A Case Presentation

Presented by:

General Objectives
Our group aims to formulate a comprehensive analysis That would provide essential knowledge and skills in delivering quality health care to patients diagnosis with UTERINE MYOMA

Within 4 hours of our case presentation the participantas will be able to: y Describe the characteristic of myoma. y Present the anatomy and physiology of myoma related with our clients condition. y Discuss the pathophysiology and clinical manifestation of our clients condition. y Relate the significance of laboratory results to clients conditions or the disease process. y Identify the classification, indication, mechanism of action, special precautions, side effects, dosage and availability and nursing responsibilities of the drug administered to the client y Discuss comprehensively nursing care plans formulated specifically based on clients condition y Discuss the medical and surgical interventions related to the client. y Discuss the Physical Assessment and Gordons Functional Health Pattern

Specific Objectives

Patients Profile
Patients Name: PATIENT XX Ward/Service: OB-gyne ward Sex: Female Civil Status: Married Date of Birth: April 29, 1964 Age: 47 years old Birthplace: Calamba Misamis Occidental Religion: Roman Catholic Occupation: Housewife Admission: Date of Admission: January 7, 2012 Time: 7:45pm Attending Physician: Dr. Jovita C. Yazar Type of Admission: New Admission Social Service Classification: Classification Sw Admission Diagnosis: Uterine Myoma vs. Ovarian Neogrowth Fathers Name: Florentino Castillon Mothers Name: Anastacia Gumapet Spouse Name: Dionesio Lacquiao Admitting Clerk: Mary Joy/Digao (RN Heals) Attending Physician: Dr. Jovita C. Yazar

Address: Tampilisan ZN Address: Tampilisan ZN Address: Sindangan ZN

yHISTORY OF PRESENT ILLNESS

Present condition started about 3 years prior to admission. When patient noted heavy vaginal bleeding and body weakness every menstrual period that last almost a week. Due to that instance, she went to the Dumaguete hospital for check-up and she found out that she has a myoma. Her attending physician said that she need to undergo surgery, and do a check-up on January 2012. Until, her relative noted her to be pale, having dizziness and body weakness bought her to the hospital at DJRMH on first week of January 2012. After a series of examination, she was scheduled and prepared her to surgery.
y

ySOCIO CULTURAL
Patient X is a very caring mother and a strong willed person. Along with her 4 children, she managed to run the family despite of her present condition. Her husband does a living to sustain the family. She is closed with her support person her 2 nieces, being a housewife she loves to do videoke at their own house. She was admitted at Dumaguete Hospital few years ago. Patient X admits to drinks alcohol at her late 40s of age but not too much. She said she loves to eat vegetables and exercise by doing the house chores.

yReview of the

ANATOMY & PHYSIOLOGY

What parts make-up the female anatomy?

y The function of the external female

reproductive structures (the genital) is twofold: To enable sperm to enter the body and to protect the internal genital organs from infectious organisms. The main external structures of the female reproductive system include:

External Part of Vagina

The main external structures of the female reproductive system include:

 Labia majora: The labia majora enclose and protect the other external reproductive organs. Literally translated as "large lips," the labia majora are relatively large and fleshy, and are comparable to the scrotum in males. The labia majora contain sweat and oil-secreting glands. After puberty, the labia majora are covered with hair.

 Labia minora: Literally translated as "small lips," the labia minora can be very small or up to 2 inches wide. They lie just inside the labia majora, and surround the openings to the vagina (the canal that joins the lower part of the uterus to the outside of the body) and urethra (the tube that carries urine from the bladder to the outside of the body).  Bartholins glands: These glands are located next to the vaginal opening and produce a fluid (mucus) secretion.  Clitoris: The two labia minora meet at the clitoris, a small, sensitive protrusion that is comparable to the penis in males. The clitoris is covered by a fold of skin, called the prepuce, which is similar to the foreskin at the end of the penis. Like the penis, the clitoris is very sensitive to stimulation and can become erect

Physiology
The female reproductive system is designed to carry out several functions. produces the female egg cells necessary for reproduction, called the ova or

oocytes. The system is designed to transport the ova to the site of fertilization. Conception, the fertilization of an egg by a sperm, normally occurs in the fallopian tubes. After conception, the uterus offers a safe and favorable environment for a baby to develop before it is time for it to make its way into the outside world. If fertilization does not take place, the system is designed to menstruate (the monthly shedding of the uterine lining). In addition, the female reproductive system produces female sex hormones that maintain the reproductive cycle.

Internal Reproductive Organ

Internal reproductive organs include:

Vagina: The vagina is a canal that joins the cervix (the lower part of

uterus) to the outside of the body. It also is known as the birth canal. Uterus (womb): The uterus is a hollow, pear-shaped organ that is the home to a developing fetus. The uterus is divided into two parts: the cervix, which is the lower part that opens into the vagina, and the main body of the uterus, called the corpus. The corpus can easily expand to hold a developing baby. A channel through the cervix allows sperm to enter and menstrual blood to exit. Ovaries: The ovaries are small, oval-shaped glands that are located on either side of the uterus. The ovaries produce eggs and hormones. Fallopian tubes: These are narrow tubes that are attached to the upper part of the uterus and serve as tunnels for the ova (egg cells) to travel from the ovaries to the uterus. Conception, the fertilization of an egg by a sperm, normally occurs in the fallopian tubes. The fertilized egg then moves to the uterus, where it implants to the uterine wall

Pathophysiology
Predisposing Factors
y Advance age y Genetics y Race y Stress

Precipitating Factors
 Overweight  Hyperestrogenic state  Hypertension  Nulliparity  Multiparity  Menopause  Contraceptives  smoking

PATHOPHYSIOLOGY
Benign tumors originating in the smooth muscular uterine tissue, though sometimes theyoriginate in the smooth muscle of the uterine vesselsStress 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 circulatingestrogens

Express maximal growth during the generative age of a female, when estrogen secretion is at its highest, and growth curve is especially slope in the decade 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

Laboratory Results yID: OB SW Requested Physician: Dr. Quintano yName: Patient XXX Specimen: Blood yDate: January 7, 2012 yTime: 9:42am yAge: 47y/o

Laboratory Results
Test Hemoglobin Hematocrit Red Blood Cells White Cell Count Neutrophils Lymphocyte Eosinophil Metamyelocytes 0.78 0.21 0.01 0.25 Result Normal Value F: 12.0 M: 15.0gms% F: 12.0-15.0gms% F: 4-0-4.x10(12)x/L F: 5-10x10g/L 0.55-0.65 0.25-0.35 0.02-0.06 0.00-0.01

Laboratory Results
Sedementation Rate Bleeding Time Clotting Time Platelet Count Reticulocyte Count Malarial Smear MCH MCH MCHC RDW 76-95 f 27-35p 30-35 s/dL 11.5-14.5C 1-3 minutes 5-15 minutes 175-350 g/L M:0-10mm/hr F:0-20mm/hr

y y y y y y y y y y y y y y y y y y y y y y y y y y y

Laboratory Results ID: OB SW Name: Lucasita Lacquiao Date: January 7, 2012 Time: Age: 47y/o Sex: Female Test Hemoglobin Hematocrit M:0.42-0.52 Red Blood Cells 4-6-5.2x10(12)/L White Cell Count Neutrophils Lymphocyte Eosinophils Monocytes Basophils Metamyelocytes Sedementation Rate Bleeding Time Clotting Time Platelet Count Reticulocyte Count Malarial Smear MCH Result 0.25 Requested Physician: Dr. Quintano Specimen: Blood

Reference F: 12.0 M: 15.0gms% F: 12.0-15.0gms% F: 4-0-4.x10(12)x/L M: F: 5-10x10g/L 0.55-0.65 0.25-0.35 0.02-0.06 0.03-0.05 0.00-0.01 0.00-0.01 M:0-10mm/hr F:0-20mm/hr 1-3 minutes 5-15 minutes 175-350 g/L

0.78 0.21 0.01

76-95 fl

Theorist

Age Stage

Description

Erik Erikson

47

Generativity versus Stagnation

In the initial stage of being an adult we seek one or more companions and love. As we try to find mutually satisfying relationships, primarily through marriage and friends, we generally also begin to start a purposeful family together, though this age has been pushed back for many couples who today don't start their families until their late fifties.

NURSING CARE PLAN

Risk for Bleeding related to Distended abdominal Pain

Diagnosis: Risk for Bleeding related to Distended Abdominal Pain Assessment

Subjective: Makamata ko sa alas 3 sa kadlawon pukawon sa kasakit sa akong tiyan Objective: a.)The client has urinary frequency b.)abdominal pain c.)Complaints of blood discharges when she urinates d.)Body Malaise e.)Weakness

Planning
At the end of our care the client will exhibit, free of signs of active bleeding or excessive blood loss as evidenced by: a.)Lesser urinary frequency b.)Verbalization of relieved comfort c.)Minimal Vaginal bleeding d.)Absence of Body Malaise

Intervention
INDEPENDENT 1.)assess vital signs including blood pressure, pulse, respiration 2.)Note the client report of pain in specific areas, whether pain is increasing, diffuse/localized 3. Assess skin color & moisture, including intake & output 4.Encourage client in bed rest until bleeding abates 5.Assist patient in transfer ability 6.Encourage the patient to estimate blood loss DEPENDENT 1.)Review Client s Laboratory Data

Rationale
1.)To monitor invasive hemodynamic parameters & to determine if intravascular fluid deficient exist 2.)Can help identify bleeding into tissues organs/ body cavity 3.May indicate of blood loss defecting systemic circulation 4, To ensure Comfort 5.)To protect the client from falls trauma

Evaluation
At the end of our nursing care, the patient has partially manifested any risk of bleeding. As evidenced by: 1.) Sakit raman japon siya day pero gamay nalang  Pain Scale 5/10 2.)The client still have urinary frequency 3.)Estimated blood loss of 4 tablespoon 4.)Has only a slight body malaise 5.)Absence of weakness

NURSING CARE PLAN

Deficient Fluid Volume

Diagnosis: Deficient Fluid Volume Assessment

Subjective: Kadtong ganina kape ra akong gipamahaw Objective: a.)Client claimed to drink 5 glasses of water only throughout the day b.) Skin is pale and dry decreased skin or tongue turgor c.)Increase Urine Output d.)Tired expression e.)Weakness d.)Hydration

Planning
At the end of our comprehensive nursing intervention the client will exhibit maintained fluid volume at a functional level as evidence by: a.)Adequate urinary output b.)Moist mucous membrane, skin turgor, and prompt capillary refill c.)Absence of weakness & tired expression

Intervention
1.)Monitor vs every 4 hours 2.)Encourage client to increased fluid intake 3.)Monitor Intake and output 4.)Measure & report all fluid losses including emesis, diarrhea, wound fistula

Rationale
1.)To detect orthostatic hypotension, tachycardia, fever 2.)To prevent dehydration and shifts of electrolyte 3.) To ensure accurate picture of fluid states 4.)Loss of fluid rich in electrolytes can lead to imbalances 5.)Impaired thirst sensation inability to express thirst on obtain needed fluids may lead to hypernatremia

Evaluation
After 8 hours of our comprehensive nursing care, client manifested maintained fluid volume as evidenced by: a.) Karon daghan na gyud akong gi-inom b.)Client still have dry skin but prompt capillary refill and moist mucous membranes c.)Has voided 6 times during my shift d.)Absence of weakness e.)Appears to be hydrates

NURSING CARE PLAN

Diagnosis: Impaired transfer Mobility related to Prescribed Movement restrictions; medication

Diagnosis: Impaired transfer Mobility related to Prescribed Movement restrictions; medication Assessment
A.)Clients report of pain and discomforts and movements B.)IVF Blood Transfusion hooked at the right arm @ 30gtts/min C.)Hass chills afterwards D.)Weakness E.)Body Malaise

Planning
At the end of our comprehensive nursing intervention the client exhibit desired transfer safely as evidenced by: A.)Verbalization of comfort B.)Make desires transfer C.)Loss of weakness D.)Absence of chills

Intervention
1.)Monitor vital signs hourly 2.)Clearing floor and bed from clutter 3.)Demonstrate and reinforce safety measures, as indicated such as standing, posture, balance and going to toilet 4.)Teach and encourage the client especially the S.O. about body mechanics

Rationale

Evaluation

After 8 hours of nursing 1.)To detect any allergic evidence of intervention the client manifested Blood Transfusion desired transfer 2.)To avoid safely, as evidenced possibility of fall and by: subsequent injuries Kadtong ganina 3.)Facilitates grabeng pagka transfer and allows tugnaw nako pero client to obtain karon okay na day assistance for transfer, as needed 1.Slight weakness 4.)To facilitate 2.Stabled body clients view of our temperature postural alignment 3. Successful transfer

Physical Assessment

Body Parts

Normal Findings

Actual Findings

Significance

Head

Normocephalic, No abnormal mass Normal Hair color Scalp is clean and dry Sparse dandruff may be visible Hair is smooth and firm

Normocephalic No abnormal mass

Normal

Hair and scalp

Normal Hair color Normal Scalp is clean but oily No dandruff Hair is smooth and firm

Eyes

Symmetric to the face Not normal Both eyes coordinated with parallel alignment

Due to dehydration

External eye structure eyebrows

Hair evenly distributed, Hair evenly distributed, normal skin intact skin intact

Lacrimal Gland

No edema or tearing Black in color equal in size, Normally 3-7 mm in diameter, round smooth border, iris flat and round Symmetrically aligned to the face, firm and not tender, w/ no discharged noted Symmetric and straight, no discharges or flaring

No edema or tearing Black in color, equal in size, 4mm in diameter

normal

Pupils (color,shape,symmetr y Size)

Normal

Ears

Nose

Positioned Normal symmetrically to the face, no notable ear discharge, clean and dry Symmetric and Normal straight No nasal discharges noted No flaring noted

Mouth Lips

Tongue

Uniform pink in color, Soft, moist and smooth Tongue at midline without lesion Complete, white shiny tooth enamel, free of debris

Uniform, dark color Not normal due to dry dehydration

Dry and free of lesions incomplete teeth

Normal

Teeth

Not normal, aging is a factor, affecting loss of teeth, and also insufficient calcium and fluoride Normal

Neck

Coordinated smooth movement with no discomfort, No masses tenderness Pinkish in color

Coordinated movement with no discomfort, No masses, tenderness Pallor

Upper extremities

Not normal is a manifestation of inadequate circulating blood or hemoglobin

Heart Lower extremities skin

Normal heart rate 60-100bpm No lesion, can move freely, capillary refill: 1-2seconds Smooth, highly vascular and intact epidermis Capillary refill of 1-2 seconds Symmetric chest expansion, quiet, rhythmic and effortless respiration Quiet rhythmic
Normally firm, no contracture, no swelling, equal size on both sides of the body

Cardiac rate of 80

Normal

Snails

No edema, no Normal deformities can move freely, capillary refill: 2 seconds Pink, smooth texture, Normal convex curvature Capillary refill: 2 seconds Symmetric chest Normal expansion, quiet, rhythmic and effortless respiration, Quiet rhythmic
Normally firm No contracture or swelling Equal size on both sides of the body Normal

Chest and Lungs

Arms

yGordons

Functional Health Patterns

Health Patterns

Before Hospitalization
a.) Perceives to be healthy b.)Believes in quack doctors hilots and herbal medicines c.) The patient does not take any multivitamins supplementation

During Hospitalization
a.)Hospitalized due to abdominal pain as diagnosed with Uterine Myoma vs Ovarian Neogrowth b.) Dependent on the health care provider c.) Conscious and responsive upon interviewed IVF 0.9% Sodium Chloride hooked at the right arm with remaining solution of 750cc 2 40gtts/min d.) Complaints of pain at the abdomen and sometimes felt every night that keeps her awaken during the dawn

Nursing Diagnosis

Health Perception

Risk for Bleeding

Health Patterns
Nutritional/ Metabolic

Before During Nursing Hospitalization Hospitalization Diagnosis

a.)Eats anything she wants such as fishes, vegetables, rice b.) Has an allergy of Pork c.) Consumes 8-10 glasses daily d.) Drink little amount of alcohol e.)Does not smoke a.)During my shift Impaired nutrition @ 7-3pm, she is less than body only having a cup requirements of coffee for breakfast b.)During lunchtime she ates 1cup of rice and fish escabeche c.)Drinks 3 glasses of water d.)Diet as tolerated

Health Patterns
Elimination Pattern

Before During Nursing Hospitalization Hospitalization Diagnosis

a.)No voiding difficulties b.) Usahay man jud magkalibanga, kay tanan man gyud ta makasulay ana as verbalized c.)Moderate Perspiration d.)Has a habit of defecation once or twice daily a.)During my shift of Readiness for 7-3pm, Patient XX , enhanced urinates twice and elimination defecates only once b.)About approx. 3 glasses of urine/ urination c.)The patient keeps on going to the bathroom every now and them Kada mo adto, ko ug CR kung maka-ihi ko, medyo dunay dugo mo gawas as verbalized

Health Patterns
Activity- Exercise

Before During Nursing Hospitalization Hospitalization Diagnosis

a.)Has a good range of motion b.)Capable of doing activities of daily living such as sweeping the floor, wash the dishes, arranging Housewife Perceived ability: Feeding: 0 Bathing: 0 Toileting: 0 Dressing: 0 Sleeping: 0 General Mobility: 0 a.)IVF 0.9% Sodium Chloride hooked at the right arm with 750cc remaining @30gtts/min b.)Patient XX is fond of chatting with her two nieces and a cousin Impaired transfer mobility

Health Patterns
Sleep-Rest Pattern

Before During Nursing Hospitalization Hospitalization Diagnosis

a.)Patient XX usually sleeps 8am10pm, sometimes it s varied depends how busy she was b.)Last June, she has sleeping disturbances Putolputol lage ninf katulog pukawon sa sakit sa tiyan as verbalized c.)She is getting used during the night it s their videoke time d.)Has a habit of waking up 5:00am to 4:00am in their home a.)During my shift Disturbed Sleep she wakes up at Pattern 5:00am b.)Has a short frequent naps during days c.) Usahay pod mga alas 3 sa kadlawon makamata, pukawon sa kasakit sa tiyan.

Health Patterns
Self-Perception

Before During Nursing Hospitalization Hospitalization Diagnosis

a.)Physically healthy as claimed b.) Active and able to interact with people c.) Able to take care of the things in their house a.) Dependent on Readiness for heakth care enhanced selfprovider concept b.) Able to interact with people c.) Can walk independently d.) Kabalo ra man ko magkuha sa akong dextrose kung mag CR ko as verbalized

Health Patterns
Role Relationship Pattern

Before During Nursing Hospitalization Hospitalization Diagnosis

a.)Has a good relationship to her husband b.)No physical abuse or any harm throughout their relationship c.) Usahay kay kini lagging mga bata badlongon as verbalized d.)Patient XX has four children y A 23 y.o. y A 21 y.o. y A 19 y.o y A 7 y.o a.)Her cousin brought Readiness for her food and water enhanced b.)Apparently, they are communication happily chatting with one another c.)Her two nieces is at her bedside

Health Patterns
CognitivePerception Pattern

Before During Nursing Hospitalization Hospitalization Diagnosis

a.)No hearing problems b.)Able to answer questions directly and follow instructions as given alert and coherent c.)Patient XX has reached College level Readiness for enhanced decision making

Health Patterns
Sexuality/ Reproductive SexualPattern

Before During Nursing Hospitalization Hospitalization Diagnosis

a.)Patient XX is a female b.)Dresses accordingly to her gender c.)47y/o married, a housewife with 4 children d.)Acclaimed to have, never used with any contraceptive a.)The patient dresses accordingly to her age b.) Diagnosed with Uterine Myoma versus Ovarian Neogrowth Ineffective sexuality pattern associated with Uterine Myoma with Ovarian cyst

Coping Stress Mechanism

a.)The patient usually sleeps

a.) Mrs. Lacquaio sleeps or takes a

Readiness for enhanced coping

Health Patterns Value Belief Pattern

Before Hospitalization a.)Patient is a Roman Catholic b.)Unable to attend church mass weekly c.)Acclaimed to believe in hilots and Superstitious beliefs

During Hospitalization a.) Due to her diagnosed condition Patient XX is unable to attend Church b.)She is a devoted Catholic

Nursing Diagnosis Readiness for enhanced spiritual being

-FIN-