This Is It- Myoma Case Presentation

Uterine Myoma

Presented by: Abu, Camile Granada, Glyde Pebbles Landicho, Katrina Linatoc, Jeanne Lyn Luza, Ailen Maralit, Ma. Krishna Sim, Khay Ulan, Darlene Umali, Marianne Lyn Avena, Gaudencio Dimaculangan, Argenald Joseph Hernandez, Michael Franklin

GENERAL OBJECTIVE  Our group aims to be formulate a comprehensive case analysis that would provide essential knowledge and skills in delivering quality health care to patient’s diagnosis with uterine myoma.

SPECIFIC OBJECTIVES To be able to: > know the disease ,its clinical manifestations, risk factors, pathophysiology and diagnostic procedures for the disease. > Identify different medical and surgical management of a patient diagnosed with uterine myoma. > Enhance our skills in caring a patient with uterine myoma. > Familiarized us with the medications used to managed the disease. > Recognized appropriate nursing care and management. > Help the patient realized her role in maintaining and improving health.

INTRODUCTION Uterine myoma is the most common tumors of the female genitalia tract. Myoma commonly called fibroid. It is the benign tumor of the smooth muscle in the wall of the uterus. Hysterectomy has been a common therapy in patients who have completed reproduction. Total hysterectomy plus bilateral salphingo oophorectomy TAHBSO- this procedure removes the uterus, cervix, both ovary and both fallopian tube.

Fibroids can be present and be apparent. However they are clinically apparent in up to 25 % of the women. Although, myoma is generally considered to be slowly growing tumor in 20-40% of women at the age of 35 and more have uterine fibroids of significant sizes with severe clinical symptoms. Moreover, myoma can be relapse in 7-28% of patient after surgical treatment and in certain case it may even turn to malignant tumor, this could causes significant morbidity including prolonged or heavy menstrual bleeding, pelvic pleasure and pain and in rare cases reproductive dysfunction. Myoma affects one of every four women ¾ of woman with this condition,however, experience no symptoms.

Uterine myoma is developing on the background of hyper estrogen, progesterone, deficits in hyper gonodotrophine. The majority of the researches say that the growth of myoma depends on concentration of cystosolic receptors to the sex hormones and their interactions, with the endrogen or extrogen hormones. In accordance to clinical observations, it can be admitted that both growth and regressions of myoma are estrogen-dependent, is the tumor size gets increased during pregnancy and is regressed after menopause. The only that needs to clear is to find out whether it is decreased in receptors numbers of estrogen, progesterone and androgen- hormones quantities which lead to regression in myoma size ( regarding androgen there is an hypothesis that myoma is sensitive to androgen ) for growth that formed tumors, the need to be further supported by negative factors.

Abortions, long term used of inadequate contraceptive pills, chronic sub-acute and acute inflammation of uterus or its appendices, stress, ultraviolet radiation, cystic formation of ovary etc. for example, the woman who had ten abortions by the age of thirty have double to developed uterine myoma at fourty years old. In fact, uterine myoma = account for 20% of 650,000 hysterectomies performed annually in the U.S interest in the uterine preservation and organ preserving surgery through techniques minimally invasive surgery has increased the first reports of laparoscopic myomectomy.

PATIENT’S PROFILE PATIENT’S NAME: Lady L. AGE: 48 years old GENDER: Female PERMANENT ADDRESS: Inosluban, Lipa City BIRTHDATE: August 26, 1960 BIRTHPLACE: Lipa City, Batangas CIVIL STATUS: Married CITIZENSHIP: Filipino RELIGION: Roman Catholic ADMISSION DATE: August 22, 2008 ADMISSION DIAGNOSIS: Uterine Myoma ATTENDING PHYSICIAN: Dra. Lovely Cacho Dra. Alice Lojo

HISTORY OF PRESENT ILLNESSS Present condition started about 6 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 hospital for check-up and she found out that she has a myoma. Her attending physician said that she need to undergo surgery but they didn’t have enough money that time, they would need to save for the hospitalization and operation that will undergo. Until August 22, 2008, when her relative noted her to be pale, having dizziness and body weakness bought her to the hospital. After a series of examination, she was scheduled and prepared her to surgery.

PAST MEDICAL HISTORY She has never been hospitalized except when she had two breech presentations with her two sons. Other than that, she usually experiences cough, cold, fever and buys over the counter drugs to treat the said illnesses. Prior to that, sometimes she consults the said quack doctors or faith healers if she thinks that it’s just that a simple illness.

SOCIO – CULTURAL She is a friendly person. She is closed with her four sons and loves them so much. She admitted that few years ago, she used to smoke when she is defecating and after eating. She said that she loves to eat vegetables and she exercises regularly. She cooks in a canteen in Lipa bus stop which sustains their basic needs.

PHYSICAL ASSESSMENT ACTUAL NORMAL VITAL SIGNS VALUES

INTERPRETA TION

RR- 24

12-20 beats/min.

Normal

PR- 80

60-100 beats/min.

Normal

BP- 120/70

90/60- 130/90 mmHg

Normal

Height = 5’1’’

Weight = 57 Kg.

Body Parts Technique Normal used findings

Actual findings

Significance

Head

Inspection Palpation

NormocephaNormocephaNormal lic lic Normal No No abnormal abnormal mass mass

Hair and scalp

Inspection

Evenly distributed, Thick hair, no infection and infestation

Even Normal distribution of hair , no infection and infestation

Eyes

Inspection

Symmetric Sunken to the face, eyeball both eyes coordinated with parallel alignment.

Not Normal. Due to dehydration

External eye Structure Eyebrows

Inspection

Hair evenly Evenly distributed, distributed Skin intact with skin intact

Normal

Eyelashes

Inspection

Equally distributed, Curled slightly outward

Equally Normal distributed, Curled slightly outward

Eyelids

Inspection

Skin intact, Skin intact, Normal No no discharge, discharge, No no discolorationdiscoloration , , lids are Lids close symmetrical. symmetricall y

Lacrimal gland

Inspection No edema No edema Normal or tearing. and tearing

Pupils Inspection Black in (color , color, equal shape and in size symmetry normally 3of size) 7 mm in diameter, round smooth border , iris flat and round.

Black in Normal color, equal in size 4mm in diameter

Ears

Inspection Symmetrica Positioned Normal lly aligned symmetrically to the face, to the face, firm and No notable ear not tender discharge, with no clean and dry,. discharged noted.

Nose

Inspection Symmetric and straight, no discharges or flaring

Symmetric Normal and straight , no nasal discharges noted, no flaring noted

Mouth Lips

Inspection Uniform Uniform dark pink in color dry color, soft and moist and smooth

Tongue

Inspection Tongue at midline without lesion

Not Normal due to chemical content of cigarette such as nicotine.

Dry and free ofNormal lesion

Teeth

Inspection

Complete, Incomplete, Not normal. white, shiny missing teeth, ill Aging is a tooth enamel, fitting dentures factor free of debris affecting loss of teeth and also insufficient calcium and fluoride.

Neck

Inspection Palpation

Coordinated , Coordinated Normal smooth movement with Normal movement no discomfort with no No masses, discomfort tenderness No masses, tenderness

Upper Inspection Extremities Skin

Palpation

Pinkish in color

Pallor

Not normal. It is a manifestatio n of in adequate circulating blood or hemoglobin.

Slightly moist

Poor skin turgor Not normal due to dehydration

Palpation

Arms

Normother Not warm, not Normal mia cold to touch, T=36

Inspection Normally Normally firm, Normal Palpation firm, no no contracture, Normal contracture, no swelling, no swelling, equal size on equal size both sides of on both body sides of Pulse rate: 80 body Pulse Rate: 60-100

Nails

Inspection Palpation

Smooth, highly Pink, smooth Normal vascular and texture, convex Normal intact curvature epidermis Capillary refill: 2 Capillary Refill seconds of 1-2 seconds

Chest and Lungs

Inspection

Symmetric Symmetric chest Normal chest expansion, quiet, expansion, rhythmic and quiet, rhythmic effortless and effortless respiration respiration

Palpation

No No retraction, Normal retraction, no tenderness, no no masses tenderness, no masses

Auscultatio Quiet, n rhythmic Heart

Adventitious Presence of breath sounds secretion

Auscultatio Normal Cardiac rate of Normal n heart rate 80 60-100bpm

Abdominal

Inspection

Unblemishe Lesions noted Not normal d skin, on the surgical because of uniform in site post color procedure done

Auscultation Average Audible bowel Normal normal sound of 8 per bowel minute sounds 5-25 per minute

External genitalia

Inspection No No discharge Normal discharges No lesion No lesions

Lower Inspection No lesion, extremities Palpation can move Skin freely Capillary refill: 1-2 seconds

No edema, no Normal deformities Normal and can move freely Capillary refill: 2 seconds

STRUCTURE

Cervix

LOCATION & DESCRIPTION

FUNCTION

The lower narrower portion During childbirth, of the uterus. contractions of the uterus will dilate the cervix up to 10 cm in diameter to allow the child to pass through. During orgasm, the cervix convulses and the external is dilates

Fallopian tubesExtending upper Egg transportation from part of the uterus ovary to uterus (fertilization on either side. usually takes place here).

Ovaries (female gonads)

Pelvic region on Provides an environment for either side of the maturation of oocyte. uterus. Synthesizes and secretes sex hormones (estrogen and progesterone).

Vagina

Canal about 10-8 cm long going from the cervix to the outside of the body.

Receives penis during mating. Pathway through a woman’s body for the baby to take during childbirth. Provides the route for the menstrual blood (menses) from the uterus, to leave the body. May hold forms of birth control, such as an IUD, diaphragm, neva ring, or female condom

Uterus Endometrium Myometrium Perimetrium

Located in the center of House and nourishes the fetus. the pelvic cavity Contains glands that secrete fluids The innermost layer of that bathe the uterine lining. uterine wall. Contract to help expel the baby. Smooth muscle in the Covers the uterus uterine wall. Outer layer of the uterus

Uterus Endometrium Myometrium Perimetrium

Located in the House and nourishes the center of the pelvic fetus. cavity Contains glands that The innermost layer secrete fluids that bathe of uterine wall. the uterine lining. Smooth muscle in Contract to help expel the uterine wall. the baby. Outer layer of the Covers the uterus uterus

ESTROGEN

It is the most important hormone during puberty in female and is responsible for secondary sexual characteristics (e.g. breast enlargement, menstruation, pelvic enlargement, long bones). Generally secreted by the ovary specifically secreted by the Grafian follicle.

Estrogen production Hypothalamus ↓ GnRH ↓ Anterior Pituitary Gland ↓ FSH ↓ Graafian Follicle ↓ Estrogen

V.

PATHOPHYSIOLOGY Early Menarche (11 years old)

Pregnancy

Increase Estrogen production

Increase the lifetime exposure to estrogen

Stimulates the growth of fibroid

Grows in the anterior wall of the uterus

Pelvic pain

Deform uterine cavity Menorrhagia

Myoma

VI. COURSE IN THE WARD

Day 1 A 48 years old female was admitted at exactly 2:16:07 p.m last August 22, 2008, accompanied by her son, with a chief complaint of body weakness. She was admitted under the service of Dra. Lovely Cacho and Dra. Alice Lojo and following orders were given. Diet as tolerated, temperature, pulse rate and respiratory rate must be recorded every shift, for chest x-ray posterioranterior, for electrocardiogram x 12 leads, for complete blood count blood typing and for chem. 7. It was done at the same day. The physician ordered a 5% Dextrose in Lactated Ringers 1 liter plus 1 ampule of EC to be regulated at 20 gtts/min. The physician ordered four units of whole blood that are properly typed and cross matched to be run for 4-6 hours. The physician also ordered “Lady L” that may have full diet at 4:40 p.m. The first unit of whole blood with a serial number B-08-4660 started at 10:00 p.m.. Diphenhydramine 1 ampule intravenous 30 min. prior to blood transfusion.

Day 2 The above unit of blood finished at August 23, 2008, 2:20 a.m. There is no reaction during and after the blood transfusion. At the same time, the second unit of whole blood with a serial number B-08-4681 was hooked and consumed at 7:20 a.m. The third unit of blood with a serial number B-08-4666 was started at same time. The blood transfusion site was transferred from left to right at 11:20 a.m. At 12:30 p.m., the third unit of whole blood with a serial number B-084668 was consumed and followed up of fourth unit of whole blood and consumed at 4:30 p.m. Intravenous fluid number one consumed and followed the number two 5% Dextrose in Lactated Ringers 1 liter plus one ampule of EC regulated at the same rate. By 11:10 p.m. “Lady L” is under nothing per orem. “Lady L” informed about Total Hysterectomy Bilateral Salphingo Oophorectomy with signed consent of her husband and her son at the same day. Anesthesiologist on deck was informed. Cefuroxime 750 mg, intravenous started every 8 hours after negative skin testing. At 11:40 p.m. Valium tablet 5 mg one tablet was given as pre-operative drugs.

Day 3 August 24, 2008, at exactly 7:00 a.m. “Lady L” was brought to the operating room. At 4:50 p.m. post-op orders were given. Monitor vital signs every 15 minutes until fully stable. Nothing per orem temporarily. The patient was instructed to lie flat on bed and low back rest for pneumonia precaution. Oxygen inhalation administered at 3 liters per minute. Suction secretion when necessary. Intake and output were recorded hourly. 5% Dextrose Lactated Ringers 1 liter post-op to run at 15gtts/min then to follow 5% Dextrose Lactated Ringers 1 liter at same rate. Last dose of Cefuroxime to consumed, Metronidazole 500 mg slow intravenous push every 6 hours. Tramadol 500 mg after negative skin testing every 6 hour. Intravenous fluid regulated at 30 gtts/min when blood transfusion finished. Repeat hemoglobin and hematocrit.

At 5:20 p.m. the operation ended and at 6:40 p.m. patient was bought to the intensive care unit and hooked to ventilator and Furosemide 40 mg IV was given. At around 8:45 p.m Omeprazole 40 mg IV was given. Serum, sodium, potassium, chloride, prothrombin time, partial prothrombin time done and result in “Lady L” was nebulized if Combivent 1 neb and maintained every 8 hours potassium 30 millequivalent incorporate to her intravenous fluid and decrease it to 8 hours. Another one unit of packed red blood cell, Calcium gluconate one ampule was given thru slow intravenous push.

Day 4 August 25, 2008, 5a.m. patient was brought to room 206 and then nebulization started and extubated at the time and secretion suctioned. Oxygen maintained at 4 liters per minutes via nasal canula. Diphenhydramine one ampule was given at 3:30 p.m, 30 minutes prior to blood transfusion. Blood type “B” with a serial # of BO8-445 run at 4-6 hours. At 6:05 p.m “Lady L” was confirmed that she has a positive flatulence. Measuring drained output was recorded shiftly.

Day 5 1 a.m. of August 26, 2008, to follow intravenous fluid 5% Dextrose Lactated Ringers 1 liter regulated at same rate and encouraged patient to turn side to side. Serum, creatinine, and complete blood count done. At 9:37 a.m. the physician advised to continue medications. At 10:00a.m. patients temperature is 38.2˚C and paracetamol 200 mg one ampule was given thru intravenous. At 11:03 a.m. nebulization was stopped. The physician suggests changing Cefuroxime to Tazocin 4.5 grams intravenous every 8 hours. Above intravenous fluid consumed and followed up of 5% Dextrose in Lactated Ringers 1 liter regulated at same rate. At 3:15 p.m. incentive spirometer every 8 hours and two minutes oxygen inhalation was discontinued. Patient was encouraged to ambulate. At 8:30 p.m. intravenous to follow of 5% Dextrose Lactated Ringers 1 liter regulated at same rate. Foley catheter was removed at 9:15 p.m. At 10:45 p.m “Lady L” gargled one tablespoon of Orahex solution plus 30 cc water every 6 hours.

Day 6 Nursing care done. Vital signs are monitored and recorded. Intravenous fluid regulated at 15 gtts/min “Lady L” has no further complaint. The patient is ambulatory. Tazocin 4.5 grams intravenous every 8 hours was given. Attending Physician did not visit’s the patient and no new orders were made that day.

Day 7 August 28, 2008, patient may have clear liquid then soft diet at 4 p.m., above intravenous fluid consumed and followed up of 5% Dextrose Lactated Ringers 1 liter regulated at the same rate. For possible discharge on the next day.

Day 8 August 29, 2008, removal of jackson-pratt drain was done and intravenous fluid was terminated. There is no o objection for discharge. Home medications instructed and patient may go home and start oral medication. At 8 p.m. patient was discharged accompanied by her son via the wheelchair.

VII. LABORATORY

AUGUST 22, 2008 ULTRASOUND Transvaginal Ultrasound Transabdominal pelureus shows an enlarged uterus measure about 12.6x7.5x9.1 cm (LxWxAP). There is a large hypo echoic mass in the posterior lower segment of the uterus, measuring approximately 10.0x10.0x9.0 cm. There is a cystic structure with internal echoes and septations in the night adnexae, measuring about 60x4.5x4.3 cm. There is no fluid in the posterior culde-sac. Impression: Enlarged uterus with large sub serous myoma wit intramural component, posterior lower segment consider ovarian cyst at the right. Normal left ovary.

AUGUST 22, 2008 CLINICAL CHEMISTRY Laboratory Test

Normal Value

Result

Significance/Inter pretation

FBS

3.89-5.84 mmol/L 4.24 mmol/L

Normal

BUN

2.5-8.33 mmol/L 2.80 mmol/L

Normal

Creatinine

45-235 u/L

Normal

Bld. Uric Acid

143-345 mmol/L 179.0 mmol/L

Normal

Triglyceride

0.11-2.37 mmol/L 0.58 mmol/L

Normal

HDL

0.25-2.65 mmol/L 1.50 mmol/L

Normal

LDL

1.10-3.81 mmol/L 2.52 mmol/L

Normal

89.0 u/L

AUGUST 22, 2008 HEMATOLOGY Diagnostic/Laborat Normal Value Result ory Test

Significance/Interpret ation

Hemoglobin

M 13.0-18.0 6.93 g/dL g/dL F 12.0-16.0 g/dL

Anemia, recent hemorrhage

Hematocrit

M 40-54% F 37-47%

21 %

Anemia

WBC

5,000-10,000

5,000

Normal

Platelet Count

150,000-450,000 337,000 cu/mm Normal cu/mm

Segmenters

0.51-0.57

0.70

Lymphocytes

0.21-0.35

0.20

Monocytes

0.02-0.35

0.10

Normal

AUGUST 23, 2008 HEMATOLOGY Diagnostic/Laborat Normal Value ory Test

Result

Significance/Interpret ation

Hemoglobin

M 13.0-18.0 10.8 g/dL g/dL F 12.0-16.0 g/dL

Anemia, recent hemorrhage

Hematocrit

M 40-54% F 37-47%

36.70 %

Anemia

WBC

5,000-10,000

6,500

Normal

Platelet Count

150,000-450,000 247,000 cu/mm Normal cu/mm

Segmenters

0.51-0.57

0.83

Infection

Lymphocytes

0.21-0.35

0.11

Infection

Monocytes

0.02-0.35

0.06

Normal

AUGUST 24, 2008 HEMATOLOGY Diagnostic/Laborator y Test

Normal Value

Result

Significance/Interpretati on

Hemoglobin

M 13.0-18.0 g/dL 12.5 g/dL F 12.0-16.0 g/dL

Normal

Hematocrit

M 40-54% F 37-47%

37.5 %

Normal

WBC

5,000-10,000

20,600

Infection

Platelet Count

150,000-450,000 cu/mm

225,000 cu/mm

Normal

Segmenters

0.51-0.57

0.93

Infection

Lymphocytes

0.21-0.35

0.03

Infection

Monocytes

0.02-0.35

0.04

Infection

Eosinophill

0.01-0.04

Infection

AUGUST 24, 2008 CLINICAL CHEMISTRY

Laboratory Normal Value Test Sodium Potassium

135-145 mmol/L

Result

Significance/I nterpretation

142.3 mmol/L Normal

4-4.5 mmol/L 3.133 mmol/L Hypokalemia

Chloride

99.9-110 mmol/L

106.7 mmol/L Normal

Pro- time

12-15 seconds 13 seconds

Normal

AUGUST 24, 2008 CHEST X-RAY AP > There are no active parenchemal infiltrates. > The heart is not enlarged. > Aorta is tortous. > The rest of the findings are unremarkable. > ET at level of T4. Impression: > Tortous Aorta ` AUGUST 24, 2008 ABDOMEN AP > Hx: S/P TAHBSO > Free air is noted at the pelvic cavity. > There are feces filled undilated bowel loops obscuring the renal and psoas shadows. > The flank stripes are intact > No abnormal calcification noted. Impression: >Pneumoperitoneum, likely post surgical.

AUGUST 25, 2008 HEMATOLOGY Diagnostic/Labo ratory Test

Normal Value

Result

Significance/Interp retation

Hemoglobin

M 13.0-18.0 10.5 g/dL g/dL F 12.0-16.0 g/dL

Anemia, recent hemorrhage

Hematocrit

M 40-54% F 37-47%

Anemia

32.70 %

WBC

5,00010,000

16,600

Infection

Platelet Count 150,000450,000 cu/mm

206,000 cu/mm

Normal

Segmenters

0.51-0.57

0.96

Infection

Lymphocytes 0.21-0.35

0.02

Infection

Monocytes

0.02-0.35

0.01

Infection

Eosinophill

0.01-0.04

0.01

Normal

AUGUST 26, 2008 HEMATOLOGY Diagnostic/Lab oratory Test Hemoglobin

Normal Value

Result

M 13.0-18.0 11.4 g/dL g/dL F 12.0-16.0 g/dL

Significance/Inter pretation Anemia, recent hemorrhage

Hematocrit

M 40-54% 35.10 % F 37-47%

Anemia

WBC

5,00010,000

15,200

infection.

196,000 cu/mm

Normal

Platelet Count 150,000450,000 cu/mm Segmenters

0.51-0.57 0.90

Infection

Lymphocytes 0.21-0.35 0.08

Infection

Monocytes

Normal

0.02-0.35 0.02

AUGUST 26, 2008 CLINICAL CHEMISTRY

Laboratory Test

Normal Value

Result

Significance/Interp retation

Potassium 4-4.5 mmol/L

3.56 mmol/L Hypokalemia

Creatinine 45-235 u/L

102.0 u/L

Normal

VIII.MEDICAL MANAGEMENT Treatment depends on various factors, including: •Age •General health •Severity of symptoms •Size of fibroids •Whether you are pregnant •If you want children in the future •Some women may just need pelvic exams or ultrasounds every once in a while to monitor the fibroid's growth.

Treatment for fibroids may include: •Birth control pills (oral contraceptives) to help control heavy periods •Iron supplements to prevent anemia due to heavy periods •Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naprosyn for cramps or pain with menstruation •Some women may need hormonal therapy (Depo Leuprolide injections) to shrink the fibroids.

SURGICAL MANAGEMENT: Hysterectomy Hysterectomy A hysterectomy is a surgical procedure whereby the uterus (womb) is removed. Hysterectomy is the most common non-obstetrical procedure of women in the United States. Why is a hysterectomy performed? The most common reason hysterectomy is performed is for uterine fibroids The next most common reasons are abnormal uterine bleeding, endometriosis, and uterine prolapse (including pelvic relaxation). Only 10% of hysterectomy is performed for cancer of the uterus or very severe pre-cancers (called dysplasia).

Uterine fibroids (also known as uterine leiomyomata) are by far the most common reason a hysterectomy is performed. Uterine fibroids are benign growths of the uterus, the cause of which is unknown. Although they are benign, meaning they do not cause or turn into cancer, uterine fibroids can cause medical problems, such as excessive bleeding, for which hysterectomy is sometimes recommended.

What tests or treatments are performed prior to a hysterectomy? Prior to having a hysterectomy for pelvic pain, women usually undergo more limited (less extensive) exploratory surgery procedures (such as laparoscopy) to rule out other causes of pain. Prior to having a hysterectomy for abnormal uterine bleeding, women require some type of sampling of the lining of the uterus (biopsy of the endometrium) to rule out cancer or precancer of the uterus. This procedure is called endometrial sampling. In a woman with pelvic pain or bleeding, a trial of medication treatment is often given before a hysterectomy is considered.

How is a hysterectomy performed? Most commonly, a hysterectomy is done by an incision (cut) through the abdomen (abdominal hysterectomy) or through the vagina (vaginal hysterectomy). The hospital stay generally tends to be longer with an abdominal hysterectomy than with a vaginal hysterectomy (4 vs. 6 days on average) and hospital charges tend to be higher. The procedures seem to take comparable lengths of time (about 2 hours), unless the uterus is of a very large size, in which case a vaginal hysterectomy may take longer.

What are complications of a hysterectomy? Complications of a hysterectomy include infection, pain, and bleeding in the surgical area. An abdominal hysterectomy has a higher rate of post-operative infection and pain than does a vaginal hysterectomy. Aftercare After surgery, a woman will feel some degree of discomfort; this is generally greatest in abdominal hysterectomies because of the incision. Hospital stays vary from about two days (laparoscopic-assisted vaginal hysterectomy) to five or six days (abdominal hysterectomy with bilateral salpingo-oophorectomy). During the hospital stay, the doctor will probably order more blood tests.

Risks Hysterectomy is a relatively safe operation, although like all major surgery it carries risks. These include unanticipated reaction to anesthesia, internal bleeding, blood clots, damage to other organs such as the bladder, and post-surgery infection. Other complications sometimes reported after a hysterectomy include changes in sex drive, weight gain, constipation, and pelvic pain. Hot flashes and other symptoms of menopause can occur if the ovaries are removed. Women who have both ovaries removed and who do not take estrogen replacement therapy run an increased risk for heart disease and osteoporosis (a condition that causes bones to be brittle). Women with a history of psychological and emotional problems before the hysterectomy are likely to experience psychological difficulties after the operation.

Alternatives Women for whom a hysterectomy is recommended should discuss possible alternatives with their doctor and consider getting a second opinion , since this is major surgery with life-changing implications. Whether an alternative is appropriate for any individual woman is a decision she and her doctor should make together. Some alternative procedures to hysterectomy include:

•Embolization. During uterine artery embolization, interventional radiologists put a catheter into the artery that leads to the uterus and inject polyvinyl alcohol particles right where the artery leads to the blood vessels that nourish the fibroids. By killing off those blood vessels, the fibroids have no more blood supply, and they die off. Severe cramping and pain after the procedure is common, but serious complications are less than 5% and the procedure may protect fertility. ·Myomectomy . A myomectomy is a surgery used to remove fibroids, thus avoiding a hysterectomy. Hysteroscopic myomectomy, in which a surgical hysteroscope (telescope) is inserted into the uterus through the vagina, can be done on an outpatient basis. If there are large fibroids, however, an abdominal incision is required. Patients typically are hospitalized for two to three days after the procedure and require up to six weeks recovery. Laparoscopic myomectomies are also being done more often. They only require three small incisions in the abdomen, and have much shorter hospitalization and recovery times. Once the fibroids have been removed, the surgeon must repair the wall of the uterus to eliminate future bleeding or infection.

•Endometrial ablation. In this surgical procedure, recommended for women with small fibroids, the entire lining of the uterus is removed. After undergoing endometrial ablation, patients are no longer fertile. The uterine cavity is filled with fluid and a hysteroscope is inserted to provide a clear view of the uterus. Then, the lining of the uterus is destroyed using a laser beam or electric voltage. The procedure is typically done under anesthesia, although women can go home the same day as the surgery. Another newer procedure involves using a balloon, which is filled with superheated liquid and inflated until it fills the uterus. The liquid kills the lining, and after eight minutes the balloon is removed. Endometrial resection. The uterine lining is destroyed during this procedure using an electrosurgical wire loop (similar to endometrial ablation).

THE PATIENT HAD UNDERGONE: Total abdominal hysterectomy This is the most common type of hysterectomy. During a total abdominal hysterectomy, the doctor removes the uterus, including the cervix. The scar may be horizontal or vertical, depending on the reason the procedure is performed, and the size of the area being treated. Cancer of the ovary(s) and uterus, endometriosis, and large uterine fibroids are treated with total abdominal hysterectomy. Clearly a woman cannot bear children herself after this procedure, so it is not performed on women of childbearing age unless there is a serious condition, such as cancer. Total abdominal hysterectomy allows the whole abdomen and pelvis to be examined, which is an advantage in women with cancer or investigating growths of unclear cause.

Abdominal hysterectomies take from one to three hours. The hospital stay is three to five days, and it takes four to eight weeks to return to normal activities. Salpingo-Oophorectomy (Removal of the Ovaries and/or Fallopian Tubes) Salpingo-oophorectomy is the removal of the ovary and its adjacent fallopian tube. This procedure is performed for cancer of the ovary, removal of suspicious ovarian tumors, or Fallopian tube cancer (which is very rare). It may also be performed due to complications of infection, or in combination with hysterectomy for cancer.

Application of Jackson-Pratt Drain A Jackson-Pratt drain, JP drain, or Bulb drain, is a suction drainage device used to pull excess fluid from the body by constant suction. The device consists of a flexible plastic bulb -shaped something like a hand grenade -- that connects to an internal plastic drainage tube.

IX. DRUG STUDY

NAME

CLASSIFICATION

ACTION

Generic Antiprotozoals or Direct -acting Name:Metronida Antimicrobia trichomonacide zoleBrand and amebicide Name:Flagyl that works inside and outside the intestines. It’s thought to enter the cells of microorganisms that contain nitroreductase, forming unstable compounds that bind to DNA and inhibit synthesis, causing cell death.

INDICATION& ADVERSE DOSAGE REACTION

NURSING CONSIDERATION

>Amebic liver >CNS: headache, > Monitor liver abcess>To seizure, fever, function test prevent post vertigo, ataxia, result carefully in operative dizziness>CV: elderly patient.> infection in flattened T wave, Observe pt. for contaminated or edema, edema especially potentially flushing>EENT: if receiving contaminated rhinitis, sinusitis, corticosteroid>Re colorectal surgery pharyngitis>GI: cord number and Dosage:500mg nausea, character of IV abdominal stools when drug cramping or pain, is used to treat. stomatitis, vomiting, diarrhea>GU: vaginitis, darkened urine, polyuria,

NAME

CLASSIFICATION

Generic Cephalosporins name:Cefuroxime Brand Name: Zinacef

ACTION

Inhibits cell wall synthesizes promoting osmotic instability

INDICATION& ADVERSE DOSAGE REACTION

NURSING CONSIDERATION

Serious lower > CV: > Before giving respiratory tract thrombophlebitis, drugs, ask patient infection, UTI, phlebitis > GI: if he allergic to skin structure diarrhea, nausea, penicillin or infection, bone or vomiting, cephalosporins> joint infection, anorexia> Skin: Obtain specimen gonorrheaDosage maculo papular, for culture and :750mg IV erythematous sensitivity test rashes before giving first dose

NAME

CLASSIFICATION

ACTION

INDICATION& ADVERSE DOSAGE REACTION

Generic Opioid Analgesic > Bind to opioid > Moderate to Name:TramadolB receptors and moderately rand inhibit reuptake severe Name:Ultram of norepinephrine painDosage:50m or serotonin g IV

NURSING CONSIDERATION

> CNS: dizziness, > Monitor CV, headache, and respiratory vertigo, anxiety, status withhold confusion> CV: dose and notify vasodilation > prescriber if EENT: visual respiration disturbances> GI: decrease or rate is constipation, below 12bpm> nausea , Monitor bowel vomiting, and bladder abdominal pain> function > For GU: menopausal better analgesic symptoms urine effect give drug retention before onset of intense pain.

NAME

CLASSIFICATION

Generic Anti Ulcer Drug Name:Omeprazol eBrand Name:Losec

ACTION

INDICATION& ADVERSE DOSAGE REACTION

> Inhibits activity > Symptomatic > CNS: asthenia, of acid pump and GERD without dizziness, bind to hydrogen esophageal headache> GI: potassium lesion> short abdominal pain, adenosine, term treatment of constipation, triphosphatase at active benign nausea, vomiting secretory surfaces gastric of gastric parietal ulcerDosage:40m cells to block g IV formation of gastric acid

NURSING CONSIDERATION > Drug increases its bioavailability with repeated doses. Drug is unstable in gastric acid; less drug is loss to hydrolysis because drug increases gastric pH.>Dosage adjustment may be necessary in Asians and patients wit hepatic impairment.

NAME

CLASSIFICATION

Generic Bronchodilators Name:Salbutamol Brand Name:Combivent

ACTION

INDICATION& ADVERSE DOSAGE REACTION

>Relaxes >To prevent or bronchial, uterine treat and vascular bronchospasm in smooth muscle patients with by stimulating reversible beta2 receptors. obstructive airway diseaseDosage:1 nebule

NURSING CONSIDERATION

>CNS: tremor, >Drug may nervousness, decrease headache >CV: sensitivity of spirometry used tachycardia , for diagnosis of palpitations, hypertension>E asthma.>Use of a ENT: dry and AeroChamber may improve irritated drug delivery to nose>GI: lungs.>Tell nausea, vomiting,anorex patient to remove canister and wash ia inhaler with warm, soapy water at least once a week.

NAME

CLASSIFICATION

Generic Antibiotics Name:Piperacilli n SodiumBrand Name:Tazocin

ACTION

>Inhibits cellwall synthesis during bacterial multiplication.

INDICATION& ADVERSE DOSAGE REACTION

NURSING CONSIDERATION

>Moderate to >CNS: headache, >Before giving severe infections insomnia, fever drug, ask patient from piperacillin- >CV: about allergic resistantDosage:4hypertension, reactions to .5g IV tachycardia, chest penicillins>Obtai pain>EENT: n specimen for rhinitis >GI: culture and diarrhea, nausea, sensitivity test vomiting before giving first dose.>Monitor patient’s sodium intake.

X. NURSUNG CARE PLAN

ASSESSMENT

DIAGNOSIS

PLANNING

SUBJECTIVE: Pain related to After 4 hours of “Masakit ang tahi tissue trauma and nursing ko” as verbalized incisional intervention by the patient. discomfort as patient’s pain OBJECTIVE: manifested by evidenced by Restlessness grimace and pain pain scale =7 be Irritability scale =7. reduced to 3. With cold clammy skin Excessive perspiration Facial grimace Increased respiration RR=26 bpm Pain scale = 7: pain scaling of 110 where 1 is the least painful and 10 is the most painful Impaired thought

NURSING INTERVENTIONS INTERVENTIONS

RATIONALE

EVALUATION

After 4 hours of nursing intervention the Change the position Pain is sometimes patient reported of the patient due to the position of pain was Provide comfort the patient lessened to pain  To reduce the measures scale =3. Assist patient in discomfort breathing techniques To assist in muscle Provide quiet and generalized environment relaxation Relay on the patient For patient report of pain comfortabili-ty and Encourage lessen the discomfort. divertional activities To reduce anxiety Monitor vital sign felt by the patient Administer analgesic To divert the as ordered by the AP attention from pain to activities Usually altered in pain. To maintain acceptable level of pain.

ASSESSMENT

DIAGNOSIS

PLANNING

NURSING INTERVENTIONS

EVALUATION

OBJECTIVE: Fluid volume After 8 hours INTERVENTION RATIONALE After 8 hours of Poor skin turgor deficit related to of nursing S nursing Dry lips the risk of post- intervention the intervention, the Change To dressings protect the Weak in operative patient will patient was frequently skin and appearance hemorrhage. maintain fluid maintained fluid as monitor losses Pale looking at a functional Provide frequent To prevent manifested by v/s of: level. good skin turgor oral care injury from BP = 100/80 dryness PR = 64 Measure input and To monitor RR = 26 output fluids in the T = 37.8 body Monitor v/s

To assess the patient and it serve as base line data

 Administer IV fluids as indicated

 helps maintain fluids in the body

To reduce Give medications blood loss as ordered by the attending physician

ASSESSMENT DIAGNOSIS PLANNING NURSING INTERVENTIONS EVALUATION SUBJECTIVE: “Hindi ako makagalaw ng ayos” as verbalized by the patient. OBJECTIVE: Impaired ability to turn side to side. Cannot eat without support Slowed movement Irritable Limited ROM

Impaired After 8 hours INTERVEN- RATIONA- After 8 hours of mobility relatedof nursing TIONS LE nursing to decreased intervention the intervention, the Provide To reduce muscle strength patient will be patient was able to activities with the fatigue as manifested able move move safely and Promotes adequate rest by limited safety and independently. period. well being and ROM. independently. Encouraged maximize adequate intake energy of fluids production Advise to move To hands and legs exercise/mobili slowly zation of body  Encourage parts and participation in develop muscle self care strength Enhances self concept and sense of independence

XI.

DISCHARGE PLANNING Medication Ciprofloxacin 500 mg 1tablet 3x a day for 1 week Metronidazole 500 mg 1 tablet 3x a day for 1 week Tramadol (Dolcet) 1 tablet 3x a day for pain Environment Instruct patient’s relative to provide the patient an environment conducive for her easy recovery. Her place/room in their house must be the most accessible area. Her environment should be free from contamination and infection.

Treatment The patient should follow the physician’s prescription and should take his home medication on the right time and right dose. Health Teaching Instruct the patient the importance of proper taking of medication on time. Instruct the patient and her family the proper wound care to avoid contamination and infection at surgical site. Instruct the patient to eat nutritious foods. Encourage ambulation for early recovery. Good sanitation is advised.

Out Patient Department The patient should return on the scheduled date of her follow up check-up on September 5, 2008 in Metro Lipa Medical Center from 4:30 pm to 6:30 pm and should continuously take her home medication as prescribed by her physician. The patient should visit her physician whenever she feels any discomfort. Diet Diet as Tolerated. In order to attain proper diet, the patient should be guided to the prescribed foods as advised by her physician. Her meals should include Vitamin C-rich foods for wound healing.

Spiritual Patient should enhance her spiritual relationship with God. Have faith and trust in God’s divine power, and believed that the lord will help in her early recovery. Keep on praying, because praying is the number one key to live a healthy life and to be close to God.

XII. PROGNOSIS The mortality rate in uterine myoma is low provided early diagnosis and management are made and no complication will occur. According to the attending physician the case of Lady L greatly improved after the management, therefore, the prognosis is good.

XII. EVALUATION Date

22

23

24

25

26

27

28

D5LR 1L √

√

√

√

√

√

√

BT FWB√

√

29

TPR temp

36.7

36.2

36

37.3

36.8

36.2

37.6

36.2

BP

120/70

120/80

120/70

130/80

130/80

110/70

140/90

120/70

RR

24

20

21

24

22

20

28

22

PR

80

90

72

91

68

75

80

68

MEDS

22

23

Omeprazol e

24

25

27

28

29

√

Salbutamo l (combiven t) Piperacilli n (Tazocin)

√

√

√

√

√

√

√

√

√

√

√

√

√

√

√

Tramadol (ultram)

√

√

Diphenhyd √ ramine HCl (Benadryl)

√

√

√

√

√

Metronida zole (Flagyl)

26

Metronidazole (Flagyl)

√

Cefuroxime (Zinacef)

√

Paracetamol

√

√

√

CXR AP

√

Abdomen AP

√

√

√

√

UTZ

√

Clinical Chemistry

√

√

Cross Matching

√

√

Hematology

√

√

√

√

√

DIET

22

23

24

25

26

DAT

√

√

27

28

Soft diet NPO

29

√ √

√

√

√

The patient is able to recognize her role in maintaining and improving her help and adheres and complies with her medical regimen prescribed by her health care providers as exhibited by avoiding everything that would aggravate her condition or would rise to complications and is able to verbalize her concerns about her condition and role in maintaining her health. The students are equipped with better understanding of the condition and could give better nursing care to patients having the same condition. Students learned about the diseases’ clinical manifestations, risk factors, pathophysiology, and diagnostic procedures for the disease. They can perform better assessment and execute more effective nursing procedures necessary for patients having uterine myoma.