Ovarian Cyst_cs

Liceo de Cagayan University College of Nursing

NCM501202 A Care Study

Submitted to

As Partial Requirement for NCM501202

Submitted by

TABLE OF CONTENTS Page I. Introduction

3

A. Overview of the Case

3

B. Objective of the Study

3

C. Scope and Limitation of the Study

4

II. Health History

5

A. Profile of Patient

5

B. Family and Personal Health History

7

C. History of Present Illness

7

D. Chief Complain

7

III. Developmental Data

8

IV. Medical Management

11

A. Medical Orders and Laboratory Results

11

B. Drug Study

16

V. Pathophysiology with Anatomy and Physiology

23

VI. Nursing Assessment

29

(System Review and Nursing Assessment II) VII. Nursing Management

33

A. Ideal Nursing Management (NCP)

33

B. Actual Nursing Management (SOAPIE)

36

VIII. Referrals and Follow-up

39

IX. Evaluation and Implications

39

X. Documentation

40

A. Documentation of evidence of care for 1 week rotation

40

B. Organization/ Grammar/ Bibliography

41

XI. Rating Scale

41

2

I.

Introduction

A. overview

What is an ovarian cyst? An ovarian cyst is a fluid-filled sac in or on the ovary. Many ovarian cysts are noncancerous cysts that occur as a result of ovulation (the release of an egg from the ovary). These are called functional cysts. Functional cysts normally shrink on their own over time, usually in about 1 to 3 months. Often functional cysts do not cause any symptoms (you may not even know you have one), but other times they can cause abdominal pain, menstrual irregularities, nausea and vomiting. If you have a functional cyst, your doctor may want to check you again in 1 to 3 months to make sure the cyst has gotten smaller. If you develop functional cysts often, your doctor may want you to take birth control pills so you won't ovulate. If you don't ovulate, you won't form functional cysts. If you do have a cyst, your doctor will probably want you to have a sonogram so he or she can look at the cyst. What your doctor decides to do after that depends on your age, the way the cyst looks on the sonogram and if you're having symptoms such as pain, bloating, feeling full after eating just a little, and constipation. f you are menopausal and are not having periods, you shouldn't form functional cysts, but it is possible for you to form other types of ovarian cysts. You should call your doctor if you experience any of the symptoms of an ovarian cyst.

3

B. Scope of the Study 

The study focuses on Medical Ward patient, admitted at Cagayan de Oro Medical Center , Cagayan de Oro City, having the diagnosis of Pulmonary Tuberculosis.



Nature,

causes,

signs

&

symptoms,

pathophysiology,

medical

management, nursing management, and prognosis of the disease. 

Involves the ideal and actual nursing intervention appropriate to address the needs of Mr. X’s, the drug study of the medications given to her, the health teachings as well as referrals for Mr. X.



Assessment of Mr. X’s personal health history, and history of present illness.

C. Limitation of study 

Limited only to the history of the patient which is comprised of the patient’s profile, family and personal health history, chief complaint and history of present illness.



Information being collected from the patient during the patient assessment and from his watchers.



The patient was only taken cared of for 2 days, starting from the 1st day of his admission at Cagayan de Oro Medical Center, Cagayan de Oro City.



Other relevant information was kept confidential including his true identity to protect his privacy.

4

II. Health History A. Patient’s Profile Client’s Name: Age:

28 Years old

Address:

,

Civil Status:

Single

Sex:

Female

Nationality:

Filipino

Religion: Educational Attainment: College Graduate Height:

4’10’’

Weight:

65 kg

Occupation:

Govt Employee

Income:

13000/monthly

Informant:

Cousin

Date of Admission: August 4, 2008

5

Time of Admission: 3:15 pm Chief Complaint:

Irregular Menses, Left Adnexal cyst

Admitting Diagnosis: Para-ovarian cyst Attending Physician: Re-admission date: Re-admission Chief Complaint: Attending Physician:

6

History of Present Illness Chief Complaint : Irregular Menses, Left Adnexal cyst a 28 years old, female, UCCP, a government employee, currently residing at ------------- was admitted in Polymedic General Hospital for the first time last August 4, 2008 at 3:15 pm. On follow up ultrasound (UTZ) noted increase in size of mass thus advised surgery.

Personal Health History In

relation

to

the

health

history

of

the

----------

family,

Ms.

------------------------ has not undergone any previous hospitalization.

7

III DEVELOPMENTAL THEORY 

Erik Erikson’s Theory of Psychosocial Development Erik H. Erikson (1963-1964), adapted and expanded Freud’s theory of

development to include the entire lifespan, believing eight stages of development. Erikson envision life as a sequence of levels of achievement. Each stage signals a task that must be achieved. The resolution of task can be complete, partial, or unsuccessful. Erikson believes that the greater the task achievement, the healthier the personality of the person; failure to achieve a task influence s a person’s ability to achieve the next task. These developmental tasks can be viewed as a series of crises, and successful resolution of these crises is supportive to the person’s ego. Failure to resolve the crises is damaging to the ego. Erikson’s eight stages reflects both positive and negative aspect of the critical life periods. The resolution of the conflicts at each stage enables the person to function effectively in society. Each phase has kits own developmental task, and individual must find a balance between. According to Erik Erikson’s developmental task. Mr N.S , 65 years old, belongs to developmental task of older age, with a central task of integrity versus despair. As I observed, he was kin the positive resolution of development at his stage because according to his daughter he has a good relationship with his parent’s, brothers and sisters and most especially with his wife and children, he had raised them well and really tried his best to support his children, he was a loving father and even though he experienced an illness on his older stage of life, still he was able to show courage and strength while admitted in the hospital. He has a positive coping mechanism skill especially in participating during administration of medication. 

Robert J. Havighurst Developmental Task Theory Havighurst (1900-1991) theorized that the developmental task one must

accomplish throughout life. He described developmental task as doing those

8

things that make up health and satisfactory growth kin society. The task are organically and socially determined. Accomplishing task at a lower level, or at an earlier stage, is the first step in the progression toward accomplishing task at later age. A developmental task is a task which arises at or about a certain period in the life of individual, successful achievements of which leads to his happiness and to success with later task, while failure leads to unhappiness in the individual, disapproval by society, and difficulty with later task. According to Havighurst developmental theory, Mr.N.S 65 years of age, belongs to a period of middle age which was achieving adult civic and social responsibility since at his age he has his own income for being a punong baranggay graduate which he would received an amount of twenty five thousand a month as his salary, also he has his own farm “durian Farm” and according to his daughter her father was really happy with his life and as I observed during the interview and assessment Mr. N.S was really satisfied with his achievements and success in life. 

Jean Piaget Cognitive Developmental Task Theory Piaget’s believes that cognitive structures are complete during the formal

operations period, from roughly 11 to 15 years. From the time formal operations characterize thinking throughout adulthood and are applied to more areas. Egocentrism continue to decline; however these changes in its content and stability. Some may use post-formal operations strategies to assist them in understanding the contradictions that exist in both personal and physical aspects of reality. The experiences of the professional, social and personal life in the middle-aged persons will be reflected in their cognitive performance. The middleaged adult can imagine, anticipate, plan and hope. In relation to our patients, his cognitive and intellectual abilities change very little. As a punong barangay in there area, He uses his intellectual abilities in dealing with problems related to his position. But there were also times that he gave opinions as well as solutions to his people, but there were times that he

9

experienced failure and received pessimistic opinions from other people. Some dragged him down but he never losses hoping in helping others. Even though, He did’nt allow the idea he could not help served other people. According to these treats made him strong and he learned more. 

Sigmund Freud Psychosocial Developmental Task. Psychosocial Development refers to the development of personality. It can

be considered se the outward expression of the inner self. It encompasses a persons temperament, feelings, character, traits, independence, self-esteem, self concept, behavior, ability to interact with others, and ability to adapt to life changes. The culminating stage of Psychosocial Development is Genital Stage ( 13 years and after ) were energy is directed toward attaining a mature sexual relationship. This stage involves a reactivation of the pregenital impulses. These impulses are usually displaced and the individual passes are usually displaced and the individual passes to the genital stage or maturity. An inability to resolve conflicts can result in sexual problems, such as frigidity, impotence and the inability to have satisfactory sexual relationship. Our patients 65 years old, in his age right now, he encountered many things that made him strong. He was blessed with a loving wife and 4 children where he offers all his achievements. All her children graduated from college. But unfortunately, his 2 children migrated here in CDO to work and live. He hates the idea of being away from his children but he still accepted it. According to him, “ it’s a part being a parent”. He was also engaged in politics where his socialization, decision making and being an achiever was practiced. But because of his illness, his turn or position being a Barangay Captain was transferred to another official. According to his wife, he then became moody. If you need something or you will ask something, he got easily irritated.

10

IV. Medical Management A. Doctor’s Order August 4, 2008 Please admit under the service of Dr. To provide care and close monitoring Paano-Go NPO Labs; CBC, FBS, SGPT, HepBAg,

To prepare for surgery To obtain baseline data’s and to know

chest x-ray, PA, ECG 12 L For pelvic lap on 8/5/08 Secure consent Inform OR Inform me once patient is admitted

any abnormalities Removal of ovarian cyst For documentation For preparation To start the surgery

Pre Operative August 4, 2008 Please start D5LR 1L regulated @ 30 To maintain fluid and electrolytes gtts/min tomorrow @ 6:30 am Emergency order and body hygiene HepB precaution Cefuroxime 750 mg IV ++ ANST (-) to

To protect and prevent infection To prevent infection

begin 1 hour before surgery

11

Post Operative August 5 2008 9:30 AM NPO To prevent irritation of the intestinal wall Post spinal care To give comfort Monitor vital signs every 15 mins x 2, To monitor patients condition after every hour x 4 hours every shift until

surgery

stable General liquid diet May turn to side

To prevent irritation in GIT To prevent bed sore and promote blood circulation

May give Nalbuphine

August 6 2008 6:30 AM DAT To give adequate nutrition to the patient Remove FBC and refer if unable to Provide comfort urinate 6 hours after Discontinue Famotidine Multivit 1 tab 2x/day Ferrous sulfate (feosol), 1 tab OD May sit up on bed

To nourish the patient To supplement iron intake of the patient To promote blood circulation and

Regulate IVF at KVO

ambulation To keep vein open

9:00 AM D5LR 1L at KVO To maintain fluids and electroytes Give paracetamol 500mg 1 tab every 4 To prevernt fever and relief to any pain hours RTC Discontinue Nalbuphine

August 7 2008 10:30 AM Discontinue IVF when dry mouth Discontinue Cefuroxime IV Prevent occurrences of side effects Cefuroxime 500mg every 12 hours PO Prevent antiterrorist Discontinue Nalbuphine For healing May ambulate

12

Laboratory Results August 4 2008

Fasting Blood Sugar Sero and Immuno HbeAg

Result

Normal range

Rationale

89.95

60-100mg/dL

within normal limit

1.0 nonreactive

reactive HBeAg

.107

Hematology Test

Results

Normal Range

Clotting time

3:49 mins

3-7 mins

Bleeding time

2.05 mins

1-3 mins

Complete Blood count Test

Results

Normal range

WBC

+10.82 x10/L

5-10

RBC

4.80 x10/L

3.69-5.90

Hemoglobin

13.5 g/dL

11.70-14

Hematocrit

40.7 %

34.10-44

Differential Count

53.6 %

55-62

Neutrophils

34.8 %

20-40

Lymphocytes

8.7 %

4-10

Monocytes

2.8 %

1-6

Eosinophils

0.1 %

0-1

Basinophils

13.1 %

11.5-14.5

Chemistry Test

Results

Normal range

SGPT (ALT)

28.98 U/L

9-36

Potassium

4.33 meq/L

3.50-5.50

Sodium

138.60 meq/L

135-155

13

Creatinine

1.06 mgs/dL

.07-1.30

Radiology Request Form Request Examination:

ECG 12 L

Request by:

Dr. Paano-Go Radiologic Report

Lungs are clear. Heart is not enlarged. Midline structures are displaced. The CP sulci and hemidiaphrams are intact. The rest of the included structures are all unremarkable Normal chest findings Pelvic (endovaginal) sonogram Impression: Increase in size of the previously noted non-septated pelvic cystic mass, as described. Normal size uterus with endometrial thickness of 1.5 cm Sonographically normal right ovary, adnexal and urinary bladder non visualized left ovary. Well defined non-septated left Para ovarian cyst (7.2 x 6.6 x 6.3 cm) Normal sized uterus with endometrial thickness of 1.6 cm Tiny Nabothian cyst Normal sized urinary bladder

14

B. Drug Study Generic name

Cefuroxime

Brand

Date

name

ordered 8-4-08

Classification

Dose/

Mechanism

Specific

Frequency/

of action

Indication

Contraindication

Side effects

Nsg Precautions

Antibiotic

Route 750 mg IV

Bactericidal;

Parenteral:

Allergy to

Headache,

Renal

Cephalosphori

ANST ( - )

inhibits the

Lower

cephalosphorin or

dizziness,

Failure,

n

give 1 hour

growth of

respiratory

penicillin

lethargy,

lactation,

before

baterial cell

infections

Nausea,

pregnancy

surgery

wall, causing

caused by S.

vomiting,

death

pyogenes

diarrhea,

Dermatoligi

abdominal

c Infection

pain, pain,

UTI’s

infection at

Septicemia

the

Meningitis

injection

Preoperative

site

prophylaxis

15

Generic name

Ranitidine

Brand

Date

name

ordered 8-5-08

Classification

Dose/

Mechanism

Specific

Frequency/

of action

Indication

Contraindication

Side effects

Precautions

Antihistamine

Route 20 mg IV

Blocks

Short-term

Allergy to

Headache,

,

every 12

daytime and

treatment of

ranitidine and

malaise,

gastrointestina

hours

nocturnal

active

lactation

dizziness,

basal gastric

duodenal

somnolence

acid

ulcer;

, insomnia,

secretion

maintenance

vertigo,

stimulated

therapy for

mental

by histamine

duodenal

confusion,

and reduces

ulcer patient

agitation,

gastric acid

after healing

depression,

release in

of acute

hallucinatio

response to

ulcer;short-

ns in older

food,

term

adults.

pentagastrin,

treatment of

and insulin.

active,

Shown to

benign

inhibit 50%

gastric

of the

ulcer;

stimulated

treatment of

gastric acid

pathologic

l Agent

Nsg

Hepatic and renal dysfunction. pregnancy

secretion.

16

Post Operative medications Generic name

Brand

Date

name

ordered

Classification

Dose/

Mechanism

Specific

Frequency/

of action

Indication

Contraindication

Side effects

Nsg Precautions

Route Cefuroxime

8-5-08

Antibiotic

7 50 mg IV

Bactericidal;

Parenteral:

Allergy to

Headache,

Renal

Cephalosphori

every 12

inhibits the

Lower

cephalosphorin or

dizziness,

Failure,

n

hours

growth of

respiratory

penicillin

lethargy,

lactation,

baterial cell

infections

Nausea,

pregnancy

wall, causing

caused by S.

vomiting,

death

pyogenes

diarrhea,

Dermatoligi

abdominal

c Infection

pain, pain,

UTI’s

infection at

Septicemia

the

Meningitis

injection

Preoperative

site

prophylaxis

17

Generic name

Brand

Date

name

ordered

Classification

Dose/

Mechanism

Specific

Frequency/

of action

Indication

Competitiv ely blocks the action of histamine at the histamine (H2) receptors of the parietal cells of the stomach; inhibits basal gastric acid secretion and chemically induced gastric acid secretion.

Short-term treatment and maintenance of duodenal ulcer Short-term treatment of benign gastric ulcer Treatment of pathologic hypersecreto ry conditions Short-term treatment of GERD, esophagitis due to GERD OTC: Relief of symptoms of heartburn, acid indigestion, sour stomach

Contraindication

Side effects

Nsg Precautions

Route Famotidine

8-5-08

Histamine 2 20 mg IV (H2) every 12 receptor hours antagonist

Contraindicated with allergy to famotidine; renal failure; lactation.

CNS: Headache, malaise, dizziness, somnolence , insomnia Dermatolo gic: Rash GI: Diarrhea, constipatio n, anorexia, abdominal pain Other: Muscle cramp, increase in total bilirubin, sexual impotence

Use cautiously with pregnancy, renal or hepatic dysfunction.

18

Generic name

Brand

Date

name

ordered

Classification

Dose/

Mechanism

Specific

Frequency/

of action

Indication

Analgesic action that relieves moderate to severe pain with apparently low potential for dependence

Symptomati c relief of moderate to severe pain. Also preoperative sedation analgesia and as a supplement to surgical anesthesia

Contraindication

Side effects

Nsg Precautions

Route Nalbuphine

8-5-08

CENTRAL NERVOUS SYSTEM (CNS) AGENT; ANALGESIC ; NARCOTIC (OPIATE) AGONISTANTAGONIS T

5 mg IV every 10 hours

History of hypersensitivity to drug. Safety during pregnancy (category C) or lactation is not established. Prolonged use during pregnancy could result in neonatal withdrawal.

Hypertensi on, hypotensio n, bradycardia , tachycardia , flushing. GI: Abdominal cramps, bitter taste, nausea, vomiting, dry mouth.

History of emotional instability or drug abuse; head injury, increased intracranial pressure; impaired respirations; impaired kidney or liver function; MI; biliary tract surgery.

19

Generic name

Brand

Date

name

ordered

Classification

Dose/

Mechanism

Specific

Frequency/

of action

Indication

Reduces or eliminates the pain of rheumatoid and osteoarthritis

Relief of S&S of osteoarthriti s and rheumatoid arthritis. Treatment of acute pain and primary dysmenorrh ea.

Contraindication

Side effects

Nsg Precautions

Route Celecoxib

8-5-08

CENTRAL NERVOUS SYSTEM AGENT; ANALGESIC ; NONSTEROI DAL ANTIINFLAMMA TORY DRUG (NSAID); COX-2; ANTIPYRETI C

400 mg OD cap P.O

Severe hepatic impairment; hypersensitivity to celecoxib; asthmatic patients with aspirin triad; advanced renal disease; concurrent use of diuretics and ACE inhibitors; anemia; pregnancy (category D) in third trimester; lactation

Body as a Whole: Back pain, peripheral edema. GI: Abdominal pain, diarrhea, dyspepsia, flatulence, nausea. CNS: Dizziness, headache, insomnia. Respirator y: Pharyngitis , rhinitis, sinusitis, URI. Skin: Rash..

Patients who are P450 2C9 poor metabolizers; patients who weigh <50 kg; moderate hepatic impairment; renal insufficiency; aspirin use; prior history of GI bleeding or peptic ulcer disease; asthmatics; pregnancy

20

Intravenous Fluids Date Ordered 8-5-08 8-5-08 8-6-08 8-6-08

Solution #1 D5LR 1L @ 30 gtts/min post op + 50 mg omdis #2 D5LR 1L @ KVO #3 D5LR 1L @ KVO

21

Anatomy and Physiology Female Reproductive System The female reproductive anatomy includes internal and external structures. The female reproductive system contains two main parts: the vagina and uterus, which act as the receptacle for the male's sperm, and the ovaries, which produce the female's ova. All of these parts are always internal; the vagina meets the outside at the vulva, which also includes the labia, clitoris and urethra. The vagina is attached to the uterus through the cervix, while the uterus is attached to the ovaries via the Fallopian tubes. At certain intervals, the ovaries release an ovum, which passes through the fallopian tube into the uterus. If, in this transit, it meets with sperm, the sperm penetrate and merge with the egg, fertilizing it. The fertilization usually occurs in the oviducts, but can happen in the uterus itself. The zygote then implants itself in the wall of the uterus, where it begins the processes of embryogenesis and morphogenesis. When developed enough to survive outside the womb, the cervix dilates and contractions of the uterus propel the fetus through the birth canal, which is the vagina. The ova are larger than sperm and are generally all created by birth. Approximately every month, a process of oogenesis matures one ovum to be sent down the Fallopian tube attached to its ovary in anticipation of fertilization. If not fertilized, this egg is flushed out of the system through menstruation. 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:

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). Bartholin's 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 22

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.

The internal reproductive organs in the female 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. The vagina is the tubular tract leading from the uterus to the exterior of the body in female mammals, or to the cloaca in female birds and some reptiles. Female insects and other invertebrates also have a vagina, which is the terminal part of the oviduct. The vagina is the place where semen from the male is deposited into the female's body at the climax of sexual intercourse, commonly known as ejaculation.

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. The uterus or womb is the major female reproductive organ of humans. One end, the cervix, opens into the vagina; the other is connected on both sides to the fallopian tubes.

A pictorial illustration of the female reproductive system. The uterus mostly consists of muscle, known as myometrium. Its major function is to accept a fertilized ovum which becomes implanted into the endometrium, and derives nourishment from blood vessels which develop exclusively for this purpose. The fertilized ovum becomes an 23

embryo, develops into a fetus and gestates until childbirth. If the egg does not embed in the wall of the uterus a woman gets her period and the egg is flushed away.

Ovaries: The ovaries are small, oval-shaped glands that are located on either side of the uterus. The ovaries produce eggs and hormones. The ovaries are the place inside the female body where ova or eggs are produced. The process by which the ovum is released is called ovulation. The speed of ovulation is periodic and impacts directly to the length of a menstrual cycle. After ovulation, the ovum is captured by the oviduct, where it travelled down the oviduct to the uterus, occasionally being fertilised on its way by an incoming sperm, leading to pregnancy and the eventual birth of a new human being. The Fallopian tubes are often called the oviducts and they have small hairs (cilia) to help the egg cell travel. 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.

The cervix is the lower, narrow portion of the uterus where it joins with the top end of the vagina. It is cylindrical or conical in shape and protrudes through the upper anterior vaginal wall. Approximately half its length is visible; the remainder lies above the vagina beyond view. 24

Oviducts The Fallopian tubes or oviducts are two very fine tubes leading from the ovaries of female mammals into the uterus.\ On maturity of an ovum, the follicle and the ovary's wall rupture, allowing the ovum to escape and enter the Fallopian tube. There it travels toward the uterus, pushed along by movements of cilia on the inner lining of the tubes. This trip takes hours or days. If the ovum is fertilized while in the Fallopian tube, then it normally implants in the endometrium when it reaches the uterus, which signals the beginning of pregnancy

25

Pathophysiology of Ovarian cyst Ovary \\\

Produces Graafian Follicles

Release of a mation

Oocyts becomes the curpu lutuem

No fertilization

She know of fertilization

Curopose luteum initiliably, decrease in size ang thendrually them

Ocytes undergone fibrosis

Enlargement of the corpus luteum

Ovarion Cyst

26

27

VI. NURSING ASSESSMENT NURSING SYSTEM REVIEW CHART Name:____Mara Nova C. Lapeceros________________________________________ Date Temp.:_39.5 C____ Pulse Rate:_92bpm___ Height:_50cm___ Weight:_7 kgs_____ INSTRUCTIONS: Place an [X] in the area of abnormality. Comment at the space provided. Indicate the location of the problem in the figure using [X]. EENT: [X] impaired vision [ ] blind [ ] pain [ ] reddened [ ] drainage [ ] gums [ ] hard of hearing [ ] deaf [ ] burning [ ] edema [ ] lesion [ ] teeth Assess eyes, ears, nose throat for abnormalities. [ ] no problem RESPIRATORY: [ ] asymmetric [ ] tachypnea [ ] apnea [ ] rales [ ] cough [ ] barrel chest [ ] bradypnea [ ] shallow [ ] rhonchi [ ] sputum [ ] diminished [ ] dyspnea [ ] orthopnea [ ] labored [ ] wheezing [ ] pain [ ] cyanotic Assess resp. rate, rhythm, pulse blood breath sounds, comfort [ x] no problem CARDIOVASCULAR: [ ] arrhythmia [ ] tachypnea [ ] numbness [ ] diminished pulses [ ] edema [ ] fatigue [ ] irregular [ ] bradycardia [ ] murmur [ ] tingling [ ] absent pulses [ ] pain Assess heart sound, rate, rhythm, pulse, blood pressure. circulation, fluid retention, comfort [X] no problem GASTROINTESTINAL TRACT: [ ] obese [ ] distention [ ] mass [ ] dysphagia [ ] rigidity [X] pain Assess abdomen, bowel habits, swallowing bowel sounds, comfort. [ ] no problem GENITO-URINARY AND GYNE: [ ] pain [ ] urine color [ ] vaginal bleeding [ ] hematuria [ ] discharge [ ] nocturia assess urine frequency, control, color, odor, comfort, gyne bleeding, discharge [x] no problem NEURO: [ ] paralysis [ ] stuporous [ ] unsteady [ ] seizures [ ] lethargic [ ] comatose [ ] vertigo [ ] tremors [ ] confused [X] vision [ ] grip assess motor, function, sensation, LOC, strength grip, gait, coordination, speech [ ] no problem MUSCULOSKELETAL AND SKIN: [ ] appliance [ ] stiffness [ ] itching [ ] petechiae [ ] hot [ ] drainage [ ] prosthesis [ ] swelling [ ] lesion [ ] poor turgor [ ] cool [ ] deformity [X] wound [ ] rash [ ] skin color [ ] flushed [ ] atrophy [x] pain [ ] ecchymosis [ ] diaphoretic [ ] moist assess mobility, motion, gait, alignment, joint function skin color, texture, turgor, integrity [ ] no problem

B

X

__________________ __________________ __________________ _Dizzy_____________ __________________ __________________ __________________ __________________ __________________ Incision site_________ Pain upon exertion or_ movement__________ __________________ D5LR 1L @ 30 gtt/min __________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ _____________ _____ __________________ __________________ __________________ __________________ ___ _______________ __________________ __________________ __________________ __________________ __________________ ___ _ _____________ __________________ __________________ __________________ __________________ __________________ __________________ __________________

28

NURSING ASSESSMENT II SUBJECTIVE COMMUNICATION: [ ]Hearing loss Comments “lipong pa [x]Visual changes siya, bag-o paman [ ]Denied siya ni gawas sa OR Verbalized by the cousin of the patient OXYGENATION: [ ]Dyspnea Comments: “Wala may [ ]Smoking history problema sa iyang pag[ ]Cough ginhawa” as verbalized [ ]Sputum by her cousin [x]denied CIRCULATION: [ ]Chest pain Comments: “wala man [ ]Leg pain ngsakit iyang dughan” [ ]Numbness of as verbalized by the Extremities patient’s cousin [X]Denied NUTRITION: Diet NPO_ [X]N [X]V Character [ ] Recent change in Weight, appetite [ ]Swallowing Difficulty [x]denied ELIMINATION: Usual bowel pattern 1 x a day________ [ ]Constipation Remedy None date of last BM 08-03-08 [ ]Diarrhea Character

OBJECTIVE [ ]Glasses [ ] languages [ ]Contact lenses [ ] hearing aid R L Pupil size 2-3 mm □speech difficulties Reaction Pupil equally round but not reactive to light accommodation Resp. [x] regular [ ]irregular Described: Breathing are regular R equal expansion to left lung L equal expansion to right lung Heart rhythm [x] regular □ irregular Ankle edema ___none_________ Pulse Car. Rad. DP. Fem* R + + + + L + + + + Comments: all pulse are palpable *If applicable [ ]Dentures

Comments: ”wala paman pud siya nagkaon” As verbalized by the patient’s cousin

urinary frequency diaper_____ [ ]urgency [ ]dysuria [ ]hematuria [ ]Inconsistence [ ]Polyuria [ ] foly in place [x ]denied

[ x ]none Full

patient Upper Lower

[x] [x]

partial [ ] [ ]

with [ ] [ ]

Comments Bowel sounds Patient has not audible elimination bowel Abdominal distension since the surgery Present □yes □no Urine* (color, consistency, Odor) Urine is yellow drainig Well into the the FBC If foley is in place

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MGT. OF HEALTH & ILLNESS: [ ]Alcohol [x]denied (amount frequency) ______none_____________ □SBE Last Pap Smear n/a LMP__n/a__________ SKIN INTEGRITY: □Dry Comments “wala man □Itching sad kapangatul ang □Other iyang lawas ”as □denied by the patients Cousin ACTIVITY/SAFETY: [ ]Convulsion [X]Dizziness [x]Limited motion Of joints Limitation in ability to [x]ambulate [x]bathe self [ ]other [ ]denied

Comments: Lipong paman siya dili paman gani paistoryahon sa doctor” verbalized by the patients cousin

COMFORT/SLEEP/AWAKE: [x]Pain Comments: “sakit (location) Lagi daw iyang opera” Frequency verbalized by the Remedies) patients cousin [ ]Nocturia [ ]Sleep difficulties [X ]denied COPING: Occupation Government Employee Members of Household 6 Most supportive person father

Bfiefly described the patient’s ability to follow treatments (diet, meds, etc.) for chronic health problems (if present) The patient is closely monitored and compliant to medications.

Dry cold pale Flushed x warm Moist cyanotic *rashes, ulcers, decubitus(described size, location, drainage) superficial partial thickness burn. LOC and orientation patient is unconscious and not oriented to time Galt: [ ]walker [ ]cane [ ]others [x]Steady [ ]unsteady_______ [ X]Sensory and motor losses in face or extremities No sensory or motor losses in extremities [ ]ROM limitations Patient has limited range of motion due to loss of sensory [x]Facial grimaces [X]Guarding [x]Other signs of pain:______________ [ ]Siderail release form signed (60+ years) Not applicable Observed non-verbal behavior patient is compliant to this treatment plan the person and his contact number that can be reach any time Cousin

30

SPECIAL PATIENT INFORMATION ___________ daily weight none PT/OT N/A ___________ BP q Shift none Irradiation Not taken Neuro vs Urinalysis Urine test routine urinalysis Not taken CVP/SG. Reading N/A none 24 hour urine collection Date Diagnostic/Laborator Date Date I.V: Date ordered y done ordered Fluids/Blood Disc. Exams 08-04-08 Complete blood 08-04-08 08-04-08 #1 D5LR 08-05-08 count 08-04-08 HepBeAg 08-04-08

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VII Nursing Management A. Ideal Nursing Care Plan 1. NURSING DIAGNOSIS: Acute Pain related tissue trauma secondary to abdominal surgery Independent Interventions: 1. Investigate pain reports, noting location,

duration,

intensity,

1. Changes in location/intensity are

(1-10

not uncommon but may reflect

scale), and characteristics ( e.g. dull,

developing complications. Pain

sharp, constant).

tends to become constant, more intense, and diffuse over the entire abdomen as inflammatory process accelerates; pain may localize if an abscess develops

2. Maintain semi-fowler’s position as indicated

2. facilitates fluid/ wound drainage by

gravity

diaphragmatic abdominal

,

reducing

irritation

tension

,

and

thereby

reducing pain. 3. Move client slowly and deliberately, splinting painful area.

3. reduces guarding,

muscle which

tension/ may

help

minimize pain of movement 4. Provide comfort measures e.g. massage, back rubs, deep breathing. Instruct in relaxation/ visualization exercises. Provide diversional activities. 5. Provide frequent oral care. Remove noxious environmental stimuli

4. promote

relaxation

and

may

enhance client’s coping abilities by refocusing attention. 5. reduces nausea and vomiting, which

can

increase

intraabdominal pressure/pain.

32

Dependent Intervention 1. Administer medication as indicated: Analgesic, narcotics;

1. reduces

metabolic

intestinal

rate

irritation

and from

circulating/local toxins, which aid in relied and promote healing. Note: pain is usually severe and may control.

require

narcotic

Analgesics

may

pain be

withheld during initial diagnostic process because they can mask signs/ symptoms. 2.Nursing Diagnosis : Risk for Constipation risk factors may include physical factors: abdominal surgery. Independent Interventions: 1. Auscultation bowel sounds. Note abdominal distention, presence of nausea / vomiting. 2. Assist client with sitting on the edge of the bed and walking. 3. Encourage adequate fluid intake, including fruits juices, when oral is resumed 4. provide sitz bath Dependent Intervention: 1. Adminster medications e.g. stool softeners, mineral oil, laxative, PRN

1. Indicators of presence / resolution of ileus, affecting choice of interventions. 2. Early ambulation helps stimulate intestinal function and return of peristalsis. 3. promotes softer stools, may aid in stimulating peristalsis. 4. promotes muscle relaxation, minimizes discomfort. 1. Promote formation/ passage of softer stools

33

3. Nursing Diagnosis : Risk for ineffective tissue perfusion risk factors may include postoperative tissue trauma. Independent Interventions: 1. Monitor Vital signs, palpate peripheral pulses note capillary refill, assess urinary output,/ characteristics, evaluate changes in mentation 2. Inspect dressings and perineal pads, noting color, amount, and odor of drainage. Weigh pads and compare with dry weight if client is bleeding heavily.

3. Turn client and encourage frequent coughing and deep breathing exercises. 4. Avoid high Fowlers position and pressure under the knees or crossing of legs. 5. Assist with/ instruct in foot and legs exercises and ambulate as soon as able. 6. Note erythema, swelling of extremity, or reports of sudden chest pain with dyspnea Dependent Intervention 1. Administer IVF, blood products PRN

1. Indicators of adequacy of systemic perfusion, fluid/ blood needs, and developing complications. 2. Proximity of large blood vessels to operative site and/ or potential for alteration of clotting mechanism ( e.g. cancer ) increase risk of postoperative hemorrhage. 3. Prevents stasis of secretion and respiratory complication. 4. Creative vascular stasis by increasing pelvic congestion and pooling of blood in the extremities, potentiating risk of thrombus formation. 5. Movement enhance circulation and prevents stasis complications. 6. may be indicative of development of thrombophlebitis/ pulmonary embolus 1. Replacement of blood losses maintains circulating volume and tissue perfusion.

34

B. Actual Nursing Care Plan 1st Priority

S O A P

“sakit akong tiyan kung mulihok ko” as verbalized by the patient 

Facial grimace

 Guarding Acute Pain related tissue trauma secondary to abdominal surgery Short term: At the end of 15-30 minutes, the patient will be able report pain is relieved Long term: At the end of 8 hours, the patient will be able to demonstrate

I

relaxation skills, other methods to promote comfort. Independent: 1. Provide palliative measures e.g. reading books, watching T.V, to divert the patient’s attention 2. Provide comfort measures e.g. massage, back rubs, deep breathing, provide comfort 3. move client slowly, minimize the feeling of pain 4. ambulate patient PRN, to promote blood circulation thus facilitate healing Dependent: 1. Administer medication as needed e.g. Analgesics, relieve pain

E

After 15 minutes, the patient was relieved from feeling of pain

35

2nd Priority

S O

A P

“Wala pako nakalibang pag abot nako dinhi” as verbalized by the patient 

No bowel movement for 3 consecutive days



Dry skin

 Less movement Constipation related to pain in surgical area Short term: At the end of 1 day, the patient will reestablish normal patterns of bowel functioning

I

Long term: pass stool of soft/semiformed consistency without straining Independent: •

Note abdominal distention and auscultate bowel sounds, observe the patient’s condition

•

Provide privacy, promotes psychologic comfort

•

Encourage early ambulation, facilitates passage of flatus

•

Offer bed pan, to encourage patient to defecate

Dependent: 2. Administer medication e.g. Laxatives, stool softener PRN, softens stools

E

After 1 day the patient’s normal bowel movement was reestablished

36

3rd Priority

S O

A P

“ma lipong ko basta mutindog ko” as verbalized by the patient 

Disoriented to person, place and time



Change in usual response to stimuli

 Impaired ability to concentrate, reason, make decision Disturbed sensory perception related to hypoxia Short term: At the end of 15-30 minutes, the patient will recognize limitations and seek assistance as PRN Long term: at the end of 1 hour the patient will regain usual level of

I

consciousness Independent: •

Speak in normal, clear voice, without shouting, being aware of what you are saying Minimize discussion of negatives (e.g. clients personal problems) within clients hearing. Explain procedures and environmental events even client those not seem aware

•

Use bed rail padding, medical protective devices PRN

•

Secure Parenteral line ( ET tube, catheter, if present, and check for patency)

•

Maintain quite, calm environment

Dependent:

E

Refer to physician for alternate care option At the end of 30 minutes the patient recognizes limitations and seek assisstance

37

VIII Referrals and Follow ups For the health problems of Ms. Lapeceros, who has undergone through surgery for the removal of her ovarian cyst, she should be referred accordingly to any hospital institution whenever symptoms of complication and/or infection occur. Patient should contact to her physician for immediate management of her condition if any unusualities occur. Patient should instructed to have her follow-up check up with her physician in the exact day at the exact time of schedule, even if she doesn’t feel better, after being discharged from the hospital.

XI Evaluation and Implications

During the 2nd day nursing care of the patient, Ms Lapeceros was able to manifest stable vital signs and signs and symptoms that may lead to the progress of the physical well-being. After rendering health care service and doing necessary interventions to the patient. An improvement of Ms Lapeceros’s health status was observed as evidenced by normal vital signs and verbalization of normal breathing pattern. At the end of the shift, the interventions and procedures done to the patient were successful and the patient was able to participate actively to the treatment regimen. The condition of the patient implies that the surgery was reliable for reliance as the last resort of any condition. In this case, through Ms. Lapeceros’s experience proved that surgery is still trustworthy and that health is very importance to maintain in order to prevent ourselves from getting sick or getting ill.

38

X Documentation a) Documentation of evidence of care for 1 week rotation

Assessing Ms. Lapeceros

39

b. Organization/Grammar/ Bibliography

Douges, M.E. et.al., (2002). Nurse’s pocket guide: diagnosis, interventions & rationales. (8th Edition). Philadelphia: F.A. Davis Company. Douges, M.E. et.al., (2002). Nursing care plan: guidelines for individualizing patient care (6th Edition) Philadelphia: F.A. Davis Company. Gulandick, M. et.al., Nursing care plan. (3rd Edition) Ignatavicius, D.D. & Workman, M.L. (2006). Medical-surgical nursing: critical thinking for collaborative care. (5th Edition). St. Louis, Missouri: Elsevier Saunders. Kozier, B. et.al., (2004). Fundamentals of nursing: concepts, process & practice. (7th Edition). Philippines: Pearson Education South Asia PTE Ltd. Smeltzer, S.C. & Bare, B.G. (2004).Textbook of medical-surgical nursing(10th Edition, Volume 2). Philadelphia: Lippincott Williams and Wilkins. pp 553-538. Spratto, G.R. & Woods, A.L. (1994). Nurse’s drug reference. USA: Delmar Publishers Incorporated. Ulrich & Canale. (2005). Nursing care planning guides. (6th Edition).

40

LICEO DE CAGAYAN UNIVERSITY COLLEGE OF NURSING NCM501202 A CARE STUDY Mara Nova C. Lapeceros Name of Client Submitted to Mrs. Gina Batasin-in, RN Name of faculty As Partial Requirement for NCM501202 Submitted by Michael Angelo D. Simyunn Jr. Name of Student RATING SCALE

A. Written I. introduction a. overview of the case b. objective of the study c. scope and limitation of the study II. Health History a. profile of patient b. family and personal health history c. history of patients illness d. chief complain III. developmental data IV. medical management a. medical orders and rationale b. drug study V. Pathophysiology with anatomy and physiology VI. Nursing assessment VII. Nursing Management a. Ideal nursing management (NCP) b. actual nursing management (SOAPIE) VIII. referral and follow-up IX. Evaluation and implication X. documentation a. documentation of evidence of care for 1 week rotation b. organization/grammar/bibliography TOTAL SCORE EQUIVALENT GRADE

WEIGHT 5

RATING

5

5 20 (10) (10) 10 10 30 (10) (20) 5 5 5 100

41

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