G RLE B

Arao, Sheila PRESENTS

R Buguina,
Kathlene
O Collera, Diane
College of Health and Allied

U Mabunga, Ailyn
University of Saint Louis

Pasiola,
P Joanna Carla
Romero, Janine
B Pamittan, Mc
Nilo
Tuguegarao

A Case Presentation
Sciences

January 25, 2010 in

Ovarian Cysts
 Introduction Laboratory Examinations

Statistics
Anatomy and Physiology

Patient’s Profile
Pathophysiology

Patient’s History
Drug Study

Gordon’s Functional Patterns

Nursing Care Plan

Physical Assessment Discharge

 OBJECTIVES
GENERAL OBJECTIVE :
 
This case will be presented in order
for us to have a comprehensive knowledge
of Dermoid ovarian cyst and correlate the
importance of effective nursing care plan
in dealing with the manifestations of the
disease, preventing further complications
of the said disease and to apply all
concepts and theories we have learned in
school, improving our skills and putting
them into practice with the appropriate
attitude of a health care provider and
for future reference.
 OBJECTIVES
SPECIFIC OBJECTIVES :
At the end of the case
presentation, both the presenters and
the audience will be able to: 

ØTo define Ovarian Cyst

 
ØTo determine the signs and symptoms of the
disease manifested by the patient.
 
ØTo trace and review the pathophysiology of
Dermoid Ovarian Cyst
v
 OBJECTIVES
ØTo review the anatomy and physiology of
the affected systems
 
ØTo identify the appropriate nursing
care plan in providing quality health
care to the patient
 
ØTo know the drugs being used, its
actions, contraindications, adverse
effects & nursing responsibilities of
the prescribed
 
ØTo know the laboratory findings
performed with corresponding clinical
analysis
 INTRODUCTION
OVARIAN CYSTS (DERMOID)

vIs a sac filled with liquid or semi-

liquid material arising in an ovary.
vIt is very common, particularly in child
bearing years ( 15-40 ). They may be single
or multiple, and can occur in one or both
ovaries. Most are benign, but
approximately 15 percent are malignant
(cancerous).
vNORMAL = During ovulation the ovary
produces a hormone to make the follicles
grow and the eggs within it mature. Once
the egg is ready, the follicle ruptures
and the egg is released. Once the egg is
released, the follicle changes into a
smaller sac called the corpus luteum.
vABNORMAL = Ovarian cysts occur as a
result of the follicle not rupturing,
the follicle not changing into its
smaller size, or doing the rupturing
itself.
 Five common types of ovarian cyst:
1 . Functional Cysts
ØBoth of these types of functional cysts
develop as part of the natural function of
the ovary.
ØFollicle Cyst . This cyst occurs during
ovulation when an egg is released into the
fallopian tube or when a developing follicle
fails to rupture. These cysts grow from 1½
inches to 2 inches in diameter, and will
usually dissolve within one to three months.
ØCorpus Luteum Cyst . This cyst is caused
by a malfunction of the corpus luteum. Unless
a woman is pregnant, the corpus luteum
disintegrates. But in the formation of a
corpus luteum cyst, it fills with fluid and
remains in the ovary.
2 . Polycystic Ovaries
ØPolycystic ovaries is a
condition in which the follicles
never erupt from the ovaries.
ØUnder normal circumstances,
follicles grow, mature, and rise to
the surface of the ovary, where they
burst and release an egg to the
Fallopian tube, a process controlled
by pituitary hormones. The remnants
of the burst follicle then begin to
produce progesterone, which
stimulates the lining of the uterus
(endometrium) to grow thicker in case
it needs to support a fertilized egg.
The effect on the pituitary of an
increase in progesterone production
is to signal it to stop stimulating
 In polycystic ovaries, the follicles
grow just under the ovaries' surface, and
are produced again and again because the
pituitary has not been signaled to shut
off. Both ovaries become filled with tiny
cysts and can become enlarged
 3 . Endometrial Cysts
ØEndometrial cysts (also known as
endometriomas or "chocolate cysts"-filled with
dark blood) form as a result of endometriosis.
Endometriosis is a disease in which the
endometrial tissue normally found in the
uterus grows in other areas. After successive
menstrual cycles, this misplaced endometrial
tissue bleed, gradually forming endometrial
cysts. Over time the cysts grow and can become
as large as a grapefruit.
4 . Cystadenomas
Cystadenomas are known as neoplasms (new
growths). Ovarian neoplasms are new and
abnormal formations that develop from the
ovarian tissue.

Two types of Cystadenomas:

ØSerous cystadenoma is filled with a
thin watery fluid and can grow to be
between 2 inches to 6 inches in
diameter.
ØMucinous cystadenoma is filled with
a sticky, thick gelatinous material and
can grow to be between 6 inches to 12
inches in diameter. There have been rare
cases where the cyst measured 40 inches
in diameter and weighed over 100 pounds.
5 . Dermoid Cysts

ØDermoid cysts are also known as

ovarian neoplasms and consist of
skin or related tissue such as
hair, teeth or bone instead of
fluid like the cystadenomas.
Dermoid cysts develop from the
ovary's germ cells (cells that
produce the egg and the
beginnings of all human tissues).
Dermoid cysts may be present at
birth but are not noticed until
adulthood. They generally measure
between 2 inches to 4 inches in
diameter.
Reason for visit :

ØDiscomfort & pain in the lower

abdomen
ØDiscomfort with intercourse
ØDifficult bowel movements
ØFrequent micturation
ØIrregularity of the menstrual cycle
ØAbnormal vaginal bleeding
ØEarly onset of menarche
ØAbdominal fullness or bloating
ØIndigestion
ØHeartburn
ØInfertility
ØOligomenorrhea
ØObesity
 Symptoms of ovarian
cyst
TYPE OF OVARIAN :
CYST SYMPTOMS
All types of ovarian cyst -Intense abdominal pain
Functional cyst - Menstrual changes such as late periods,
bleeding between periods or irregular
periods
Polycystic ovaries - Infertility
- Heavy menstrual flow
- Menstrual changes such as late periods,
bleeding between periods or irregular
periods
- Weight gain
Endometrial cyst - Pain with sexual intercourse
- Pain during bowel movement
- Severe menstrual cramps
- Internal bleeding
- Infertility
- Weight gain
Cystadenoma -abdominal or back pain, vomiting/nausea,
weight loss
Dermoid cyst -asymptomatic
Treatment of Ovarian
Cysts
•Treatment depends on
many factors, including
the type of cyst, its
size, its location, the
type of material it
contains and the woman's
age.
 For functional cysts a "watch and wait" approach is
taken. Functional cysts tend to dissolve over time and
treatment is not needed. The doctors require the woman to
return after two menstrual cycles to get a pelvic exam and/or
ultrasound again. If the cyst is still present and growing
(over 2 inches) the doctor may recommend a laparoscopy to
remove the cyst. If the cyst comes and goes, the doctor may
prescribe birth control pills. These pills reduce the hormones
that promote growth of cysts and prevent formation of large
cysts.
For polycystic ovaries the treatment varies. A major
symptom of polycystic ovaries is infertility, and whether the
woman is trying to conceive or not determines the treatment. If
the woman is trying to conceive and having fertility problems,
the doctor will prescribe Clomid which helps stimulate
ovulation. If the woman is not trying to conceive and is having
infrequent or no periods, the doctor will prescribe Provera.
Provera restores normal menstrual flows.
 For endometrial cysts, cystadenomas and
dermoid cysts the treatment is to surgically remove
the cyst. If the cyst is small enough the doctor can
remove it via laparoscopy. If the cyst is over 2 ½
inches in diameter the available procedures are:
•Ovarian cystectomy - removal of cyst
•Partial oophorectomy - removal of the cyst and a
portion of the ovary
•Salpingo-oophorectomy - removal of the cyst,
ovary and fallopian tube. This procedure is done
dependent upon the size of the cyst and complications
encountered such as bleeding, rupturing and twisting
of the cyst.
•Total abdominal hysterectomy with bilateral
salpingo-oophorectomy - removal of the cyst, ovaries,
fallopian tubes and uterus. This procedure is rarely
used unless the cyst is cancerous.
Prevention
•Improve the quality of your diet.
•Increase your exercise.
•Control chronic stress.
•Use bio-identical hormones, supplements and herbs to help
balance your hormonal system.
•Current use of oral contraceptive pills protects
against the development of functional ovarian cysts.
Current and previous use within 15 years reduces
the risk of epithelial ovarian cystadenocarcinoma.
•All women should undergo an annual gynecologic
examination. No generalized screening test is
available for ovarian cystadenocarcinoma, but women
at high risk based on family history or previous
history of breast cancer should undergo an annual
ultrasonographic examination and CA125 test.
Referral for genetic counseling should be
considered.
•Women at high risk for ovarian cystadenocarcinoma
may be offered prophylactic oophorectomy, which will
prevent the development of ovarian cancer but not
peritoneal carcinoma.
Diagnostic tests
Pelvic examination
-Internal vaginal examination.
•In a pelvic exam, the doctor checks the
uterus, vagina, ovaries, fallopian tubes,
bladder, and rectum for any changes in
their shape or size. During a pelvic exam,
an instrument called a speculum is used to
widen the vagina so that the upper part of
the vagina and the cervix can be seen.
re to the patient. Instruct the patient to empty the bladde
Ultrasound
•A transvaginal ultrasound is sound wave
technology to visualize the woman's reproductive
organs (ovaries, cervix, vagina, uterus); the sound
wave transducer is inserted through the vagina to
see these organs, and can also be used to assess
the fetus and the fetal heart rate.
•This is the primary imaging tool for a patient
considered to have an ovarian cyst
•Nursing responsibility: explain the purpose &
procedure to the patient.
Laparoscopy
•Laparoscopy is a procedure to visualize the
abdominal and pelvic areas using a laparoscope, an
instrument that is inserted through a cut in the belly
area.
Nursing responsibility : explain the
procedure to the patient. Instruct the patient
not to eat/drink anything after midnight or the
night before the procedure. If medications are
taken in the morning, check with the doctor on
whether to take them with a sip of water, take
without water or skip the dose.

Laparotomy
•A surgical incision made in the wall of the
abdomen to gain access in abdominal cavity
CT scan
•A computed tomography (CT) scan is an imaging
method that uses x-rays to create cross-sectional
pictures of the body.
•CT san allows examination of the abdominal
contents & retroperitoneum in cases of malignant
ovarian cyst.
CT scan, wear loose clothing & remove all metals. Explain that he/she wi
ies & other accessories should be removed because they can interfere wit
Doppler flow studies
These studies can help identify blood flow within a
cyst wall & adjacent areas, including tumor surface,
septa, solid parts within the tumor. The principle is
that new vessels within tumors have lower
resistance to blood flow because they lack
developed smooth muscles in the walls. This can
be quantitated into a resistive or pulsatility index
Other imaging
•CT scanning aids in assessing the extent of the condition. MRI
scanning may also be used to clarify results of an ultrasound.

Serum CA-125 assay

•This blood test checks for a substance called CA-125(Cancer antigen
125 -is a protein expressed on the cell membrane of normal ovarian
tissue and ovarian carcinomas), which is associated with
ovarian cancer. This test is used in the assessment of epithelial ovarian
cancer and may help determine if an ovarian mass is harmless or
cancerous. However, sometimes benign conditions may result in the
elevated levels of CA-125 in the blood, so the test does not positively
establish the diagnosis of ovarian cancer.
•CA-125 is used to monitor therapy during treatment for ovarian
cancer. It is also used to detect whether cancer has come back
after treatment is complete. This test is sometimes used to
follow high-risk women who have a family history of ovarian
cancer but who do not yet have the disease. CA-125 testing has
been shown to help detect certain ovarian cancers at an earlier
stage.
Hormone levels
•A blood test to check LH, FSH, estradiol,
and testosterone levels may indicate potential
problems concerning these hormone levels.

Pregnancy testing
•The treatment of ovarian cysts is different
for a pregnant woman than it is for a non-
pregnant woman. An ectopic pregnancy
(pregnancy outside the uterus) must be ruled
out because some of the symptoms of ectopic
pregnancy may be similar to those of ovarian
cysts.
he uterine cervix.
in the cul-de-sac. This test may also be done when the doctor suspects a

it for a short time before the test is done. Inform that she/he may have a
Complications
•Ovarian torsion : Sometimes, there is also twisting of the
ovary, which can lead to infertility. Ovarian torsion may
disturb blood supply to the ovary as well. This leads to
another complication called as ovarian necrosis, which leads
inflammation and septic shock
•Ruptured ovarian cyst : This is one the most serious form
of complication. Ruptured ovarian cyst can lead to internal
bleeding and in some cases it can be very dangerous. Ruptured
ovarian cyst can cause hemorrhage, which requires immediate
medical attention.
•Abdominal Hemorrhage
•Malignant change : The potential of benign ovarian
cystadenomas to become malignant has been postulated but, to
date, remains unproven. Malignant change can occur in a small
percentage of dermoid cysts and endometriomas.
•Peritonitis: Pertitonitisis the inflammation of the mucus
membrane. As this membrane lines the abdomen cavity, it can
cause excruciating pain and in some cases the resulting
complications can be life threatening.
•Infertility : Infertility caused by ovarian cysts can be
temporary or permanent depending upon the extent of the
damage.
 Dermoid cyst is a cystic teratoma that contains
developmentally mature skin complete with hair follicles
and sweat glands, sometimes luxuriant clumps of long hair
, and often pockets of sebum, blood, fat, bone, nails,
teeth, eyes, cartilage, and thyroid tissue. Because it
contains mature tissue, a dermoid cyst is almost always
benign.
•Dermoid ovarian cysts do not affect the fertility of
the women.
•Dermoid cyst is non cancerous and is usually harmless.
•Sometimes, irregular menstruation can also signal
possible case of dermoid ovarian cysts.
•Dermoid cyst on ovaries is asymptomatic
•It is only when the dermoid cyst on ovaries ruptures or
twists in itself that it will cause severe pain;
otherwise, the woman would feel that nothing is wrong and
would continue on with her current activities like
normal.
•Dermoid ovarian cysts can cause women to get irregular
menstruation, severe pain, gain in weight and be visited by other
problems.
Signs & Symptoms of Dermoid cyst:
•Majority of Dermoid Cyst are asymptomatic-rarely any
symptoms until they become large
•Pain or discomfort in the lower abdomen
•Discomfort with intercourse particularly deep penetration
•Difficulty of bowel movements
•Frequent micturation due to pressure on the bladder
•Irregularity of menstrual cycle & abnormal vaginal
bleeding may occur.
•Abdominal fullness & bloating.
•Indigestion, heartburn, or early satiety.
•Vomiting, irregular menstruation, abnormal laboratory
values, pain during menstruation.
Risk factors
•Irregular menstrual cycles
•History of previous ovarian cysts
•Increased upper body fat distribution
•Early menstruation (11 years or younger)
•Infertility
•Hypothyroidism or hormonal imbalance
Diagnostic Exams and Tests
Determine if a woman has an ovarian cyst or to help
characterize the type of cyst that is present:
•Endovaginal ultrasound: This type of imaging test is a special
form of ultrasound developed to examine the pelvic organs and is
the best test for diagnosing an ovarian cyst. A cyst can be
diagnosed based on its appearance on the ultrasound.
•An endovaginal ultrasound is a painless procedure that resembles
a pelvic exam. A thin, covered wand or probe is placed into the
vagina, and the examiner directs the probe toward the uterus and
ovaries.
•This type of ultrasound produces a better image than a scan
through the abdominal wall can because the probe can be
positioned closer to the ovaries.
•Using an endovaginal ultrasound, the internal cystic structure
may be categorized as simple (just fluid filled), complex (with
areas of fluid mixed with solid material), or completely solid (with
no obvious fluid).
•Other imaging: CT scanning aids in assessing the extent of the condition. MRI
scanning may also be used to clarify results of an ultrasound.
•Laparoscopic surgery: The surgeon fills a woman's abdomen with a gas and
makes small incisions through which a thin scope (laparoscope) can pass into the
abdomen. The surgeon identifies the cyst through the scope and may remove the
cyst or take a biopsy from it.
•Serum CA-125 assay: This blood test checks for a substance called CA-125
(Cancer antigen 125 -is a protein expressed on the cell membrane of normal ovarian
tissue and ovarian carcinomas), which is associated with ovarian cancer. This test is
used in the assessment of epithelial ovarian cancer and may help determine if an
ovarian mass is harmless or cancerous. However, sometimes benign conditions may
result in the elevated levels of CA-125 in the blood, so the test does not positively
establish the diagnosis of ovarian cancer.
•Hormone levels: A blood test to check LH, FSH, estradiol, and testosterone levels
may indicate potential problems concerning these hormone levels.
•Pregnancy testing: The treatment of ovarian cysts is different for a pregnant
woman than it is for a non-pregnant woman. An ectopic pregnancy (pregnancy
outside the uterus) must be ruled out because some of the symptoms of ectopic
pregnancy may be similar to those of ovarian cysts.
•Culdocentesis: This test involves taking a fluid sample from the pelvis with a
needle inserted through the vaginal wall behind the uterine cervix.
 Treatment
Medical Care
•Many patients with simple dermoid ovarian cysts based
on ultrasonographic findings do not require treatment.
•In a postmenopausal patient, a persistent simple cyst
smaller than 5 cm in dimension in the presence of a
normal CA125 value may be monitored with serial
ultrasonography examinations. Some evidence suggests that
cysts up to 10 cm can be safely followed in this way.
•Premenopausal women with asymptomatic simple cysts
smaller than 8 cm on sonograms in whom the CA125 value
is within the reference range may be monitored with a
repeat ultrasonographic examination in 8-12 weeks.
Hormone therapy, including the use of the oral
contraceptive pill, is not helpful in causing resolution.
 Surgical Care
•Persistent simple ovarian cysts larger than 5-10 cm, especially
if symptomatic, and complex ovarian cysts should be considered for
surgical removal.
•The surgical approaches include an open incisional technique
(laparotomy) and a minimally invasive technique (laparoscopy) with
very small incisions. Whichever route is used, the goals remain the
same and include the following: 
•To confirm the diagnosis of an ovarian cyst
•To assess whether the cyst appears to be malignant
•To obtain fluid from peritoneal washings for cytologic
assessment
•To remove the entire cyst intact for pathologic analysis
(This may mean removing the entire ovary.)
•To assess the opposite ovary and other abdominal organs
•To perform additional surgery as indicated
•Laparoscopy is preferred to laparotomy when indicated because
it has less adverse effects for the patient and leads to faster
recovery. However, it is essential that the disease outcome for the
patient is not inferior to that achieved with laparotomy.
•Some patients, including those with chronic lung disease who
are unable to tolerate a high intra-abdominal pressure or a steep
head-down position, are unsuitable for laparoscopy. Others are
unsuitable because of previous surgeries causing severe adhesions.
For many situations the most important factor is the skill and
experience of the surgeon.
•With benign cysts there is no absolute contraindication
to the use of laparoscopy. Such patients include those
considered to have a dermoid cyst or endometrioma, those
with functional or simple cysts that are causing symptoms
and have not resolved with conservative management, and
those presenting with acute symptoms. Although the aim
should be to remove all cysts intact, if this is not
possible the cyst and/or affected ovary may be placed in a
protective bag that allows the cyst to be ruptured and
drained without contamination prior to removal.
•Malignant ovarian cysts associated with widespread
disease are usually managed by laparotomy.
•Some controversy surrounds the surgical approach for
very large benign-appearing ovarian cysts. The traditional
approach for both was a long, midline incision. Some now
promote the laparoscopic drainage of the former allowing
the ovary to be removed through a small incision. The down
side to this is the potential for the cyst to spill cancer
cells into the abdominal cavity. Laparoscopy is now used
to remove small to medium-sized cancerous ovarian cysts
(up to about 12 cm) and to stage ovarian cancer.
•Excision of a benign cyst alone, with conservation
of the ovary, may be performed in patients who desire
retention of their ovaries for future fertility or
other reasons. Included are endometrioma, dermoid, and
functional cysts.
•If the ovarian cyst is benign, removal of the
opposite ovary should be considered in
postmenopausal, perimenopausal, and premenopausal
women older than 35 years who have completed their
family and are considered at increased genetic risk
for subsequent development of ovarian carcinoma.
These indications are all relative and the issues
should be discussed with the patient prior to any
surgery.
•A gynecologic cancer specialist should be available
to help with any patient who undergoes surgery for a
potentially malignant ovarian cyst. This allows the
appropriate surgery to be performed on patients found
to have cancer. Whenever possible, the patient should
have consulted with the specialist prior to the
surgery to allow all issues to be addressed.
 Why did we choose this case?
Ovarian cyst is a very rare disease & not
all of us are familiar with this disease. We
chose this case, Dermoid ovarian cyst because
at the first place, it is indeed very
interesting since it is related to our major
subject. It is for our own patronage because
we had already a background on the terms used
especially in the Anatomy & Physiology, which
is more focused on reproductive system of
female. It’s an opportunity for us to discuss
this kind of disease wherein we can deeper
our understanding about it & again a new
knowledge for us.
 STATISTICS
International
Country 2008 2009
Paris 22% 18%
Canada 28% 31%
China 5% 3%
Japan 13% 6%
Russia 15% 9%
 International

rian cysts shows that New York has the higher percen
 
ovarian cysts which has the total of 117% cases com
 National

Place 2008 2009

Davao 12% 8%

Baguio 17% 10%

Laguna 9% 12%
Occidental occidental 18% 11%

Cebu 7% 9%

Pangasinan 5% 7%
 National

The statistics shows that Negros Occidental

the higher percentage in year 2008 and
Laguna in the year 2009.
Year 2008 has the lower incidence of ovarian
cysts which has the total of 68% cases
compared to year 2009 which has higher
cases of 98%.
 Local
People’s General Hospital
Month 2008 2009
January 2 7
February 0 12
March 1 3
April 1 7
May 1 4
June 4 3
July 1 4
August 3 0
September 3 4
October 0 2
November 0 4
December 0 1

otal 16 51
 Local

Year 2009 has a bigger number of cases of

having an ovarian cyst than year 2008.
 Local
Clinica De Leon
Month 2008 2009
January 0 0
February 0 0
March 0 0
April 0 0
May 0 0
June 0 0
July 0 0
August 0 0
September 0 0
October 0 0
November 0 2
December 0 0

Total 0 2
 Local

having an ovarian cyst. In 2009, only in t

 Local
Cagayan Valley Medical Center
Month 2008 2009
January 0 2
February 0 2
March 0 2
April 0 2
May 0 2
June 0 2
July 0 2
August 4 2
September 4 2
October 4 2
November 0 2
December 0 2

Total 12 24
 Local

the disease than 2008. The total number o

 PATIENT’S PROFILE

Name: M. B.
Age: 22 y/o
Gender: Female
Civil Status: Married
Nationality: Filipino
Address: Ugac Norte, Tuguegarao City
Date of Birth: October 12, 1988
Place of Birth: Tuguegarao City
Occupation: Housewife
Religion: Roman Catholic
Educational Attainment: College Graduate
Source of Information: Patient, Patient’s chart &
S.O.
Mode of arrival: Ambulatory
Date of Admission: January 11, 2010
Time of admission: 12:15 pm
Date of Discharge: January 14, 2010
Date of discharge: 11:30 am
Attending Physician: Dr. Teresita Reyes
Chief Complaint: “ kasi sabi ng doctor lumalaki
yung cyst kaya nagpaconfine ako”
Admitting diagnosis: Dermoid cyst left, G1P2 S/P
Final diagnosis: Dermoid cyst, left
Surgical procedure: Salpingo-oophorectomy
Date of surgery : January 11,
2010
 NURSING HISTORY
HISTORY OF PRESENT ILLNESS

The patient verbalized that during her pregnancy she

often experienced lower abdominal pain and she easily gets tired.
After she gave birth to her twin baby last year at Morong
Hospital in Manila, she was diagnosed to have ovarian cyst in her
right ovary and ovarian new growth probably dermoid in her left
ovary. She said that she wants it to be removed thereafter but the
doctor said that it can’t be removed yet because she has
hypertension that may lead to eclampsia.
She also stated that 2 months prior to admission, she
decided for an ultrasound at Dr. Reyes Clinic and had confirmed
that her ovarian cyst grew bigger so she decided to undergo
surgery (salpingo-oophorectomy) and it was scheduled last
January 11, 2010 at the Peoples General Hospital.
 HISTORY OF PAST ILLNESS

m when she was in elementary and had experience also peptic ulce
FAMILY HISTORY

The patient emphasized that her family

has no history of any obstetric disorder. She
said that she was the first member of their
family who had suffered from ovarian cyst.
She claims that her mother had suffered from
goiter and her father has a hypertension. She
also said that they do not have genetically
acquired diseases other than the two first
stated.
 SOCIAL / PERSONAL HISTORY

The patient is a HRM graduate, a housewife

and a mother of twin baby and is currently living with
her husband. She belongs in a nuclear family. She
said that she has close ties with her family. She stated
that even though she’s friendly, she doesn’t go out
with her friends anymore because she had her twins to
take care of. She also said that she decides things with
her husband and describes that their financial status is
average.
Family Health History
The patient’s paternal side
had a history of Hypertension which
she inherited. Her father died of
cardiac arrest at the age of 60. She
stated that 2 of her children is
hypertensive.
On her maternal side, her
mother died from diabetes. Her
younger sister inherited the
disease.
Personal and Social History

The patient stated that she’s

widowed since 3 months. She used to
smoke and consumes 3 sticks/day and
had good relationship with her
neighbors as well as to her friends.
She also stated that she is a good,
loving and caring mother to her
children and grand children.
 Gordon’s Functional Patterns
Health perception –
Health management
pattern
BEFORE
HOSPITALIZATION

e usually takes OTC drugs such as Midol for pain rel

Her perception about health is
still “Health is Wealth”.
She feels weak but she was very
cooperative during therapeutic
monitoring and did not resist
whenever medications were given.
She has a positive view about her
health but she is nervous about
her operation.
HOSPITALIZATION
DURING
 NUTRITIONAL - METABOLIC
PATTERN
BEFORE
HOSPITALIZATION

sn’ t have allergies on food and medicines. She does

 NUTRITIONAL - METABOLIC
PATTERN
DURING
HOSPITALIZATION

the patient was on NPO diet due

She urinates 3-4 times a day
with yellowish color. The patient
defecates once a day usually in
the morning with either soft or
hard stool.
She has no difficulty in
urinating and defecating
BEFORE HOSPITALIZATION
ELIMINATION PATTERN
 ELIMINATION
PATTERN
DURING
HOSPITALIZATION

by an Indwelling Foley Catheter. She did

 ACTIVITY - EXERCISE
PATTERN
BEFORE
HOSPITALIZATION

culty. She performs daily household chores whi

 ACTIVITY - EXERCISE
PATTERN
DURING
HOSPITALIZATION

encouraged to ambulate. She can’t do thin

 COGNITIVE - PERCEPTUAL
PATTERN
BEFORE
HOSPITALIZATION

ehend well. She could simply organize

 COGNITIVE - PERCEPTUAL
PATTERN
DURING
HOSPITALIZATION

in hearing and she can easily grasp i

SLEEP - REST
PATTERN
BEFORE
HOSPITALIZATION
The patient has a usual sleep of
8-9 hours of sleep and has his
nap time for at least 30 minutes.
She usually sleeps at 9 o’clock
in the evening and wakes up 6
o’clock in the morning. She
doesn’t use any sleeping aids.
She is well rested and is ready
for daily activities when she
wakes up.
 SLEEP - REST
PATTERN
DURING
HOSPITALIZATION

ain in her suture and due to monitori

 SELF - PERCEPTION
AND SELF - CONCEPT
PATTERN
BEFORE
HOSPITALIZATION

also considered herself as jolly, fr

 SELF - PERCEPTION
AND SELF - CONCEPT
PATTERN
DURING
HOSPITALIZATION
.

soon as possible, to be at a fu
 ROLE RELATIONSHIP
PATTERN
BEFORE
HOSPITALIZATION

er husband and talks to him whenever they enc

 ROLE RELATIONSHIP
PATTERN
DURING
HOSPITALIZATION

ot change. The patient and her husband

 SEXUALITY -
REPRODUCTION PATTERN

BEFORE
HOSPITALIZATION

ds per day(not soaked).She used pills as contra

 SEXUALITY -
REPRODUCTION PATTERN

DURING
HOSPITALIZATION

esn’t think of any sexual

 COPING - STRESS
PATTERN
BEFORE
HOSPITALIZATION

ng. In terms of crisis the patient usually

 COPING - STRESS
PATTERN
DURING
HOSPITALIZATION

ping mechanism when experiencing rest

 VALUE - BELIEF
PATTERN
BEFORE
HOSPITALIZATION

eglects to ask God’s guidance and protection. Asking

 VALUE - BELIEF
PATTERN
DURING
HOSPITALIZATION

in God and her family is her

 PHYSICAL ASSESSMENT

for 8 hours regulated at 30 gtts/min., hooked at the left arm

anifested signs of distress & showed difficulty in moving &
 PHYSICAL ASSESSMENT
Latest Vital Signs :
BP - 120/90 mmHg
BT - 37.1 C
RR - 18 cpm
PR - 90 bpm
 
Height : 5’4”
Weight: 54kg
BMI : 20.32
Area Technique Normal findings Actual findings remarks
assessed used
SKIN
color Inspection Light to deep Varies from Normal
brown deep brown to
light
texture Palpation Smooth Feels smooth Normal
temperatur Palpation Warm to touch, Warm to touch, Normal
e uniform uniform
Skin turgorPalpation When pinched, Springs back Normal
skin goes back to easy when
previous state in 1- pinched
2 seconds

Presence Inspection No lesions No lesions Normal

of lesions
uniformity Inspection Uniform except areas Uniform except in Normal
exposed to sun; areas areas expose in sun;
of lighter areas of lighter
pigmentation(palm, pigmentation
lips, nail beds)in dark
skinned people
moisture Palpation Moisture in skin fold Moisture in skin fold Normal
& axilla (varies in and axilla
environmental temp.,
body temp.& activity)

thickness Palpation & Epidermis is Epidermis is Normal

inspection uniformly thin, uniformly thin,
thickened callous thickened callous
normal in palms & normal in palms &
sole of feet sole of feet
HAIR
color Inspection Black(depending on race) Black(depending on Normal
race)

distributio Inspection Evenly distributed hair Evenly distributed Normal

n hair

texture Palpation Silky, resilient hair Silky, shiny and Normal

resilient

Presence Inspection No infection or No infection or Normal

of infestation infestation
parasites
SCALP
Symmetry Inspection symmetrical symmetrical Normal

appearanceInspection Absence of lesions Absence of lesions Normal

NAILS

Color(nail Inspection pinkish pinkish Normal

bed)

shape Inspection Convex curve Convex curve Normal

(160 degrees-n) (160 degrees-n)
texture Inspection Smooth Smooth Normal
tissue Inspection intact epidermis intact epidermis
surroundin
g nail
Capillary Palpation Prompt return of pink or Prompt return of Normal
refill test usual color(1-2 seconds) pink or usual
color(1-2 seconds)

HEAD

shape Inspection normocephalic normocephalic Normal

appearanceInspection Rounded with smooth Rounded with Normal

skull contour with (-) smooth skull contour
nodules with (-) nodules

Size & Inspection Appropriate to body size Appropriate to body Normal

circumfere & age size & age
nce
FACE
symmetry Inspection symmetrical symmetrical Normal

EYEBROWS
distributio Inspection Equally distributed Equally distributed Normal
n

Quality of Inspection Eyebrows moves the Eyebrows moves the Normal

movement same way same way

alignment Inspection aligned aligned Normal

EYELAS
HES
evenness Inspection Equally distributed Equally distributed Normal
Direction Inspection Slightly curved outward Slightly curved Normal
of curl outward

EYELIDS
Ability to Inspection Has the ability to blink; Has the ability to Normal
blink blink bilaterally blink; blink
bilaterally

Frequency Inspection 15 to 20 blinks/min. 18 blinks/min. Normal

of blink

EYES
color Inspection white sclera white sclera Normal

conjunctiv Inspection Pink palpebral Pink palpebral Normal

a conjunctiva conjunctiva

CORNEA
Appearanc Inspection shiny shiny Normal
e
(clarity)
Corneal Inspection Presence of blink when Presence of blink Normal
sensitivity the cotton tip applicator when the cotton tip
touches the edge of the applicator touches
eyelids the edge of the
eyelids

PUPILS
color Inspection Black, no cloudiness Black, no cloudiness Normal

shape Inspection rounded rounded Normal

Symmetry Inspection Equal in size(3-7mm) Equal in size (4 mm) Normal
of size
Direct Inspection Both pupils are reactive toBoth pupils are Normal
reaction to light reactive to light
light
Consensua Inspection Both pupils constrict Both pupils constrict Normal
l reaction though only one pupil is though only one
to light lighted by the penlight pupil is lighted by
the penlight
Extra Inspection Both eyes are coordinated Both eyes are Normal
ocular coordinated
movement

Visual Inspection He was able to read prints He was able to read Normal
acquity without wearing prints without
eyeglasses wearing eyeglasses

EARS
color Inspection Same with the color of Same with the color Normal
the face of the face

symmetry Inspection Symmetrical to the head Symmetrical to the Normal

& face head & face

position Inspection Lateral to the eyebrows & Lateral to the Normal

auricles inline with eyebrows & auricles
canthus of the eye inline with canthus of
the eye
NOSE
color Inspection Same with the color of Same with the color Normal
the face of the face
Tendernes Palpation No tenderness & masses No tenderness & Normal
s & masses masses

patency Inspection Air moves freely Air moves freely Normal

flaring Inspection No nasal flaring No nasal flaring Normal

Discharge Inspection Without discharge Without discharge Normal
position Inspection midline midline Normal
MOUTH

contour Inspection symmetrical symmetrical Normal

Presence Inspection Absence of lesions Absence of lesions Normal
of lesions
lips Inspection Uniform pink color; soft, Dry lips Due to
moist & smooth dehydration
Ability to Inspection Can purse lip Can purse lip Normal
purse lips
Buccal Inspection Moist, smooth, soft, & Moist, smooth, soft, Normal
mucosa glistering, pink in color & glistering, pink in
color
teeth Inspection no tartars, no dental White, no tartars, no Normal
caries, complete set of dental caries,
adult teeth(32) complete set of adult
teeth(32)
gums Inspection Pink in color, moist & Pink in color, moist Normal
firm & firm

tongue Inspection Freely moving, pink in Freely moving, pink Normal

color, located at the in color, located at
midline, no lesions, move the midline, no
to lesions, move to
diff.direction,roughened diff.direction,roughe
From papillae ned
From papillae

uvula Inspection Positioned in the midline Positioned in the Normal

midline
 the shoulders between the
shoulders
mobility Can move spontaneous- Can move Normal
Ly in all directions spontaneous-
Ly in all directions
appearanceInspection Brown in color, no lesion Brown in color, no Normal
& redness le-
sions & redness
Sternoclei- Palpation Full strength Full strength Normal
domastoid

Lymph Palpation No tenderness or No tenderness or Normal

nodes inflammation present, no inflammation
pain felt during palpation present, no pain felt
during palpation
THORAX &
LUNGS
Breathing Inspection regular regular Normal
pat-
tern
RR Inspection 12-20 CPM 18 cpm Normal
Symmetry Inspection Chest expands symme- Chest expands Normal
Trically during symme-
respiration; effortless Trically during
respiration respiration; effortless
respiration

Chest wall Inspection Intact; no tenderness; Intact; no tenderness; Normal

& No masses No masses
Palpation
Chest Palpation Full & symmetric chest Full & symmetric Normal
expansion expansion chest
expansion
Percussion Percussion resonance resonance Normal
sound

Breath Auscultatio Bronchovesicular Bronchovesicular Normal

sounds n Breath sound Breath sound

ABDOMEN
Skin Inspection Brown/follows general Brown normal
condition body color
integrity Inspection Intact skin (+) wound Due to surgery
Bowel Auscultatio Audible bowel sounds Audible bowel Normal
sounds n (15-20/min) sounds
(18/min)
tenderness Palpation No tenderness No tenderness Normal

umbilicus Inspection Midline & inverted, no Midline & inverted, Normal

sign of discoloration no sign of
discoloration
Abdominal Inspection Flat, round scaphoid Flat, round scaphoid Normal
contour
Ascites Percussion No ascites No ascites Normal

HEART
Heart rateAuscultatio Regular;60-100 bmp Regular; 90 bmp Normal
n
Heart Auscultatio Dull, no murmurs, Dull, no murmurs, Normal
sounds n absence of s3 & s4 absence of s3 & s4
sounds sounds
precordiu Inspection Adynamic, point of Adynamic, point of Normal
m & palpation maximum impulse is at maximum impulse is
the fifth IC for adult(4th at the fifth IC for
IC for children) left adult(4th IC for
midclavicular line children) left
midclavicular line

UPPER EXTREMITIES
color Inspection Light to deep brown Light to deep brown Normal
symmetry Inspection symmetrical symmetrical Normal
Skin Palpation Warm & equal temp.;no Warm & equal Normal
characteris edema & tenderness temp.;no edema &
tics tenderness

ROM Inspection Full ROM without pain Difficulty of moving Due to surgical
incision
Muscle Palpation Present , equal Present , equal Normal
tone
LOWER EXTREMITIES

color Inspection Light to deep brown Light to deep brown Normal

symmetry Inspection symmetrical symmetrical Normal

skin Inspection Warm & equal temp.;no Warm & equal Normal
characteris tenderness temp.;no tenderness
tic

ROM Inspection Full ROM without pain Difficulty of moving Due to surgical
incision

Edema Inspection No edema No edema Normal

&
Palpation

Muscle Palpation Present, equal Present, equal Normal

tone
 Laboratory Examinations
SEROLOGY
January 11,
2010

SEROLOGY

ABO Group “O”

 URINALYSIS
January 11,
2010
URINALYSIS
Normal Findings Result Interpretation
Color Yellow Amber Straw Normal
Character Slightly Turbid Slightly Turbid Normal
pH 4.5- 7.5 5 Normal
Albumin Negative Negative Normal
Specific Gravity 1.010-1.025 1.020 Normal
Sugar Negative Negative Normal
Microscopic Exam
WBC/ hpf 1-2 1-2 Normal
RBC/ hpf 0-4 3-6 Due to bleeding
 HEMATOLOGY

January 11,
2010
HEMATOLOGY

Normal Findings Result Interpretation

WBC 4.5- 11 x 10 3/ mm3 10.2 X 10 3/ mm3 Normal

RBC 4.5- 7.5x 10 6/mm3 3.97 X 10 6/ mm3 Due to bleeding

Hgb 11- 14 g/ dL 11.1 g/ dL Normal

Hct 39- 49% 33.9 % Due to bleeding
Plt 150- 400 x 10 3 mm3 352 X 10 3/ mm3 Normal
HEMATOLOGY
Differential Count

Normal Result Interpretation

Findings
Lymphocytes 20-40 % 25.1 % Normal

Monocytes 2-9% 8.9 % Normal

Granulocytes 55-79% 66.0 % Normal

Total 100%
 ULTRA SOUND

October 24, 2009

us. Endometrium is not thickened. The right ovary is visualized showing an oval-sh
us with rough shadows within which also measure 7.0 cm x 5.8 cm x 4.5 cm (LXW

Impression:
Normal Uterus.
Ovarian cyst, right.
Ovarian newgrowth, left probably dermoid.
ANATOMY AND PHYSIOLOGY

The female reproductive system

performs the following function:
· Production of female sex cells.
· Reception of sperm cells from the
male.
· Nurturing the development of and
providing nourishment for new
individual.
· Production of female sex hormone.
.
 Internal Reproductive Organ

1. Fallopian tubes
•Are about 10 cm long and begin as funnel-shaped passages next
to the ovary.
•Site of fertilization

Fimbriae
•The finger-like projections of the fallopian tube on the near end
of the ovary.
•Surrounds the opening of the uterine tube
Cilia
•Hairy projections on the surfaces of cells at the entrance of the
fallopian tube — and the contractions made by the tube.
•Takes the egg about 5 days to reach the uterus and it is on this
journey down the fallopian tube that fertilization may occur if a
sperm penetrates and fuses with the egg. The egg, however, is only
usually viable for 24 hours after ovulation, so fertilization usually
occurs in the top one-third of the fallopian tube.
 .
2.Uterus
•a hollow cavity about the size of a pear (in
women who have never been pregnant) that
exists to house a developing fertilized egg.
•Body of the uterus:
The main part of the uterus (which sits in the
pelvic cavity)
Fundus:
•The rounded region above the entrance of
the fallopian tubes
Cervix
•Narrow outlet in the fund, which protrudes
into the vagina, is the cervix.
 .
LAYERS OF THE UTERUS
1. Endometrium
•Inner layer
•If an egg has been fertilized it will burrow into the
endometrium, where it will stay for the rest of its growth.
•The uterus will expand during a pregnancy to make
room for the growing fetus.
•A part of the wall of the fertilized egg, which has
burrowed into the endometrium, develops into the
placenta.
•If an egg has not been fertilized, the endometrial lining is
shed at the end of each menstrual cycle.
2. Myometrium
•Is the large middle layer of the uterus
•Made up of interlocking groups of muscle.
•Plays an important role during the birth of a
baby, contracting rhythmically to move the baby
out of the body via the birth canal (vagina).
•
4 . Ovaries
. •Main reproductive organs of a woman.
•Ovaries are held in place by various
ligaments which anchor them to the uterus
and the pelvis.
•Contains ovarian follicles, in which eggs
develop.
•Secretes hormones estrogen & progesterone.
 
Estrogen
•Produced by the follicle in non-pregnant
female and placenta in late pregnancy.
•Induce estrus-heat
•Responsible for female contour
•Develop duct system of mammary gland.
•Causes edema retention of water.
•Increase muscle development.
•responsible for the appearance of secondary
sex characteristics of females at puberty
and for the maturation and maintenance of
the reproductive organs in their mature
functional state.
•
Progesterone
. •it prepares the endometrium for pregnancy
•helps maintain the endometrium in a healthy
state during pregnancy.
 
 
Ovulation
•Occurs when developing egg is ejected from the
ovary into the fallopian tubes.
•Occurs in the middle of the menstrual cycle
and usually takes place every 28 days or so in
a mature female.
•It takes place from either the right or left
ovary at random.
 
There are two extremities to the ovary:
•tubal extremity- The end to which the
uterine tube attach..
the uterine extremity- It points downward, and it
is attached to the uterus via the ovarian ligament.
Cell Types
•Follicular Cells - flat epithelial cells that originate from
surface epithelium covering the ovary
•Granulosa cells - surrounding follicular cells have change
from flat to cuboidal and proliferated to produce a stratified
epithelium
•
Structure of the ovary
Germinal epithelium-it is a simple cuboidal epithelium
covering of the ovary.
Tunica albuginea-underneath the layer there is a dense
connective tissue capsule.
Oogenesis-a female sex cells or gametes develop in the
ovaries by a form of meiosis.
Ovarian follicle development- an ovarian follicle consist
of a developing oocytesurrounded by one or more layers of
cells called follicular cell.
Ovulation- Leutenizing hormone from the anterior pituitary
occurs when the mature follicle at the surface of the
ovary ruptures and releases the secondary oocyte into the
peritoneal cavity.
.
 External reproductive organ
.
Clitoris
•The visible button-like portion located near the
anterior junction of the labia minora, above the
opening of the urethra and vagina.
•It does not contain the distal portion of the
urethra. The only known exception to this is in the
Spotted Hyena.
•It is the most sensitive erogenous zone of a
woman, the stimulation of which may produce sexual
excitement and clitoral erection; its continuing
stimulation may produce sexual pleasure in the
woman and orgasm.
Mons pubis
•Also known as the mons veneris or simply the mons,
is the adipose tissue lying above the pubic bone of
adult women, anterior to the symphysis pubis.
•Forms the anterior portion of the vulva, and
limits the perineal region proximally and
anteriorly.
 •After puberty it is covered with pubic hair and
enlarges. In human females this mound is made of
fat and is supposed to be larger. It provides
protection of the pubic bone during intercourse.
Labia Majora
•Two rounded folds of skin surrounding the labia
minora & vestibule.
Labia Minora
•Two narrow, longitudinal folds of mucous
membrane enclosed by the labia majora; they unite
anteriorly to form the prepuce.
DRUG STUDY
e of Drug Classificati Dosages Indications Action Adverse Reaction Contraindications Nursing Responsibilities
on
rocortisone Corticoster 100mg IV •Severe inflammation, Not clearly CNS: euphoria, •Contraindicated in patients •Determine whether

ef) oids adrenal insufficiency defined. insomia, psychotic hypersensitive to drugs or patient is sensitive to
•Shock Decreases behavior vertigo, its ingredients, in those with other corticosteroids.
•Adjunct Treatment for inflammation, headache, systemic fungal infections, •Monitor patients wt.,BP
ulcerative colitis and mainly by paresthesia in those receiving and electrolyte level
proctitis stabilizing CV: heart failkure, immunosuppressive doses •Tell patient not to stop
leukocytes hypertension, together with live virus drug abruptly or without
lysosomal edema vaccines, and in premature prescriber consent.
membranes; EENT: cataracts, infants.
suppresses glaucoma •Use with caution in patient

immune GI: peptic with recent MI.

response; ulceration, GI •Use cautiously in patients

stimulate bone irritation, nausea, with ulcer, renal disease,

marrow; and vomiting hypertension, osteoporosis,
influences GU: menstrual DM, lactation, seizure and
protein, fat and irregularities psychotic tendencies
carbohydrate Musculoskeletal:
metabolism. muscle weakness,
osteoporosis
Skin: delayed
wound healing
Name of Drug Classification Dosages Indications Action Adverse Contraindications Nursing
Reaction Responsibilities
Acetaminophen Non opiod 500mg/t Mild pain Unknown. Hematologic: •Contraindicated in •Advise patients
(paracetamol) analgesic and ab or fever Thought to hemolytic patients that is only for
antipyretic produce anemia, hypersensitive to short term use.
analgesia by neutropenia, drugs. •Warn patients

blocking pain leucopenia, •Use cautiously in that high doses or

impulses by pancytopenia patients with long unsupervised
inhibiting Hepatic: term alcohol use long term used
synthesis of jaundice because can cause liver
prostaglandin Metabolic: therapeutic doses damage.
in the CNS or hypoglycemi cause ●Excessive
on other a hepatotoxicity in alcohol use may
substances that Skin: rash, these patients. increase the risk
sensitize pain urticaria of liver damage.
receptor to
simulation.
The drug may
relieve fever
through
central action
in he
hypothalamic
heat regulating
center.
Name of Drug Classification Dosages Indications Action Adverse Contraindications Nursing
Reaction Responsibilities
Ciprofloxacin Fluoroquinolo 500mgcap ●Mild o Inhibits CNS: •Contraindicated in •Monitor patients

(ciproxin) nes moderate UTI bacterial Headache, patients sensitive tointake and output
● DNA restlessness, fluoroquinolones •Advise patients
Complicated synthesis, tremor, •Use cautiously in to drink plenty of
intra mainly by dizziness, patients with CNS fluids to reduce
abdominal blocking fatigue disorders. risk for urine
infection DNA gyrase: CV: Edema. crystals.
●Mild to bactericidal Chest pain •Warn patient to

moderate GI: Abdominal avoid hazardous

acute sinusitis pain or task hat require
● inhalation discomfort, alertness, such as
anthrax dyspepsia, driving, until
constipation effects of drug
GU: Interstitial are known.
nephritis
Hematologic:
Leukopenia
Musculoskelet
al: Aching,
neck pain
Skin:
photosensitivit
y
Name of Drug Classification Dosages Indications Action Side effects Contraindication Nursing
s Responsibilities

GENERIC Antihistamine 10mg/tab ● Rhinovirus Antihistamines •fast, pounding, or •You should not •You may take
NAME: infection block the effects of uneven heartbeat; use this cetirizine with
cetirizine ● Kimura's histamines. •weakness, tremors medication if or without food.
BRAND disease Histamines cause (uncontrolled you are allergic •Take cetirizine

NAME: Zyrtec symptoms of shaking), or sleep to cetirizine. exactly as

allergy when problems •Do not use directed on the
released by allergic (insomnia) cetirizine label, or as
reactions in the •severe restless without telling prescribed by
body. feeling, your doctor if your doctor. Do
Antihistamines hyperactivity; you are breast- not use it in
block the ability of •confusion; feeding a baby. larger amounts
histamine to •problems with or for longer
promote the allergy vision; or than
symptoms. •urinating less than recommended.
usual or not at all.
Name of Drug Classification Dosages Indications Action Adverse Reaction ContraindicationsNursing
Responsibilities
Oxacillin Anti infectives 1.5gIV ● Treatment of Inhibits bacterial CNS: Fever Hypersensitivity •Complete course of
Sodium infections such as cell wall Dermatologic: to oxacillin or treatment as prescribed.
osteomyelitis, synthesis by Rash other penicillins ●Small, frequent meals
septicemia, binding to one or Gastrointestinal: or any and good mouth care
endocarditis, and more of the Nausea, diarrhea, component of the may help. ●Report
CNS infections penicillin binding vomiting formulation persistent fever, sore
caused by proteins (PBPs); Hematologic: throat, sores in mouth,
susceptible strains which in turn Eosinophilia, diarrhea, unusual
of Staphylococcus inhibits the final leukopenia, bleeding or bruising,
transpeptidation neutropenia, respiratory difficulty, or
step of thrombocytopenia skin rash. ●Notify
peptidoglycan , agranulocytosis prescriber if condition
synthesis in Hepatic: does not respond to
bacterial cell Hepatotoxicity, treatment.
walls, thus AST increased
inhibiting cell Renal: Acute
wall interstitial
biosynthesis. nephritis,
Bacteria hematuria
eventually lyse Miscellaneous:
due to ongoing Serum sickness-
activity of cell like reactions
wall autolytic
enzymes
(autolysins and
murein
hydrolases) while
cell wall
assembly is
arrested.
NURSING CARE PLAN
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
S

Subjective: Impaired skin At the end of > inspected skin > to determine skin Goal partially met:
“ Nagtutuklap na integrity related to nursing surfaces pressure The patient was
ang aking balat” as epidermal interventions, the >turned patient >to promote blood able to understand
verbalized by the shedding. patient will be able every circulation some of the
patient. to demonstrate/ 2 hours > to prevent techniques to
Objective: techniques to > provided vasoconstriction prevent skin
- damaged or prevent skin adequate >to prevent breakdown.
destroyed breakdown. clothing/covers formation of
epidermis >instructed to moisture that
- peeling of skin avoid use of plastic potentiates skin
materials breakdown
> provided > to promote
protection by use circulation and
of pads, pillows eliminate excessive
> kept bedclothes tissue pressure.
dry, bed free from > to prevent bed
wrinkles. sores.
> encouraged > Promotes
participation with circulation and
active and assistive reduces risks
range of motion associated with
exercise immobility
ASSESSMENT DIAGNOSIS PLANNING INTERVENTIO RATIONALE EVALUATION
NS
Subjective: Alteration in At the end of 45 > Encouraged > to alleviate Goal partially
“ medyo masakit comfort; Acute minutes, the diversional anxiety met:
ang aking balat” Pain r/t patient will be activities. > To alleviate After 45 minutes,
as verbalized by epidermal able to verbalize > Positioned the pain and enhance the patient was
the patient. shedding or report that patient in a circulation. able to report
Objective: pain is relieved comfortable > To provide non pain was relieved
- epidermal from pain scale position. pharmacological from pain scale
shedding of 5/10 to 2/10 > Provided pain of 5/10 to 3/10.
- blisters comfort management.
- Pain Scale of measures(Student > to prevent
5/10 nurse presence) fatigue
- Facial Grimace > Provided >to distract
adequate rest and attention and
sleep reduce tension.
>encouraged the
use of relaxation
techniques such
as deep breathing.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
S

Objective: Hyperthermia r/tAfter 30 minutes, > Encouraged to > to prevent Goal partially met.
Initial vital increased the patient will be increase oral fluid dehydration and The patient’s body
signs: pyrogens in the able to maintain her intake replace fluid loss temperature
BP:110/80 body body temperature >instructed to wear > to promote heat decreased from
mmhg within normal range loose and light loss by radiation 38.5 to 37.7 ⁰C.
T: 38.5 ⁰C (36.5-37.5 ⁰C) clothing and conduction
PR: 79 bpm > maintained bed >to reduce
RR: 21 cpm rest metabolic
•Warmer to > Encouraged demands
touch adequate rest > to prevent
> Monitored vital fatigue
signs > to provide
>administered baseline data
paracetamol as >to assist with
ordered measures to
reduce body
temperature
Subjective: Imbalanced At the end of 30 > Discussed eating > to provide appeal Goal met.
“ Hindi siya Nutrition less than minutes, the patient habits, including foodto clients likes/ The patient was able
masyadong body requirements will be able preferences, desires to demonstrate
nakakain” as r/t inability to ingest demonstrate intolerances > to enhance food behaviors, lifestyle
verbalized by the food. behaviors, lifestyle > Encouraged to use satisfaction and changes to regain
S/O. changes to regain flavoring agents stimulate appetite and maintain
Objective: and maintain > encouraged client > to stimulate appropriate weight.
BMI: 16.9 kg/m2 appropriate weight. to choose foods that appetite
-loss of weight from are appealing > may have a
55 kg to 46 kg. negative effect on
-weakness of > prevented appetite/eating
muscles required for unpleasant odors/ > to replace
swallowing sights insensible fluid loss.
> Provided adequate
fluid intake
ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective: Sleep pattern At the end of the •Explained necessity •Allows for longer Goal not met.
“ Hindi ako disturbance related shift, the patient of disturbances for period of interrupted Unable to evaluate
masyadong to environmental will be able to monitoring the vital sleep. due to HAMA
nakakatulog” as factors such as understand sleep signs and other care. •Napping can disrupt
verbalized by the ambient disturbance •Instructed the patient normal sleep pattern.

patient. temperature, noise to discouraged long •To reduce sleep and

Objective: and interruptions or periods of daytime interference from
•Increasing therapeutic naps. hunger
irritability monitoring. •Instructed the patient

•Restlessness to include bedtime

•Frequent yawning snack like milk and
•Fatigue appearance protein rich food.
PATHOPHYSIOLOGY
DISCHARGE PLAN
• Medication
• Instructed to take home medications as ordered:
• Tidact 150mg 1 capsule 3x a day
• Mefenamic Acid 500mg 1 capsule 3x a day
Exercise
•

• Advised to have light exercises as tolerated and encouraged to ambulate.

• Instructed also to avoid heavy lifting.
• Treatment
• Advised to continue taking medications as ordered and eat nutritious foods
for easy healing of wounds.
• Hygiene
• Advised patient to perform hygienic measures such as daily replacement of
incision dressing and wear clean and comfortable clothes. Advised also to do
personal hygiene like bathing, eye care, ear care, oral care, feet care, washing of
hands and perineal care.
• OPD
• Instructed to have a follow up check-up on January 21, 2010 at Dr. Reyes
Clinic.
• Diet
• Encouraged to consume vitamin-rich and iron-rich foods.
• Spiritual
 U ! ! !
N K YO
TH A