Case Study In Vesicovaginal Fistula

IVORY ANN A. AFABLE SUBMITTED BY: MRS. NELIA AYSON R.N CLINICAL INSTRUCTOR

I.

Biographic Data

Name: Polintan, Laonisa Espera Address: #283 T.Santiago Street Viente Reales Valenzuela City Age: 49 years old

Gender: Female

Religious Affiliation: Catholic

Marital Status: Married Chief Complaint: Involuntary Urination Provisional Diagnosis: Vesicovaginal fistula II.

Nursing History

A. Past Health History 1. Childhood Illness – Usually flu 2. Immunizations - Complete 3. Allergies - None 4. Accidents - None 5. Hospitalizations – Once (TAHBSO Surgical procedure last April 30,2008) 6. Medications used or currently taken - None B. History of Present Illness Eleven months prior to admission, patient had undergone TAHBSO (Total Abdominal Hysterectomy with Bilateral Salphyngectomy and Oophorectomy) at Quezon City General Hospital, 3 days after the Operation and removal of Internal Foley Catheter; patient noted that she cannot control her urination. She consulted the doctor who did the TAHBSO and was advised to have bladder draining, no medication was prescribed. Persistence of the involuntary urination prompted, consulted and was subsequently admitted.

C. Family History (-) Diabetes Mellitus (-) HPN (-) Asthma (-) PTB D. Obstetric History (for OB cases only) - G4P3 (3013) E. Developmental History (for Pediatrics cases only) - N/A III.

Patterns of Functioning A. Psychological Health 1. Coping patterns – Doing household chores and Praying 2. Interaction Patterns – (+) Accommodating 3. Cognitive Patterns – Easy to talk to 4. Self-concept – High self-esteem 5. Emotional Patterns – Happy 6. Sexuality – Feminine 7. Family Coping Patterns – Praying and Staying together Interpretation: Normal Psychological Health Analysis: Normal

B. Socio-Cultural Patterns 1. Cultural Patterns – Cooking Filipino dishes with family 2. Significant Relationships – with all the members of her family 3. Recreation Patterns – Staying at home cooking and cleaning 4. Environment – living with other relatives within a compound 5. Economic – Average status Interpretation: Normal Socio-cultural pattern/ Interactive to others Analysis: Normal C. Spiritual Patterns 1. Religious Beliefs and Practices – Going to church every Sunday 2. Values and Valuing – Giving respect to elders as well as to others Interpretation: Normal Spiritual Patterns, respectful Analysis: Normal IV.

Activities of Daily Living

Activities of

Before

Daily Living 1. Nutrition 2.

Hospitalization Hospitalization with appetite With appetite Daily None

Normal, adaptive normal because of diet

Elimination 3. Exercise

Daily

None

Normal because of indwelling

4. Hygiene Daily 5. Sleep and good

daily poor

catheter and attached drainage Normal adaptive normal

Rest 6.Sexual

None

Normal because she’s already a

Activity

None

During

Interpretation and Analysis

widow

7. Substance None

Prescribed by the normal

Use

doctor

V.

Physical Assessment

General

Norms

Actual

Appearance 1. Posture/Gait 2. Skin color

Findings Steady Gait Good posture Varies from light to Fair skin

deep brown 3. Personal hygiene Good 4. Nutritional Healthy Status 5.Age

Normal

Appropriateness 6. Verbal Behavior 7.Non-verbal

with age Normal Normal

Interpretation

Good Healthy

and

Analysis Normal Normal Normal Healthy

appropriate Normal

Normal appropriate to

Nice Normal

her age Normal Normal

36.5 82 20 110/80 130 kgs 5’2”

Normal Normal Normal Normal Normal Normal

behavior Measurements 1. Temperature 2. Pulse Rate 3. Respiratory Rate 4. Blood Pressure 5. Weight 6. Height VI. Date 3-1109

36.5 60-100 16-22 110/70

Laboratory and Diagnostic Examinations Findings Procedure CBC

Norms Result Hgb120- 121

Interpretation and Analysis Normal

160

40

Normal

Hct- 37-47

9.6

Normal

WBC-

3.8- 3.72

Below normal

10.8

.79

RBC- 3.9-5.2 18% Segmenters

Normal

Adequate

Lmphocytes PT

3-10-

ECG

Normal

Cystoscopy

Rhythm Vesicovaginal

Resulted

Dye test

fistula Bladder leakage

surgical operation (TAHBSO) Resulted from previous

09

Sinus Normal from

previous

surgical operation (TAHBSO)

VII. Generic

Medications, IV, Infusions, Blood Transfusion, Treatment Given Classificati

Indication

Contraindicati

on

Erythromycin

Side Effects

on

Responsibilities

Anti-

To reduce the Erythromycin is

infectives

development of

contraindicated

drug- in patients with

resistant

known

bacteria

and hypersensitivity

maintain

the to

effectiveness

Nursing

this

antibiotic.

of E.E.S. and Erythromycin is other

contraindicated

antibacterial

in

drugs,

taking

patients

terfenadine, astemizole, pimozide,

or

The most frequent side effects of oral erythromycin preparations are gastrointestina l and are dose-related. They include nausea, vomiting, abdominal pain, diarrhea and anorexia. Symptoms of hepatitis, hepatic dysfunction and/or abnormal

-Assess for infection. -Observe for any S/S of anaphylaxis. -Assess renal dysfunction.

for

cisapride. Cefuroxime

Anti-

Fights

- kidney disease

infectives

bacteria in the

-liver disease

body. -colitis -diabetes -Malnourish

Metronidazole Antiinfectives

Indicated

in Patients

the treatment severe of

with hepatic

serious disease

infections caused

metabolize by metronidazole

susceptible

slowly,

with

anaerobic

resultant

bacteria.

accumulation of metronidazole and

its

metabolites

in

the

plasma.

Accordingly, for

such

patients,

doses

below

those

usually

liver function test results may occur. Vomiting, abdominal pain, colitis, vaginitis including vaginal candidiasis, toxic nephropathy, hepatic dysfunction including cholestasis, aplastic anemia, hemolytic anemia, and hemorrhage reports have been referable to the gastrointestina l tract, particularly nausea reported by about 12% of patients, sometimes accompanied by headache,

-Assess for infection. -Observe for any S/S of anaphylaxis. -Assess for renal dysfunction

-Assess for infection. -Observe for any S/S of anaphylaxis. -Assess for renal dysfunction

recommended should

be

administered cautiously. heart disease

Diphenhydra

temporarily relieves these symptoms due glaucoma to hay fever or other upper thyroid disease respiratory allergies: diabetes

mine

runny nose sneezing itchy, watery eyes itching of the nose or throat

Morphine

Analgesics

trouble urinating due to an enlarged prostate gland high blood pressure

a breathing problem such as temporarily emphysema or relieves these chronic symptoms due bronchitis to the common cold: cough accompanied by runny nose excessive phlegm (mucus) sneezing persistent or chronic cough such as occurs with smoking, asthma or emphysema Moderate to -Hypersensitivit y severe pain. -Pregnancy -Patient who are

marked drowsiness may occur alcohol, sedatives, and tranquilizers may increase drowsiness

-Assess level of consciousness -Avoid alcoholic drinks -Promote Safety

excitability may occur, especially in children be careful when driving a motor vehicle or operating machinery

. The most frequent of these include constipation, nausea and intoxicated with somnolence. alcohol

-Encourage increase fluid intake - Promote safety

Buscopan

Anti-

Controlled-

spasmodic

release tablet indicated

Contraindicated for

the treatment of overactive bladder

with

symptoms of urge

urinary

incontinence, urgency,

and

frequency.

nasal dryness, in patients with cough, urinary pharyngolaryn geal pain, dry retention, throat; gastric retention gastroesophag and other severe eal reflux decreased disease, abdominal gastrointestinal pain, loose motility stools, flatulence, conditions, vomiting; uncontrolled

-Encourage increase fluid intake - Promote safety

narrow-angle glaucoma

and

in patients who are at risk for these Vesicare

Anti-

conditions. Indicated for Contraindicated

muscarinic

the treatment

urinary

Expected side effects of antiin patients with muscarinic urinary agents are dry mouth, retention, constipation, gastric blurred vision (accommodati retention, on uncontrolled abnormalities) , urinary narrow-angle retention, and glaucoma, and dry eyes.

frequency.

in patients who

of overactive bladder

with

symptoms of urge

urinary

incontinence, urgency,

and

have demonstrated hypersensitivity to

the

drug

-Encourage increase fluid intake - Promote safety

substance

or

other components of the product.

Treatment/ Classification

Indication

Contraindication

Infusion D5LR

Nursing Responsibilities

Non-

For fluid and Patients

pyrogenic

electrolyte

known allergy to

solution

replenishment

corn

and supply.

VIII. Pathophysiology

with or

caloric products.

corn

-Assess for any Allergy. -Monitor intake and output.

IX. Date 3-13-

Prioritized List of Nursing Problems Nursing Problems Identified Cues Justification pain Facial grimace Post operative pain

09 anxiety discomfort X.

restless restless

fear of unknown Involuntary urination

Nursing Care Plan

Assessment

Nursing

Plan of Care

Nursing

Evaluation

Diagnosis Subjective data: “Ok na naman ako ngayon medyo masakit lang yung parting naoperahan pag nagagalaw.” as verbalized by the patient. Objective data: -with IVF of D5LR 1L @ 900cc

level

regulated

@

30gtts/min on -with Jackson Pratt drain on pressure

with

bloody

will

verbalized

-Assess type and Goal met as evidence by: location of pain

adequate relief

-Acknowledge

of pain and can

existence

move with no

pain; anticipate with no facial

facial grimace

need

-patient

can

of already

move

for grimace,

verbal saying of

(Early

mild pain.

intervention may -pain decrease analgesic required.) cultural influences

on

pain response (Identifying

dealing

catheter connected urine

to bag

draining to a colored

output -dressing and intact

plays

important part in

suprapubic

dry

scale

the from 6 to 2

total amount of

practices

-with

only

analgesics.

patient’s cultural

output

tea

Patient

-Consider

the left arm

(-)

Acute pain related to post operative surgery

Interventions

with

pain management) -Use pain modifying strategies. A) Modify the environment. B) Administer prescribed analgesics as needed.

-Facial

C) Evaluate patient’s responses to medication

grimace when moving -Pain scale of

D) Consult the physician if relief of pain is not obtained.

6 out of 10 -Vital

signs

taken: BP: 110/80 Temp: 36.5 PR: 82 RR: 20

DISCHARGE PLAN

M - Ensure that that client will follow doctor’s order regarding taking medications at home. E – Encourage client to exercise regularly.

T – Inform client to seek necessary treatment as doctors advised. H – Encourage client to practice general hygiene to prevent infection O - Inform client to make necessary follow up treatment as doctors advised. D - Teach client to eat balance and healthy diet to promote healing and to gain strength. S – Have faith in God. Always pray.