They are typically one of the following: - Benign Metastasizing Leiomyoma, or BML (which usually spreads to thelung) - Disseminated Peritoneal Leiomyomatosis (which spreads to the abdominal wall Uterine Cancer - Fibroids are nearly always noncancerous, even if they have abnormal cell shapes. Cancer of the uterus nearly always develops in the lining of the uterus (endometrial cancer).

Chapter 4 Medical Management

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A. Laboratory and Diagnostic Exam Table 1. Hematology

Result COMPLETE BLOOD COUNT WBC Count Hemoglobin Hematocrit MCV MCH RBC Count MCHC RDW MPV Platelet Count DIFFERENTIAL COUNT Neutrophil Lymphocyte Monocyte Eosinophil Basophil Stab Atypical Lymphocyte Metamyelocytes Myelocytes Blast 0 0 0 Normal Normal Normal 44.20 45.90 8.30 1.00 0.60 0 0 % % % % % % % 40-74 19-48 3-9 0-7 0-2 Normal Normal Normal Normal Normal Normal Normal 7.02 123 0.38 91.90 30.10 4.08 328 13.3 9.30 252 10^9/L g/L L/L fl Pg 10^12/L g/L % F 10^9/L 4.8 10.8 120-160 0.37-0.47 81-99 27-31 4.20-5.40 330-370 11-16 7.2 11.1 150-400 Normal Normal Normal Normal Normal Decrease; anemia Decrease; anemia Normal Normal Normal Unit Reference Significance

15

Date/Time Rendered: 08/31/12 (11:47am) Date/Time Received: 08/31/12 (03:09pm)

Table 2. Urinalysis
TEST CLINICAL MICROSCOPY Routine Urinalysis Color Transparency Yellow Slightly cloudy Chemical Sp. Gravity pH 1.025 5.0 1.003-1.035 5.0 8.0 Normal Normal Normal Normal RESULT UNIT REFERENCE SIGNIFICANCE

16

Protein Glucose Bilirubin Blood Leucocytes Nitrite Urobilinogen

Negative Negative Negative +2 Negative Negative <2 mg/dl 0.1-1.8

Normal Normal Normal Normal Normal Normal Decreased due to treatment with drugs that acidify urine

Ketone Ascorbic acid Microscopic RBC

Negative Negative

Normal Normal

3-5

/hpf

0-2

Increased; blood cell in the urine may indicate some kind of kidney malfunction

WBC Epithelial cells Bacteria Mucus threads

0-1 Few Abundant rare

/hpf

0-5

Normal Normal Infection Normal

Date/Time Rendered: 08/31/12 (03:02pm) Date/Time Received: 09/01/12 (02:46pm) Table 3. Clinical Chemistry
Blood Chemistry Sodium Potassium Chloride Results 143.7 3.3 107 Reference (135-148) mmol/L (3.5-5.3) mmol/L (98-107) mmol/L Significance Normal Hypokalemia Normal

Date/Time Rendered: 07/03/11 (14:22am) Date/Time Received: 07/03/11 (14:22pm) Table 4. Immunology Report
TEST IMMUNOLOGY RESULT UNIT REFERENCE SIGNIFICANCE

17

CA 125 ( OVARIAN CA )

12.6

U/ml

<35

High due to fibroids

Date/Time Rendered: 08/05/12 (02:53 pm) Date/Time Received: 08/08/12 (08:34 am)

Ultrasound Result Taken last July 25, 2012 Uterus : 18.3 x 12.0 x 10.6 cm anteverted Cervix: 4.7 x 4.7 x 4.6 cm without nabothian cyst

Endometrium : 1.2 cm Right ovary : not visualized Left Ovary : not visualized Others : no free fluid in the cul de sac Remark : The uterus is anteverted with regular contour and inhomogenous echopattern There are well circumscribed heterogenous structures as follows M1 = 2.4 x 2.9 x 2.4 cm, anterior lower uterine segment, intramural M2 = 3.1 x 3.5 x 3.3 cm, beside M1, intramural M3 = 5.4 x 4.9 x 5.9 cm, right lateral, intramural M4 = 8.4 x 9.8 x 9.1 cm, anterior

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The cervix is closed and homogenous. The endometrium is thick and hyperechoic with intact endomyometrial interface. Both ovaries are not visualized There are no adnexal masses seen in the scan. There is no free fluid in the cul de sac. Impressions: Enlarged anteverted uterus with thick and hyperechoic endometrium. Multiple uterine myoma, as described. Both ovaries not visualized. No adnexal masses seen in this scan. No cul de sac fluid. Radiographic Report Taken last August 26, 2012 The lung fields are clear. The trachea is in the midline. The heart is not enlarged. The pulmonary vessels are within normal limits. Both hemodiaphragms are distinct . The osseous thoracic cage reveals no significant bony abnormality. Conclusion: Negative Chest Electrocardiogram Taken last August 30, 2012 Impression: Sinus Rhythm with U waves.

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Surgical Management Abdominal hysterectomy is a surgical procedure that removes your uterus through an incision in your lower abdomen. Your uterus or womb is where a baby grows if you're pregnant. Sometimes a hysterectomy includes removal of one or both ovaries and fallopian tubes. Hysterectomy is one of the most common surgical procedures among women. Hysterectomy can also be performed through an incision in the vagina (vaginal hysterectomy) or by a laparoscopic or robotic surgical approach which uses laparoscopic instruments passed through small abdominal incisions. Abdominal hysterectomy may be recommended over other surgical approaches if you have a large uterus or if your doctor wants to check other pelvic organs for signs of disease. Hysterectomy may be needed if you have one of the following conditions:

Gynecologic cancer. If you have a gynecologic cancer such as cancer of the uterus or cervix a hysterectomy may be your best treatment option. Depending on the specific cancer you have and how advanced it is, your other options might include radiation or chemotherapy. Fibroids. Hysterectomy is the only certain, permanent solution for fibroids benign uterine tumors that often cause persistent bleeding, anemia, pelvic pain or bladder pressure. Nonsurgical treatments of fibroids are a possibility, depending on your discomfort level and tumor size. Many women with fibroids have minimal symptoms and require no treatment. Endometriosis. In endometriosis, the tissue lining the inside of your uterus (endometrium) grows outside the uterus on your ovaries, fallopian tubes, or other pelvic or abdominal organs. When medication or conservative surgery doesn't improve endometriosis, you might need a hysterectomy along with removal of your ovaries and fallopian tubes (bilateral salpingo-oophorectomy).

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Uterine prolapse. Descent of the uterus into your vagina can happen when the supporting ligaments and tissues weaken. Uterine prolapse can lead to urinary incontinence, pelvic pressure or difficulty with bowel movements. Hysterectomy may be necessary to achieve satisfactory repair of these conditions. Persistent vaginal bleeding. If your periods are heavy, irregular or prolonged each cycle, a hysterectomy may bring relief when the bleeding can't be controlled by other methods. Chronic pelvic pain. Occasionally, surgery is a necessary last resort for women who experience chronic pelvic pain that clearly arises in the uterus. However, hysterectomy provides no relief from many forms of pelvic pain, and an unnecessary hysterectomy creates new problems. Seek careful evaluation before proceeding with such major surgery.

Hysterectomy ends your ability to become pregnant. If you think you might want to become pregnant, ask your doctor about alternatives to this surgery. In the case of cancer, hysterectomy might be the only option. But other conditions including fibroids, endometriosis and uterine prolapse have alternative treatments that you can try first. During hysterectomy surgery, your surgeon might also perform a related procedure that removes your ovaries and fallopian tubes (bilateral salpingo-oophorectomy). You and your doctor will discuss ahead of time whether you should have this procedure done.

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B. Pharmacotherapeutics Table 5. Amlodipine

Drug Date Ordered: August 30, 2012 Generic Name: Amlodipine Brand Name: Norvasc Indication Hypertension Action Inhibits influx of calcium ion across cell membranes to produce relaxation of coronary vascular smooth muscle (dilation of coronary arteries), decrease peripheral vascular resistance of smooth muscle (decrease blood pressure) and increases myocardial oxygen delivery in patients with vasospastic angina. Side effect/Adverse Reaction CV: arrhythmia (including ventricular tachycardia and atrial fibrillation), bradycardia, chest pain, hypotension, tachycardia, postural dizziness, postural hypotension. CNS: paresthesia, tremor, vertigo. ANS: dry mouth, sweating increased GI: anorexia, constipation, dyspepsia, dysphagia, diarrhea, flatulence, pancreatitis, vomiting. Hemopoietic: leukopenia, purpura, thrombocyte-penia Nursing Consideration/Patient Teachings

Classificat-ion: Cardiovascular Agents | Calcium Channel Blocker

Dosage: 5mg/tab | O.D (am) with small sips of water PO

Monitor BP for therapeutic effectiveness. BP reduction is greatest after peak levels of amlodipine are achieved 69 hours following oral doses. Monitor for S&S of dose-related peripheral or facial edema that may not be accompanied by weight gain; rarely, severe edema may cause discontinuation of drug. Monitor BP with postural changes. Report postural hypotension. Monitor more frequently when additional antihypertensives or diuretics are added. Monitor heart rate; dose-related palpitations (more common in women) may occur. Report significant

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swelling of face or extremities. Report shortness of breath, palpitations, irregular heartbeat, nausea, or constipation to physician. Avoid getting up too fast from a sitting or lying position, or you may feel dizzy. Get up slowly and steady yourself to prevent a fall.

Table 6. Potassium Chloride

Drug Indication To prevent hypokalemia, prophylaxis during treatment w/ diuretics Action Replace potassium and maintain potassium level Side effect/Adverse Nursing Reaction Consideration/Patien t Teachings Arrhythmias, Heart Monitor renal block, function. after surgery, dont give drug Hypotension until urine flow is Cardiac arrest established Hyperkalemia tell patient to take drug with Respiratory or after meals paralysis with full glass of water of fruit juice to lessen GI Nausea and distress vomiting , abdominal pain

Date Ordered: August 29, 2012

Generic Name: Potassium Chloride Kalium Durule

Brand Name:

Classification: Electrolytes

23 Dosage: 2 tab TID PO

Table 7. Paracetamol Drug Indication Action Side effect/Adverse Reaction Paracetamol, when taken within the recommended dose and duration of treatment, has low incidence of side effects. Nursing Consideration/Pati ent Teachings Assess for pain. Store drug at temp. not exceeding 30C Assess for hepatotoxicit y Assess for allergic reaction Evaluate therapeutic response: reduced pain

Date Ordered: August 29, 2012

Generic Name: Paracetamol Brand Name: Biogesic

Produce analgesia by for the relief blocking pain impulses by of fever, inhibiting minor aches prostaglandin and pains synthesis in the CNS or of other substances that Contraindicat sensitize pain receptors to ions: stimulation. The Anemia, drug may relief cardiac and fever through pulmonary central action in disease. the hypothalamic Hepatic or heat regulating severe renal center. disease

Skin rashes and minor stomach and intestinal disturbances have been reported.

Classification: Analgesic

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Dosage: 500 mg Q6H PO

Table 8. Bisacodyl
Drug Indication Action Side effect/Adverse Reaction CNS: Date Ordered: August31, 2012 Treatment of constipation, colonic e evacuation prior to procedures of examination. Stimulates peristalsis by directly irritating the smooth muscles of the intestine, possibly the colonic intramuscular flexus, alters water and electrolyte secretions producing intestinal fluid accumulation and laxation. Muscle weakness GI: Nausea, vomiting, anorexia cramps, diarrhea, rectal burning(suppositories ) META: Protien- losing enterophathy, alkosis, hypokalemia, tetany, electrolyte, fluid imbalances. Nursing Consideration/Patient Teachings Administer tablets 2 hours prior, or 4 hours after antacids, increased PH may dissolve the enteric coating leading to GI distress do not crush enteric coated during product . ASSESS: Blood, urine electrolytes if drug is used as often by patient. I&O ratio to identify fluid loss. Cause of constipation; identify whether fluids, bulk, or exercise missing from

Generic Name: Bisacodyl Brand Name: Dulcolax Classification: Laxatives, Stimulant Dosage: 2 tabs BID PO

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lifestyle Cramping, rectal bleeding, nausea, vomiting; if these symptoms occur, drug should be disconnected.

Chapter 5 Nursing Management

Table 9. Nursing Care Plan Component Nursing Problems a. Ineffective airway clearance related to pain as evidenced by difficulty in breathing b. Hyperthermia related to increased metabolic rate 1. Biophysical Needs due to illness c. Risk for Constipation related to pain or discomfort
LOWER ORDER NEEDS

in abdominal area

a. Acute pain related to the disease process as 2.Psychophysical Needs evidenced by reports of pain and guarding behavior

HIGHER ORDER NEEDS

3. Psychosocial Needs a. Anxiety related to upcoming surgical intervention as evidenced by expression of concerns regarding

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actual and anticipated changes in life.

Biophysical Needs Table 10. Ineffective airway clearance

Nursing Diagnosis: Ineffective airway clearance related to pain as evidenced by difficulty in breathing Subjective cues: maglisod ko ug ginhawa as verbalized Objective cues: received patient lying on bed with PNSS iL regulated @ 30 gtts/minute infusing well @ right arm,weakness noted, guarding action noted, dyspnea, febrile with oxygen inhalation at bedside regulated @ 2-3 L/min attached via nasal prong Plan of Care: After 8 hours of systematic nursing interventions, the patient will be able to demonstrate improved ventilation and adequate oxygenation of tissues by ABGs within patients normal range. Nursing Interventions- Rationale Independent: Noted respiratory rate, depth, and ease of respirations. Respirations may be increased as a result of pain. (Doenges,2007) Maintained patent airway by positioning patient to semi-Fowlers position. To promote lung expansion. (Doenges,2007) Assisted patient with deep breathing exercises. Promotes maximal ventilation and oxygenation. (Doenges,2007) Promoted bed rest. Activities increases oxygen demands. (Doenges,2007) Administered supplemental oxygen via nasal prong as indicated. Maximizes available oxygen especially when ventilation is reduced by pain. (Doenges,2007) Administered medications as ordered. Reduce pain. (Doenges,2007) Monitored ABG readings. Decreasing PaO2 or increasing paCO2 may indicate

Collaborative:

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needs for ventilatory support. (Doenges, 2007)

Evaluation: After 8 hours of nursing interventions, the patient was able to demonstrate improved ventilation and adequate oxygenation of tissues by ABGs within patients

Table 11. Hyperthermia Nursing Diagnosis: Hyperthermia related to increased metabolic rate due to illness Subjective cues: Init ako pamati as verbalized Objective cues: received patient lying on bed with PNSS iL regulated @ 30 gtts/minute infusing well @ right arm,weakness noted, febrile with oxygen inhalation at bedside regulated @ 2-3 L/min attached via nasal prong PRN, warm to touch, flushed skin noted, with body temperature of 38.4 degrees Centigrade. Plan of Care: After 1 hour of systematic nursing interventions, the patient will be able to demonstrate temperature within normal range. Nursing Interventions- Rationale Independent: Monitored patient temperature. To obtain and monitor patient status. (Doenges, 2007) Monitored environmental temperature; limited or added linens as indicated. May help reduce fever .(Doenges,2007) Increased fluid intake to replace fluids and electrolytes. To support circulating volume and tissue perfusion. (Doenges,2007) Provided tepid sponge baths; avoid use of alcohol. Used to reduce fever by its central action on the hypothalamus (Doenges, 2007) Provided supplemental oxygen. To offset increased oxygen demands and consumption. (Doenges, 2007) Administered antipyretics as ordered .Used to reduce fever. (Doenges, 2007)

Collaborative:

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Evaluation: After 1 hour of nursing interventions, the patient will be able to maintain core temperature within normal range.

Table 12. Constipation Nursing Diagnosis: Risk for Constipation related to pain or discomfort in abdominal area. Subjective cues: dili kaayo kakalibang dri as verbalized. Objective cues: Received patient lying on bed with PNSS iL regulated @ 30 gtts/minute infusing well @ right arm; facial grimaces noted; guarded movements observed Plan of Care: After 4 hours of systematic nursing interventions, the patient will be able to maintain usual pattern of elimination. Nursing Interventions- Rationale Independent: Auscultated bowel sounds. To note for any abdominal distention. (Doenges,2007) Encouraged adequate fluid intake including fruit juices. Promotes softer stool; may aid in stimulating peristalsis. (Doenges,2007) Encouraged patient to ambulate. Helps stimulate intestinal function. (Doenges,2007) Administered medications as ordered. Promotes passage of stool. (Doenges, 2007) Evaluation: After 2 hours of nursing interventions, the patient was able to demonstrate normal elimination pattern.

Collaborative:

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Psychophysical Needs Table 13. Acute Pain

Nursing Diagnosis: Acute pain related to the disease process as evidenced by reports of pain and guarding behavior

Subjective cues: Sakit akoa pus.on as verbalized Objective cues: received patient lying on bed with PNSS iL regulated @ 30 gtts/minute infusing well @ right arm,weakness noted, guarding action noted, with oxygen inhalation at bedside regulated @ 2-3 L/min attached via nasal, facial grimaces noted; with pain score of 5 ( 0 as the lowest and 10 as the highest). Plan of Care: After 2 hours of systematic nursing interventions, the patient will be able to report maximal pain relief/control. Nursing Interventions- Rationale Independent: Determined pain history, e.g. location of pain, frequency, duration, and intensity (0-10 scale), and relief measures used. Information provides baseline data to evaluate need for effectiveness of interventions (Doenges,2007) Provided basic comfort measures (repositioning, backrub) and diversional activities (e.g. music, television). Promotes relaxation and helps refocus attention.(Doenges, 2007). Encouraged use of stress management skills (e.g. relaxation techniques, visualization, guided imagery), laughter, music, and therapeutic touch. Enables patient to participate actively in nondrug treatment of pain and enhances sense of control. (Doenges, 2007). Evaluated pain relief/control at regular intervals. Goal is maximum pain control.

(Doenges, 2007) Collaborative: Adjusted medication regimen as necessary. An organized plan beginning with the simplest dosage schedules and least invasive modalities improves chance for pain control (Doenges,2007)

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Evaluation: After 2 hours of nursing interventions, the patient verbalized methods that caused alleviation of pain and facial grimacing has decreased.

Psychosocial Needs Table 14. Anxiety Nursing Diagnosis: Anxiety related to upcoming surgical intervention as evidenced by expression of concerns regarding actual and anticipated changes in life. Subjective cues: kuyawan man ko sa ako operasyon as verbalized. Objective cues: received patient lying on bed with PNSS iL regulated @ 30 gtts/minute infusing well @ right arm,weakness noted, weight loss noted, tension noted Plan of Care: After 4 hours of systematic nursing interventions, the patient will be able patient will be able to acknowledge and discuss concerns. Nursing Interventions- Rationale Independent: Ascertained what information patient has about diagnosis, expected surgical intervention. Provides knowledge base for the nurse to enable reinforcement of needed information and helps to identify patient with anxiety. (Doenges,2007) Explained purpose and preparation for the surgical procedure. Clear understandings about the operation. (Doenges,2007) Provided an atmosphere of concern, openness, and availability. Time and privacy are needed to discuss feelings of anticipated loss and otehr concerns. (Doenges,2007) Encouraged questions and provide time for expression of fears. Provide opportunity to identify and clarify misconceptions and offer emotional

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support. (Doenges, 2007)

Evaluation: After 4 hours of nursing interventions, the patient was able to acknowledge and discuss concerns.

A. Discharge Plan A case of Mrs. L.L., female, married, 43 years old, Filipino, Roman Catholic, born last April 8, 1969 in Pulang-bato, Pit-os Talamban, Cebu City, Cebu. Patient was admitted at Vicente Sotto Memorial Medical Center (VSMMC) for the third time last August 26, 2012 at 2:56pm for complaints of abdominal pain and difficulty in breathing. Patient was brought to Ward 6 (Female Ward) on the same day and was placed in bed 26. Patient was diagnosed with Multiple Uterine Myoma SP Myemectomy 2x (2003,2007). Proposed operation was Total Abdominal Hysterectomy (TAH). Medication Instructed patient to take medications as indicated at home, Amlodipine 10 mg itab PO with small sips of water once a day Kalium durule iitabs PO TID Bisacodyl Dulcolax iitabs BID PO Paracetamol 500 mg itab PO for fever and pain, Environment Instrucedt patients relative to provide the patient an environment conducive for her easy recovery. Her place/room in their house must be the most accessible area.

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Her environment should be free from contamination and infection. Treatment The patient should follow the physicians prescription and should take her home medication on the right time and right dose. Health Teaching Instrucedt the patient the importance of proper taking of medication on time. Instructed the patient and her family the proper wound care to avoid contamination and infection at surgical site. Instructed the patient to eat nutritious foods. Foods that are rich in iron and vitamin C. Encouraged ambulation for early recovery. Good sanitation is advised. Out Patient Department The patient should return on the scheduled date of her follow up check-up. Instructed patient that she should continuously take her home medication as prescribed by her physician. The patient should visit her physician whenever she feels any discomfort. Diet Diet as Tolerated. Eat foods that are rich in iron like liver and foods rich in Vit.C for faster wound healing. In order to attain proper diet, the patient should be guided to the prescribed foods as advised by her physician. Her meals should include Vitamin C-rich foods for wound healing. Eat foods that are high in potassium, low salt and low fat diet. Spiritual

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Patient should enhance her spiritual relationship with God. Have faith and trust in Gods divine power, and believe that the Lord will help in her early recovery.

Chapter 6 Conclusion and Recommendations Conclusion After going through this case study, the researcher concludes that caring is integral to nursing, especially in dealing with patient who need curative and supportive care. The theory encompasses many aspects of the human being in providing nursing care by utilizing the Ten Carative Factors which are the core ideas of the theory. It covers the totality of the patient and uplifts the dignity of the patient by recognizing and accepting her as a unique individual with unique needs, patterning the nursing interventions according to her needs and instilling care by using the Ten Carative factors in every intervention rendered. Recommendations The researcher recommends the application of the Ten Carative Factors of Jean Watson in the clinical practice especially in caring for patients who require curative and supportive care. The researcher recommends integration of the theory in the curriculum to the students as it would inculcate values and help them develop the caring attitude which is essential when they will be dealing with patients.

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This could be used as a tool for reference since the application of Ten Carative Factors of Jean Watsons Theory of Caring is not limited to these patients but the researcher would recommend the use of the theory for a wide variety of patients.

Bibliography Books Doenges, Marilynn E., et al.2007.Nursing Care Plans Guidelines for Individualizing Patient Care. F. A. Davis Company.Philadelphia. Doenges, Marilynn E., et al.2004.Nurses Pocket Guide.9th Edition. F.A. Davis Company.Philadelphia. George, Julia B. 2002. Nursing Theories: The Base for Professional Nursing Practice. 5th edition. Pearson Education, Inc. Hodgson, B. Et al. 2006.Saunders Nursing Drug Handbook. Tampa, Florida. Elsevier Saunders. Luckmann, J.1997.Saunders Manual of Nursing Care. Philadelphia.W.B. Saunders Company. Marieb, Elaine N. 2003. Essentials of Human Anatomy and Physiology,7th edition. Pearson Education, Inc. Layug, Ma. Estela. 2009. Comprehensive Reviewer for the Nurse Licensure ExamMaternal and Child Health Nursing. C & E Publishing, Inc. Sandra, Nettina.2005.Manual of Nursing Practice. 8th Edition.Lippincott Williams & Wilkins.Philadelphia. Smeltzer, Suzanne C.2004.Textbook of Medical-Surgical Nursing.10thEdition. Lippincott Williams and Wilkins, 530 Walnut Street, Philadelphia PA 19106.

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Pillitteri, Adele B. 2007. Maternal and Child Health Nursing. Lippincott Williams and Wilkins Timby, Barbara K. & Smith, Nancy E.2005. Introductory Medical-Surgical Nursing.8th Edition.J.B. Lippincott Company.New York.page 518. Internet Sources Insightec. 2012.cGuided Image Acoustic Surgery for Uterine Fibroids. Rich, Klasco. 2011. Medical Reviewer: Uterine Myoma. Health Grades, Inc. Healthgrade. 2011. Uterine Myoma and its Signs and Symptoms. Merit Medical Systems, Inc. Unpublished Materials Basubas, C. G. 2010.Watsons theory of human caring in the care of a patient with acute lymphocytic leukemia.Cebu City,Cebu Normal University Homecillo, C. 2009.Watsons theory in the care of a patient with diabetes mellitus type 2.Cebu City,Cebu Normal University

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APPENDICES A. Transmittal Letter

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B. Record of Attendance

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C. Maternal Assessment Form Name of Student: Name of Clinical Instructor: Clinical Assignment: Inclusive Dates:

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GENERAL ADMISSION INFORMATION Physical Appearance: _________________________________________________________________

____________________________________________________________________ ________________ Content of Conversation: _____________________________________________________________ ____________________________________________________________________ ________________ Social Economic History a. Native Language: b. Occupation: c. Financial Status (what is the impact of current hospitalization): d. Civil Status: Married_____ Single_____ Divorced______ Widowed ______ e. Living Situation: Lives Alone _______________________________________________________ Living with other (specify) _____________________________________________ Past Medical History a. Medical: b. Surgical: c. Medications: d. Traumatic Injuries:

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e. Orthopedic: f. Other (psychiatric, etc.): g. Habits: Smoking:______________________ Alcohol:________________________ PREGNANCY INFORMATION 1. Is this your first baby? ___ Yes ___ No 2. How many children do you have? 3. How many times have you been pregnant? 4. Have you been to the prenatal clinic/seen a doctor for pregnancy care? __Yes __No If yes, which health clinic? __________________ which unit? _______________ 5. How did you feel about being pregnant when you first found out? (For example: pleased, not sure, upset?) How do you feel about it now? ________________________________________________________________ ___________ 6. Have you had any illness or complications prior to pregnancies/deliveries? __Yes__No Explain: _______________________________________________________________

PHYSICAL ASSESSMENT

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NURSING REVIEW OF SYSTEMS (circle the appropriate symptoms) 1. EENT: Headaches Hearing loss Visions Diplopia Eye pain Eye infection Blurring Epistaxis Sinus pain Facial pain Bleeding gums Dentures Sore throat Nasal-tracheal pain Other ______________________________ 2. CARDIO-RESPIRATORY: Chest pain (site) __________________________________________________ Chest pain with exertion Dyspnea on exertion Nocturnal dyspnea Edema Hypertension Palpation Known murmur Cough Sputum Hemoptysis Pleuritic pain Diaphoresis Last X-ray: EKG: 3. GASTRO-INTESTINAL Thirst Nausea Vomiting Hematemesis Heartburn Difficulty in swallowing Flatulence Constipation Abdominal pain Jaundice Diarrhea Tarry stool Hemorrhoids Hernia Others_________________________ 4. GENITO-URINARY: Dysuria Polyuria Frequency Urgency Nocturia Burning Hematuria Stones Female Genital Tract Menstrual History: Age of Onset: ___________________________ Frequency ____________ Regularity __________________ Duration___________________ Post menopausal bleeding ______________________________________________________ Age _____________ Symptoms _________________________________________________ 5. MUSCULO-SKELETAL: Muscle pain Extremity pain Joint pain Back pain Joint swelling Neck pain Stiffness Limited motion Redness Sprains Deformity

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Other___________________________________________________________________ ___________ 6. NERVOUS : Convulsions Syncope Dizziness Vertigo Tremor Speech Difficulty Limp paralysis Peresthesia Muscle atrophy Muscle tenderness EEG____________________________________________________________________ __________ 7. ENDOCRINE Goiter Tremor Heat or Cold intolerance Exopthalmos Voice Change Polydipsia Change in body contour Infertility Others____________________________________

SOCIAL SUPPORT Describe the kind of support client gets from family: ______________________________________________________________ ________________ ______________________________________________________________ ________________

____________________________
Signature of Student

________________________________ Signature of Clinical Instructor

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D.Anatomy and Physiology

The uterus, also called womb, is an inverted pear-shaped muscular organ of the female reproductive system, located between the bladder and rectum. It functions to nourish and house the fertilized egg until the unborn child, or offspring, is ready to be delivered. The uterus has four major regions: the fundus is the broad, curved upper area in which the fallopian tubes connect to the uterus; the body, the main part of the uterus, starts directly below the level of the fallopian tubes and continues downward until the uterine walls and cavity begin to narrow; the isthmus is the lower, narrow neck region; and the lowest section, the cervix, extends downward from the isthmus until it opens into the vagina. The uterus is 6 to 8 cm (2.4 to 3.1 inches) long; its wall thickness is

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approximately 2 to 3 cm (0.8 to 1.2 inches). The width of the organ varies; it is generally about 6 cm wide at the fundus and only half this distance at the isthmus. The uterine cavity opens into the vaginal cavity, and the two make up what is commonly known as the birth canal. Lining the uterine cavity is a moist mucous membrane known as the endometrium. The lining changes in thickness during the menstrual cycle, being thickest during the period of egg release from the ovaries. If the egg is fertilized, it attaches to the thick endometrial wall of the uterus and begins developing. If the egg is unfertilized, the endometrial wall sheds its outer layer of cells; the egg and excess tissue are then passed from the body during menstrual bleeding. The endometrium also produces secretions that help keep both the egg and the sperm cells alive. The components of the endometrial fluid include water, iron, potassium, sodium, chloride, glucose (a sugar), and proteins. Glucose is a nutrient to the reproductive cells, while proteins aid with implantation of the fertilized egg. The other constituents provide a suitable environment for the egg and sperm cells. The uterine wall is made up of three layers of muscle tissue. The muscle fibers run longitudinally, circularly, and obliquely, entwined between connective tissue of blood vessels, elastic fibers, and collagen fibers. This strong muscle wall expands and becomes thinner as a child develops inside the uterus. After birth, the expanded uterus returns to its normal size in about six to eight weeks; its dimensions, however, are about 1 cm (0.4 inch) larger in all directions than before childbearing. The uterus is also slightly heavier and the uterine cavity remains larger. The uterus of a female child is small until puberty, when it rapidly grows to its adult size and shape. After menopause, when the female is no longer capable of having children, the uterus becomes smaller, more fibrous, and paler. Some afflictions that may affect the uterus include infections; benign and malignant tumors; malformations, such as a double uterus; and prolapse, in which part of the uterus becomes displaced and protrudes from the vaginal opening.

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E.Nurses Notes Table 15. Hyperthermia Nurses Progress Notes F Focus D Data A Action R Response Hyperthermia D - Init ako pamati as verbalized, received patient lying on bed with PNSS iL regulated @ 30 gtts/minute infusing well @ right arm,weakness noted, febrile with oxygen inhalation at bedside regulated @ 2-3 L/min attached via nasal prong PRN, warm to touch, flushed skin noted, with body temperature of 38.4 degrees Centigrade. A Vital signs taken and charted, monitored environmental temperature; limited or added linens as indicated, increased fluid intake to replace fluids and electrolytes, provided tepid sponge baths; avoid use of alcohol, provided supplemental oxygen, administered antipyretics as ordered. R - Patient was able to maintain core temperature within normal range. Temperature decreases from 38.4 degrees Centigrade down to 37. 5 degrees Centigrade

Date and Time September 01, 2012 2PM10 PM

Table 16. Acute pain

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Date and Time September 02, 2012 6 am 2 pm

Nurses Progress Notes F Focus D Data A Action R Response Acute pain D - Sakit akoa pus.on as verbalized, received patient lying on bed with PNSS iL regulated @ 30 gtts/minute infusing well @ right arm,weakness noted, guarding action noted, with oxygen inhalation at bedside regulated @ 2-3 L/min attached via nasal, facial grimaces noted; with pain score of 5 ( 0 as the lowest and 10 as the highest). A Vital signs taken and charted, determined pain history, e.g. location of pain, frequency, duration, and intensity (0-10 scale), and relief measures used, provided basic comfort measures (repositioning, backrub) and diversional activities (e.g. music, television), encouraged use of stress management skills (e.g. relaxation techniques, visualization, guided imagery), laughter, music, and therapeutic touch, evaluated pain relief/control at regular intervals, developed individualized pain management plan with the patient and physician, administered analgesics as ordered by the physician. R - the patient verbalized methods that caused alleviation of pain and facial grimacing has decreased.

Table 17. Anxiety

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Date and Time September 03, 2012 6 am 2 pm

Nurses Progress Notes F Focus D Data A Action R Response D - kuyawan man ko sa ako operasyon as verbalized, received patient lying on bed with PNSS iL Anxiety regulated @ 30 gtts/minute infusing well @ right arm,weakness noted, weight loss noted, tension noted D Monitored vital signs and charted, ascertained what information patient has about diagnosis and expected surgical intervention, explained purpose and preparation for the surgical procedure, provided an atmosphere of concern, openness, and availability, encouraged questions and provide time for expression of fears. R - Patient was able to acknowledge and discuss concerns on the upcoming surgery.

F.Curriculum Vitae

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NINALYN P. ESCOTON 406 Fuentes Street, Cogon East, Carmen, Cebu Philippines 6005

PERSONAL BACKGROUND Profession Date of Birth Place of Birth Religion Mother Father : : : : : : Registered Nurse February 01, 1987 Cogon East, Carmen, Cebu Roman Catholic Maria Victoria P. Escoton Flaviano G. Escoton

EDUCATIONAL BACKGROUND

COLLEGE

Colegio de San Antonio de Padua Ramon M. Durano Foundation Compound, Guinsay, Danao City Cebu, Philippines 6004

Degree :

Bachelor of Science in Nursing (BSN) Graduated: March 2008

SECONDARY

:Carmen Christian School Incorporated Dawis Norte, Carmen, Cebu Graduated: April 2004

PRIMARY

Carmen Central School

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Cangyan Heights, Poblacion, Carmen, Cebu Graduated: March 2000

CERTIFICATIONS / LICENSURES Passed the Philippine Nurses Licensure Examination Cebu City, Philippines November 2008 Civil Service Commission Cebu City, Philippines April 2008 Intravenous Therapist Nurse ANSAP Cebu Chapter July 2009

WORK EXPERIENCE ESL Instructor Cebu International Academy Danao, City July 2008 February 2009 Volunteer Staff Nurse Cebu Provincial Hospital March 2009 June 2009

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Clinical Instructor Colegio de San Antonio de Padua Guinsay, Danao City June 15, 2009 - Present

PROFESSIONAL ORGANIZATIONS Member - Philippine Nurses Association (PNA) Member Mother and Child Nurses Association of the Philippines (MCNAP)