Introduction

The student nurse has chosen this topic to be his case study primarily, because of his patient. He has been dwelling on the idea that his patient has inspired him so much. It may only be one experience of bed side and total care, but he was able to express his deepest care to the 33 year old patient during pre operative and post operative pelvic laparotomy-salphingo-oophorectomy with a diagnosis of Ovarian Cyst left ovary. The student nurse wishes to refresh his memory on the subject of medical-surgical nursing and the Anatomy and Physiology of the uterus. And because Ovarian Cyst is one of the most common disease of young adult and middle adult women, the student expect to gain knowledge on the pathophysiology of the disease and its other risk factor. The student nurse also felt the need to know about the different pharmacologic therapy to alleviate signs and symptoms of the disease and probably ways to treat or cure the disease. With this study, he aims to extend his knowledge and the disease condition of his patient so that hopefully this may help him in providing appropriate nursing care to his patient. Also, to utilize the nursing process in his approach towards holistic nursing care and increase effectiveness in dealing with his patient. An Ovarian Cyst is any collection of fluids, surrounded by a very thin wall, with in the ovary. Any ovarian follicle that is larger than about two centimeters is turned an Ovarian Cyst. An Ovarian Cyst can be a small as a pea, or larger than cantaloupe most Ovarian Cyst are functional in nature and harmless (benign). In the US ovarian cyst are found in newly all pre menopausal women, and in up to 14.8% of post menopausal women. The incidence of ovarian carcinoma is approximately 15 cases per 100,000 women per year. Ovarian Cyst affect women of all ages. The occur most often, however, during womens child bearing years. Some ovarian cyst cause problem, such as bleeding and pain. Surgery maybe required to remove those cyst.

II. Objectives
General Objectives:

After 1 day of giving nursing care to the patient, the student nurse will be able to gain knowledge developing, proper skill and attitude towards pre and post abdominal surgery patient. Specific Objectives: After 8 hours of student nurse-patient/significant others interaction, the student nurse will be able the to: a) understand fully the disease process of the patient b) formulate a plan of care for the patient c) ensure that all given nursing interventions are right and accurate base on applied knowledge d) impart heath teaching that the patient can utilize until at home in regards to her present condition e) anticipate to the patients needs during the interaction f) develop an improvement to the condition of the patient

General Objectives: After 1 day of giving holistic nursing care to the patient, the patient will be able to gain knowledge, skill and attitude in managing self before and abdominal surgery. Specific Objectives: After 8 hours of student nurse-patient interaction, the patient and family will be able to:

a.) understand and accept the reality of her condition b.) continue rendering proper self care in going home c.) expect and trust that the student nurse is giving the right treatment and care d.) learn what the student nurse has taught during heath teaching e.) know how to prioritize care f.) identify diet that is appropriate for the patient g.) take appropriate measures for the pre-operative and post-operative management of Ovarian Cyst h.) verbalize feelings and concerns about patients condition i.) show interest and positive response on how to manage the disease condition

III. Nursing Assessment

1.Personal History 1.1Patients Profile: Name: Mrs. Gemma Lawas Age: 33 years old Sex: Female Civil Status: Married Religion: Roman Catholic Date of Admission: April 12, 2010 Room No. : Annex Rm. 49 Complaints: Abdominal mass Impression/Diagnosis: Ovarian Cysts Physician: Dr. Marissa Agudo

1.2 Family and individual information, social and health history The patient had coughed. She is also hypertensive just like his husband. She has also a relative who had ovarian cyst. The linked between hereditary factor has the greater cause of the etiology of her disease. She never consulted any doctor when she had felt a cramping pain she taught that it is only normal. She manifested the disease for about 5 months prior to admission. She had abnormal pain three times a month. The day prior to admission, the patient experienced severe abdominal pain in lower left quadrant. These triggered the family to submit the patient for admission. She was scheduled for Pelvic Laparotomy possible for salphingo-oophorectomy 2 days after admission.

1.3Level of Growth and Development

1.3.1 Normal Growth and Development of Middle-aged Adult age (40-65 years old)

1.3.1.1 Physical Development Major physiological changes occur between 40-65 years old of age. The patients visible changes are graying of the hair, wrinkling of the skin and thickening of the waist. The patient do not manifest decrease in hearing and visual acuity during this period. Often this physiological changes has an impact on self-concept and body image. The most significant physiological changes during middle aged are menopause in women and the climacteric in men. (Source: Fundamentals of Nursing:Concepts and Process and Practice 7th Edition by Kozier and Erb)

1.3.1.2 Psychosocial Development The psychosocial changes in the middle adult may involve expected events. Such as children moving away from home or unexpected events such, as marital separation or the death of a close friend. Many middle adults find themselves in the sandwich generation having the responsibility or racing their own children while caring for aging parents. These changes may result in stress that can affect the middle adult overall level of health. ( Source: Fundamentals of Nursing 5th Edition Volume 1 by Potter and Perry)

1.3.1.3 Cognitive Development

Changes in the cognitive function of the middle adults are rare except with illness or trauma. The middle adult can learn new skills and information. Some middle adults Adults enter educational or vocational programs to prepare themselves for entering the job market or changing jobs. (Source: Fundamentals of Nursing 5 th Edition Vol. 1 by Potter and Perry) 1.3.1.4 Moral Development According to Kohlberg, the adult can move beyond the conventional level to the post conventional level. Kohlberg believes that extensive experience of personal moral choice and responsibility is require before people can reach the post conventional level. The patient found that the few of her subject achieved the highest level of normal reasoning. The patient move from stage 4, a law and order orientation, to stage 5, a social contact orientation, requires that the individuals move to a stage in which rights of others take precedence. People in stage 5 take steps to support anothers rights. (Source: Fundamentals of Nursing: Concept, Process and Practice 7th Edition by Kozier and Erb)

1.3.1.5 Spiritual Development Not all adults progress through Fowlers stage to the 5th called the paradoxicalconsolidative stage. At this stage, the individuals can view truth from a number of viewpoints. Fowlers 5th stage corresponds to Kohlbergs 5th stage of moral development. Fowlers believe that only some individuals after the age of 30 years reach this stage. In middle aged, people tend to be less dogmatic about religious beliefs, and religion often offers more comfort to the middle aged person that it did previously. People in this age group often rely on spiritual beliefs to help them deal with illness, death and tragedy. (Source: Fundamentals of Nursing: Concepts, Process and Practice 7th Edition by Kozier and Erb)

1.3.2 The ill person at a particular stage The patient has manifested the natural physical occurrences happening at her age. She has black hair, wrinkled skin and visible slight brown spot. The patients children still lived with her. She living with her husband. They live just nearby the house of her parents. her husband is the bred winner. She is a religious. She always go to church for praying and thanksgiving to God.

2. Diagnostic Test

Patients name: Mrs. Gemma Lawas Dianosis: Ovarian Cyst Left Surgeon: Dr. Marissa Agudo Hematology Result: DIAGNOSTIC TEST BUN Creatinine SGPT White Blood Cells NORMAL VALUES 1.8-6.1 mm ol/L 50-81 umol/L Up to 36 U/L 5,000-10,000/uL PATIENTS RESULT 4.4 mm ol/L 69 umol/L 13 U/L 14,000 u/L

case #:893835 Date: April 13, 2010 Room #: Ward 49

SIGNIFICANCE Normal Normal Normal Increase inflammation and infection. (source: Laboratory Test and Diagnostic Procedure with Nursing Diagnosis by Colbett pg.29) Normal Normal

Hemoglobin Hematocrit

12.0-16.0 g/dL 36.0-46.0 %

14 g/dL 40 %

NURSING ASSESSMENT (Pre-operative)

Name of Patient: Mrs. Gemma Lawas Diagnosis: Ovarian Cyst Left Attending Physician: Dr. Marrisa Agudo Room No.: Annex 49 Hospital No.: 893835 Age: 33 years old

NURSING HISTORY

BODY PART Head Neck >Hair &

INSPECTION

PALPATION

PERCUSSION

AUSCULTATION

-it is black, dry & evenly distributed & flakes of dandruff. >head normocephalic. -color white, -no lumps >Scalp no lice but there are small flakes caused by dandruff. is -temporal >Forehead -color slightly tan. artery is palpable with bpm of 98. -color is >Face slightly tan. -symmetrical >Eyes -hair is evenly >Brows distributed and it is symmetrical, there is no scalene in the underlying skin. -its curves >Lashes outward. lesions, >Upper Lid -no

inflammation. >Lower Lid -no styes -the color is >Sclera white, no lesions. -it is >Cornea transparent, shiny & smooth. -dark brown in >Iris color & symmetrical to the other iris. -positive in >Pupil Pupil Equally Round Reactive to Light Accommodatio n. Its is brisk. -color is >Nose slightly tan. -painless when palpated, no lesion and lumps. -non-resonant -no lumps or -not painful sound. >Frontal when palpated. sinuses & inflammation detected, Maxillary yellow in color sinuses in transilluminatio n test. >Mouth -moist, -no lumps >Lips symmetrical. -pinkish in >Gums color, smooth and moist. -no missing >Teeth tooth, yellowish in color. -dull red in >Tongue color, moist and smooth along lateral

10

>Frenulum & Sublingual >hard palate >soft palate >Uvula

margin. -pink in color, No ulceration. -whitish pink. -light pink -light pink in color and smooth. Neither ulceration nor lesion. -no discharges and symmetrical with the other ear. -can hear 2 -84 beats per syllables mins. words. -slightly tan color. -no swelling -it is not palpable,no enlargements nor tenderness. -no swelling -symmetrical with equal chest excursion during breathing with respiratory rate of 23 cpm. -symmetrical with equal chest excursion during breathing with respiratory rate of 23 cpm. -abdominal mass in suprapubic -no lumps -Bronchovesicular sound.

>Ears >external

>auditory acuity neck

>Lymph nodes

>Trachea >Thorax >chest anterior

>chest posterior

-no lumps

-Bronchovesicular sound.

>Abdomen

-painless when -dull in -hypotonic sound palpated but suprapubic area. due to constipation tender. & pressure to

11

>Extremiti es Upper

>Muscle Strength Lower

>Muscle Tone >Muscle Strength

area. -equal hair -pulse of 98 distribution. bpm and temperature of 37.3 C from the axilla. -cant tolerate opposing strength. -equal hair distribution with evidence of scars. -full flexion of legs. -can tolerate opposing strength.

abdomen. -positive ulnar, radial biceps & triceps reflex.

-positive kneejerk reflex. -negative babinski reflex.

12

1.3Present Profile of Functional Health Patterns (Pre-operative) 1. Health Perception/Health Management Mrs. Lawas describes her health as poor due to abdominal pain and general malaise. She never submits herself to consultation at the time she is experiencing pain after menopause for she thought that is just a normal. She submitted herself to hospitalization for she expect that is the way she will be relieved by the severe pain she experiencing. She is into analgesic, antiulcer and antihypertensive drugs prior to surgery. She is anxious of what will happen to her after the surgery. 2. Nutritional-Metabolic Pattern The patient eat 3 meals a day and snack in between. There usual meals consists of rice, fish and vegetables. She drinks water 8 glasses a day. At present, she losses appetite due to body malaise and nausea. She has no food restrictions. She is into Vit. C supplementation. There is a change on her weight due to anorexia.

3. Elimination Pattern The patient is experiencing difficulty in passing stole while she is admitted so she is prescribed to take laxative. For more than 4 days prior to admission she never pass stole. Even though she is into laxative, she only passed small amount, black colored and hard stools. Her skin is dry, warm and tan in color. She urinates 5-6 times a day.

4. Activity-Exercise Pattern The patient is a housewife. she is not into extreme sports. She goes to market by means of walking and she perceives it as a good exercise for her. As her condition worsens and she is experiencing severe abdominal pain, she is unable to do the usual routine. She cant work properly due to nausea and body malaise.

13

5. Rest/Sleep Pattern The patient sleep 8 to 9 hours a day but this changed as her condition worsen. It comes to a time that she was not able to sleep until down due to she felt cramping pain in the abdomen. 6. Cognitive Perceptual Pattern While the patient is admitted, she is conscious and coherent. She is able to read and write. 7. Self-perception Pattern The patient is very concerned of what will happen to her after the surgery. She is hoping for a fully recovery from her disease after her surgery. She describes herself as weak and needs to be intervening. As being ill at the present, it greatly affects her feelings about herself. Becoming ill for her is a suffering that affects her life and her family. 8. Role-relationship Pattern The patient is speaking Cebuano language. She is coherent while the interview is going on. She is able to express herself and understand others. She is living with her family. Her parents is always helping her in times of needs like financially and while she is experiencing discomfort. The patient and her husband make decision for their family.

9. Sexuality-Reproductive Pattern The patient understand that her whole reproductive system will be removed. She knew the function of the reproductive system as very essential for reproducing children. She is somehow anxious of what will happen to her without her reproductive system. She knew that she is too old to bare a child but she felt that she is anymore complete as a women without her reproductive system.

14

10. Coping-stress tolerance Pattern

The patient together with her husband makes decisions for their family. She loss her capacity to do things she did before she experienced worsening of her condition. She expects that she may get fully recover and free of disease after the surgery. She expect that her way of life will come back after being operated.

11. Values-Belief System She finds her strength from God and from her family. She stated that God is very important to her. Her family goes to church every Sunday. She is always praying to God to ask for fully recovery after the surgery.

15

NURSING ASSESSMENT (Post-operative) Name of Patient: Mrs. Gemma Lawas Diagnosis: Ovarian Cyst left Attending Physician: Dr. Marrisa Agudo Room No.: Annex 49 Hospital No.: 893835 Age: 33 years old

NURSING HISTORY

BODY PART

INSPECTION

PALPATION

PERCUSSION

AUSCULTATION

Head Neck >Hair

& -it is black, dry & evenly distributed & flakes of dandruff. normocephalic. -color white, -no lumps no lice but there are small flakes caused by dandruff. -color is -temporal slightly tan. artery is palpable with bpm of 98. -color is slightly tan. -symmetrical -hair is evenly distributed and it is symmetrical, there is no scalene in the underlying skin.

>head >Scalp

>Forehead

>Face >Eyes >Brows

16

-its curves outward. lesions, >Upper Lid -no inflammation. >Lower Lid -no styles -the color is >Sclera white, no lesions. -it is >Cornea transparent, shiny & smooth. -dark brown in >Iris color & symmetrical to the other iris. -positive in >Pupil Pupil Equally Round Reactive to Light Accommodatio n. Its is brisk. -color is >Nose slightly tan. -painless when palpated, no lesion and lumps. -no lumps or -not painful -non-resonant >Frontal when palpated. sound. sinuses & inflammation detected, Maxillary yellow in color sinuses in transilluminatio n test. >Mouth -moist, -no lumps >Lips symmetrical. -pinkish in >Gums color, smooth and moist. -no missing >Teeth tooth, yellowish in color. -dull red in >Tongue >Lashes

17

>Frenulum & Sublingual >hard palate >soft palate >Uvula

color,moist and smooth along lateral margin. -pink in color, No ulceration. -whitish pink. -dome shape. -light pink -light pink in color and smooth. Neither ulceration nor lesion. -no discharges and symmetrical with the other ear. -can hear 2 -84 beats per syllables mins. words. -slightly tan color. -no swelling -it is not palpable,no enlargements nor tenderness. -no swelling -symmetrical -no lumps with equal chest excursion during breathing with respiratory rate of 23 cpm. -symmetrical -no lumps with equal chest excursion during breathing with respiratory rate

>Ears >external

>auditory acuity neck

>Lymph nodes

>Trachea >Thorax >chest anterior

-Bronchovesicular sound.

>chest posterior

-Bronchovesicular sound.

18

>Abdomen

>Extremiti es Upper

of 23 cpm. -suture wound at suprapubic area & cleansed by betadine. -equal hair distribution.

-tympanic sound. -Borborygmus -pain felt at sound. the surgical area .

>Muscle Strength Lower

>Muscle Tone >Muscle Strength

-pulse of 98 -positive ulnar, bpm and radial biceps & temperature of triceps reflex. 37.3 C from the axilla. -cant tolerate -positive opposing kneejerk reflex. strength. -negative -equal hair babinski reflex. distribution with evidence of scars. -full flexion of legs. -can tolerate opposing strength.

19

2.3. Present Profile of Functional Health Patterns (Post-operative) 1. Health Perception/Health Management Pattern Mrs. Lawas describes her health as much better than the other days before she was submitted to surgery. She is experiencing pain on her surgical wound at the abdomen. She expected to be fully recovered from her illness now that her cyst has been removed. She is now into analgesic therapy (Tramadol 50 mg IVTT every 6 hours). 2. Nutritional-Metabolic Pattern The patient now is having small frequent meals. She has now increased in appetite and slightly able to tolerate food. She is drinking water as tolerated amount. She consumed liquids at about 5 glasses a day. She is now into venoclysis to prevent dehydration. 3. Elimination Pattern The patient verbalizes relief of constipation. She is able to defecate soft, formed stools. 4. Rest/Sleep Pattern The patient is recovering from the surgery and needs to rest, to prevent occurrence of pain, bleeding and accidental dehiscence of the sutured surgical wound. She is into analgesic therapy before doing activities such as turning and sitting from bed. 5. Self-perception Pattern The patient is very concerned of what had happen to her uterus and ovaries, that it was removed. She is hoping of full recovery from her illness. She describes herself as much better even though she still felt pain in her suture surgical

20

wound. Now that she is free of her uterus cancer, she is expecting to be healthy after the surgery. 6. Cognitive Perceptual Pattern The patient is conscious and coherent. The patient is experiencing pain from her sutured wound. She is able to have a good conversation during the interview. She is able to write and read. 7. Role-relationship Pattern The patient is speaking Cebuano dialect. She is coherent while the interview is going on. She is able to express herself and understand other thoughts. Her family is always beside her. 8. Sexuality Functioning The patient understands that her fallopian tube and left ovary has been removed. She just hope that there will be no complication that will occur. She is now more focused on her recovery rather than any sexual preferences. 9. Coping-stress tolerance Pattern The patient is recovering from her operation. She is now limited in doing things to prevent complications such as dehiscence and bleeding. Pain is also felt by her if she is excessively moving from her bed. She is expecting to recovered fully from her illness. 10. Values-Belief System She is always praying to God for guidance and good health. She stated that she needs God to recover fully.

21

Pathophysiology and Rationale

Normal Anatomy and Physiology

A. Ovary the production of hormone, among which are estrogen. B. Perimetrium the outer lining of the uterus. C. Fallopian Tube the duct that extend laterally, from the lateral angle of the fundal end of the uterus and terminates near the ovary. D. Cervix the neck of the uterus, the lower part from the internal outward. E. Fundus part of the uterine body above the opening of fallopian tube.

22

3.2. Schematic Diagram

Predisposing Factors: - Age (older age) - Genetic - Race (white women)

Precipitating Factors: - Early Menstruation - Null parity - Irregular Ovulation - Obesity - Diabetes - Ovarian Tumor

Increase in estrogen level Stimulation of the endothelial cell in the endometrium to grow Overgrowth of the cells of the endometrium Ovarian Cyst develops

Signs and Symptoms/ Manifestations: Abdominal pain Frequent Vaginal Bleeding Bleeding after the time of menopause Pink watery or White discharge from the vagina Pelvic pain on the late stage Pain during intercourse Weight Loss

23

Disease Process and Its effect to the Organ System

When a woman is menstruating for long period of time like in her 50s, she is more risk for endometrial cancer for that the uterus are more exposed to level of estrogen. When a women is a nullipara, she is risk of uterine cancer. It is the research that pregnancy does secrete more estrogen and also secretes more progesterone. The increase in progesterone mask of effects of estrogen that somehow prevents the overgrowth to endometrial cell in the endometrium. When nullipara, the women has no sufficient progesterone to counter back the level of estrogen that why the women is in high risk. Irregular ovulation or failure to ovulate can increase womens lifetime exposure to estrogen. Ovulation irregularities have many causes, including obesity and a condition known as polycystic ovary syndrome (PCOS). This is a condition in which hormonal imbalances prevent ovulation and menstruation. Treating obesity and PCOS can help restore your monthly ovulation and menstruation cycle, decreasing your risk of endometrial cancer. Ovaries arent the only source of estrogen. Fat tissue can change some hormones into estrogen. Being obese can increase level of estrogen in your body, putting you at a higher risk of endometrial cancer and other cancers. A high-fat diet also can add to your risk by promoting obesity. Some scientists even think that fatty food may directly affect estrogen metabolism, further increasing a womens risk of endometrial cancer. This is a risk factor for ovarian cancer because obesity and type 2 diabetes often go hand in hand. Estrogen

24

stimulate growth of the endometrium. Replacing estrogen alone after menopause may increase your risk of cancer. Taking synthetic progesterone, a form of hormone progesterone, with estrogen combination hormone replacement therapy causes the living of the uterus to shed and actually lower your risk of ovarian cancer. However, this combination may cause other health risk. Save tumors of the ovaries may themselves be a source of estrogen, increasing estrogen level. ( Marieb, Elaine N. Essentials of Human Anatomy and Physiology 7th Edition. Pearson Education South Asia PTE LTD. 2004 )

25

3.4. Comparative Chart of Classical & Clinical Manifestation: Classical symptoms Pre operative Post operative Clinical Symptoms Prolonged periods bleeding between periods or Manifested Clinical Symptoms Not Manifested The increase in endothelial cells in the uterus will also form new capillaries in the process of angiogenesis. Every contraction of the uterus isrupts the walls of this capillaries that results to bleeding.(Mayoclinic)Medi cal-Surgical Critical Nursing for Rationale

Thinking

Collaborative Care, Fifth edition, Volume 2 by

Donna D. Ignatavicius and Linda Workman

Manifested

Not manifested

-the increase in endothelial cells in the uterus will also

26

form new capillaries in the Any bleeding after the time of process of angiogenesis. Every contraction of uterus disrupts the wall of this capillaries that results to bleeding.(mayo clinic)Medical-Surgical Nursing Critical Thinking Manifested Not Manifested for Collaborative Care,

menopause

Fifth edition, Volume 2 by Donna D. Ignatavicius and Linda Workman - Endothelial cells secretes fluid substances for the

moisture and pH of lining of the in growth of the

endometrium increases also the Pink, watery or white or white from secretion of this cells. (Nurses Quick Check

discharge your vagina

Signs and Symptoms by Lippincott Williams and Wilkins )

27

Pelvic

pain -Not Manifested

-Not Manifested

-pain occurs when continuous growth of cancer stretches the lining of the uterus. (mayo clinic) ( http://www.emedicine after

especially late in the disease.

health.com/pain surgery. )

Weight loss.

-Manifested

-Not Manifested

-anorexia is one the most common symptoms of cancer patients. (mayo clinic)(Nurses

Quick Check Signs and Symptoms by Lippincott Williams and Wilkins)

28

Nursing Intervention 1. Actual Pre operative Patient Care 1.1 Care Guided of Patient who will undergo abdominal surgery. 1.1.1 Relieving Pain The nurse should administer analgesic drugs a prescribed to relieve the pain and to promote will being in addition to help the patient turn, cough, breathe deeply and ambulate as indicated. 1.1.2 Improving Respiratory Status Semi fowlers position is recommended to expand the lungs of the patient. Coughing and deep breathing is also essential prior to surgery. Oxygen therapy is also recommended to improve gas exchange of the patient. 1.1.3 Improving Nutritional Status It is essential for the nurse to promote good nutrition for the patient. The patient experiences anorexia because of the disease condition. The nurse should emphasize foods that are good for the patient. The nurse should also improve the environment of the patient to prevent loss appetite. Vitamin supplement is also important. Increase liquids is also important because the patient is experiencing urinary retention and high fiber diet for the constipation. 1.1.4 Improving Self Body Image It is essential for the nurse to be empathetic to the patient. Acknowledgement normally of emotional response to actual or perceived changed in the body structure or function. Help patient identify actual changes. Assist patient in incorporating actual changes into activities of daily living, social life, interpersonal relationship, and occupational activities. Help patient identify ways of coping that have been useful in the past.

29

NURSING CARE PLAN (Post-operative) Name of Patient: Gemma Lawas Chief Complaints: Abdominal Mass Hospital No.: 893835 Attending Physician: Dr. Marissa Agudo PROBLEM CUES NURSING DIAGNOSIS Alteration comfort: SCIENTIFIC BASIS OBJECTIVES OF CARE The client After 8 NURSING INTERVENTION S Measures to RATIONALE Room No.: Annex rm. 49

I. Physiologic A. Overload Pain Objective Cues:

in almost

hours of alleviate pain. 1. Encourage expression of feelings about pain. Verbalization allow outlet for emotion may coping mechanism. (Nurses Pocket is Guide Doenges Ed.) by 9th and

always has holistic pain or nursing care, the patients response is to pain in pain scale

Pain r/t discomfort occurs intermittently located at the sutured wound at the supra-pubic area of the abdomen: duration of 30-60 seconds; gnawing pain; aggravated by sudden body movements; relieved by resting in comfortable position; with Tramadol 50 mg IVTT as treatment. -pain scale of 7 sutured incised wound seconda ry post abdomi nal surgery. after surgery. Pain

enhance

subjective

to experience

and maybe from 7 t0 more intense than the 2. Perform comfort measures to 4 or 3.

These measures reduce tension muscle or

health care professiona

30

of which 1 is the lowest and 10 is the highest. -

can

promote relaxation such as

spasm. Redistribute pressure body parts.(Nursing Diagnosis Manual by Sparks, Taylor 3rd Ed.) the to To help patient focus on nonpain matter. (Nursing as Diagnosis Manual Sparks 3rd Ed). Promotes being well and by Taylor related on

appreciate. Pain after

surgery is related to

repositionin g.

Subjective Cues: the surgical - Sakit gihapon wound and ako tahi as the clients verbalized by the experience patient. with pain. SOURCE: MedicalSurgical Nursing Critical Thinking for Collaborati ve Fifth edition, Volume 2 by Donna Care, activities with patient provide distraction such 3. Plan

conversatio n and visits. 4. Maintain the room to be well ventilated and lighted. well

increase energy level important for pain relief.

31

D. Ignatavicius Linda Workman 5. Encourage use of stress managemen t techniques example deep breathing and guided imagery. and

(Nursing Diagnos Manual Sparks 3rd Ed.) Refocus attention and by Taylor

enhances sense of which reduce pharmacologica l dependency Care by 6th control may

(Nursing Plan Doenges 6. Elevate the postoperative site periodically. Ed.) Elevation

maybe required initially reduce to edema and

formation discomfort.

32

(Nursing plan Doenges 7. Encourage adequate rest periods. Ed). To

Care by 9th

prevent

fatigue. (Nurses Pocket Guide

by Doenges 9th 8. Administer pain medication as prescribed. Ed. To facilitate in relieving pain. (Nurses Pocket Guide Doenges . Ed.) by 9th

33

NURSING CARE PLAN (Post-operative) Name of Patient: Gemma Lawas Hospital No.: 893835 Attending Physician: Dr. Marissa Agudo

Room No.: Annex rm.49 Chief Complaints: Abdominal Mass PROBLEM CUES NURSING DIAGNOSIS Altered SCIENTIFIC BASIS After

Psychologic Deficit 2. Altered

OBJEC- NURSING RATIONALE TIVES INTERVENTIONS OF CARE any After 8 Measures to increase hours of muscle activity: are holistic nursing care, the patient will able 1. perform assistive- -to increase muscle strength and muscle function.(Med-

Physical surgery, mobility there Physical :Limite Mobility d Objective Cues: activity changes, physical expected

active ROM exercises.

Surg. Nursing by Smeltzer, Suzenne et al pg. 170)

-Has limited range of motion. r/t post- activity -Has slow operativ movements. e -Needs assurance incision upon mobilization seconda -Has generalized to body weakness ry lying in bed abdomi -lying in bed nal -dressing covering the surgery. sutured wound -pain upon occurs excessive limitations

be 2. scheduled activities -to reduce fatigue (Nurses to with adequate rest Pocket Guide by Doenges 9th Edition.)

and needed enhance wound car. muscle Like other surgery especially abdominal surgeries, any activity

periods during the day. 3. participation

Encourage -Enhances self concept and in self sense of independence.(Nurses

gradually care, within

occupational, Pocket Guide by Doenges 9th

diversional, recreational Ed.)

her level activities. of capacity 4. identify energy -limits fatigue maximizing Pocket

conserving for ADLs

techniques participation.(Nurses

patients are as

Guide by Doenges 9th Ed

34

movements. Subjective Cues: -Lisod kayo ilihok dong kay sakit jud ang ako gi-operahan as verbalized by the patient.

more prone evidence to complicati ons by -maximize energy Pocket

willingne 5. Encourage adequate production.(Nurses to intake of fluids

like ss

by Guide by Doenges 9th Ed.)

pulmonary problems.

participat nutritious foods. e in 6. Provide measures to decrease movement pain upon

Patient are activities encouraged . to have

example

minimal activities to prevent complicati ons. (MedicalSurgical Nursing by Ignatavicio us et Ed.) ,Doma al 5th

splint the abdomen with pillow.

7. Allow sufficient time -to prevent patient feeling of for client to accomplish increase pain.(Nurses Pocket tasks to the fullest Guide by Doenges 9th Ed.)

extent of ability. Avoid unnecessary conversation interruption. -for the patient to be able to focus and have concentration to her work.(Nurses Pocket Guide by Doenges 9th Ed)

35

8.

Assist

with -to encourage client and build success.(Nurses Pocket

unnecessary adaptations on

to accomplish ADLs. Guide by Doenges 9th Ed) Begin easily tasks. 9. medications Administer -to prior prevent maximal in with familiar,

accomplished

to effort/involvement

activity as needed for activity.(Nurses Pocket Guide pain as prescribed. by Doenges 9th Ed.)

36

NURSING CARE PLAN (Pre-operative) Name of Patient: Mrs. Gemma Lawas Room No.: Annex 49 Chief Complaints: Abdominal Mass PROBL EM CUES Physiolo gic Deficit NURSING DIAGNOSIS Impaire d skin SCIENTIFIC BASIS OBJECTIVES OF CARE The creation After 8 of surgical wound hours of disrupt the integrity of holistic the skin and its protective nursing function. Exposure of care, the deep body tissue to patient pathogens in the will be environment places the able to patient at risk of demonstr infection of the surgical ate site, a potentially behaviors life threatening of wound complication . (Medical- healing Surgical Nursing by: & Smeltzer,Suz anne et al preventio pg.445) n of complica NURSING INTERVENTION S Measure to promote wound healing and possible infection: 1. Inspect -promotes timely RATIONALE Hospital No.: 893835 Attending Physician: Dr. Marrisa Agudo

3.Impair integrit ed Skin Integrity y; Objectiv es cues: -low transvers e incision was made. -surgical incision located at the suprapub ic area of the abdomen . Disrupt ed tissue related to sutured surgical incision second ary to

wound daily intervention and for changes.(eg. Sign record wound

characteristic.(D

of oenges 9th Ed.)

infection/co mplication. 2. Practice aseptic technique cleansing the wound. -reduces risk of crosscontamination.(N urse Guide by:Doenges Ed.) 9th Pocket

post tenderne ss and abdomi pain felt on the nal

37

area. -no swelling and discharg e noted. -sutured wound was dressed with betadine paint & operating sponges. Subjecte d cues: Dako jud ang gitahi kay gikuha man ako ovary dong.as verbalize d by the patient.

surgery .

tion such as infection.

3. Provide

-to aid in comfort

devices such and as dressings healing.(Nursing and splints Pocket Guide by: Doenges 8th Ed.) -to prevent tissue

like pillow. 4. Avoid

sheaning of further tissue

with damage.(Med.Surg. or by: Smeltzer,Suzann e et al pg.1729) Nursing

dressings, clothing splints.

5. Keep free

skin -promotes for circulation.(Med. -Surg. by: Nursing Smeltzer, et al

pressure.

Suzanne pg.1463)

-compromise 6. Avoid circulation.(Med. constrictive -Surg. clothing. by:Black, Hawks vol.2 pg 1463.) Nursing

38

7. Provide position changes, active/passi ve assistive exercises

-to

promote &

circulation prevent

excessive tissue

& pressure.(Nurses Pocket guide by: Doenges 9th Ed.) -to facilitate

8. Promote healing.(Nurses good Pocket nutrition by:Doenges with Ed.) adequate protein and calorie intake, and vitamins and minerals supplements as indicated. 9th Guide

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DRUG THERAPEUTIC RECORD (Pre-operative) Name of Patient: Mrs. Gemma Lawas Room No.: Annex 49 Chief Complaints: Abdominal Mass Hospital No.: 893835 Attending Physician: Dr. Marissa Agudo

DRUG/DOSAGE/ FREQUENCY/ ROUTE/TIMING

CLASSIFICATION/ INDICATIONS/ MECHANISM OF CONTRAINDIACTION CATIONS/ SIDE EFFECTS

PRINCIPLES OF CARE

TREATMENT

EVALUATION

Ranitidine (Ulcin) Antiulcer Agents 50g IVTT Action: q8H Inhibits the action 8 am of histamine at the 4 pm H2-receptor site 12 mn located primarily in gastric parietal cells, resulting in inhibition of gastric acid secretion

Indications: Management of gastric hypersecretory states Prevention and treatment of stress-induced upper GI bleeding in critically ill patients Contraindications: hypersensitivity to the drug

Tell patient about the side effects of the medication Inform the patient about the purpose of taking the medicine

(Nursing 2008 DRUG Handbook by: Lippincott Williams & Wilkins 28th Edition.)

Side Effects: CNS: confusion, dizziness, drowsiness, hallucinations, headache CV: arrhythmias GI: altered taste, black tongue, constipation, dark stools GU: impotence ENDO: gynecomastia

Monitor vital signs Watch for any signs of complication Check IV site carefully for signs of thrombosis or drug reaction Encourage patient to have adequate rest and sleep Report for any unusualities

40

DRUG THERAPEUTIC RECORD (Post-operative) Name of Patient: Mrs. Gemma Lawas Room No.: Annex 49 Chief Complaints: Abdominal Mass Hospital No.: 893835 Attending Physician: Dr. Marissa Agudo

DRUG/DOSAGE/ FREQUENCY/ ROUTE/TIMING

CLASSIFICATION/ INDICATIONS/ MECHANISM OF CONTRAINDIACTION CATIONS/ SIDE EFFECTS

PRINCIPLES TREATMENT OF CARE

EVALUATION

Mefenamic Acid 500 mg 1 cap q5H 8 am 1 pm 6 pm

Nonsteroidal Anti- Indications: inflammatory Drugs Relief of (NSAIDs) moderate pain when therapy will Action: not exceed one Anti-inflammatory, week analgesic and antipyretic activities Contraindications: related to inhibition Contraindicated of prostaglandin with synthesis; exact hypersensitivity mechanisms of to Mefenamic action are not acid and aspirin known. allergy Side Effects: CNS: headache, (Nursing 2008 dizziness, DRUG Handbook insomnia by: Lippincott GI: nausea, Williams & Wilkins vomiting, GI pain 28th Edition.) Derm: rashes, pruritus

Tell patient about the side effects of the medication Inform the patient about the purpose of taking the medicine

Monitor vital signs Watch for any signs of complication Encourage patient to have adequate rest and sleep Report for any unusualities

41

DRUG THERAPEUTIC RECORD (Post-operative) Name of Patient: Mrs. Gemma Lawas Room No.: Annex 49 Chief Complaints: Abdominal Mass Hospital No.: 893835 Attending Physician: Dr. Marissa Agudo

DRUG/DOSAGE/ FREQUENCY/ ROUTE/TIMING

CLASSIFICATION/ INDICATIONS/ MECHANISM OF CONTRAINDIACTION CATIONS/ SIDE EFFECTS

PRINCIPLES TREATMENT OF CARE

EVALUATION

Tramadol 50 mg. Analgesic IVTT now & @ 2pm then q 4 for -inhibits ascending 4 doses pain pathways by inhibiting reuptake of norepinephrine and serotorin and alter perception and response to pain binding to opiate receptors in the CNS.

-for better analgesic -moderate to effect, give severe pain. drug before -post operative onset of pain. intense pain. -withdrawal Contraindications: symptoms -lactation may occur if -head injuries drug is -acute alcoholism stopped abruptly Side Effects: reduce -sweating dosage -dizziness gradually. -nausea -tell patient -vomiting to take drug -dry mouth as prescribe -fatigue and not to ((Nursing 2008 -confusion increase dose DRUG Handbook -headache or dosage by: Lippincott -constipation interval Williams & Wilkins unless th 28 Edition.) ordered by prescribe. -warm patient not to stop the drug abruptly.

Indications:

-Reassess patient level of pain at least 30 mins after administration. -monitor bowel and bladder function. -anticipate need for laxative. -monitor patient at risk of seizures. -monitored patient for dependence. -caution ambulatory patient to careful when rising and walking.

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HEALTH TEACHING PLAN (Post-operative)

OBJECTIVES CONTENTS METHODOLOGY TIME RESOURCES EVALUATION

General Objectives: After 8 hours of giving holistic nursing care, the patient will be able to gain knowledge, develop skill and good attitude regarding proper wound care. Specific Objectives: After 45 minutes of student nurse-patient interaction, the After minutes 45 Of

nurse-patient interaction, the patient/signif icant others

patient/significant others will be able to:

was able to: 1. state the purpose of Purpose of Proper Wound lecture proper wound care. Care: a.for fast healing of the wound. 7 mins Fundame stated ntals of purpose proper wound the of

Nursing by :Kozi

43

b.to

prevent

further

er,Barbar healing. a 7th

complications. c.to prevent contaminating the wound. d.to maintain proper

Edition.

personal hygiene. 2.enumerate the proper Proper Ways/Guidelines in lecture ways/guidelines in proper Wound Care: wound care. a.hand washing beforeand after cleansing the wound. b.all materials to be used must be ready and were kept in a non exposed place. c.all materials must be ensured clean and dry. d.provide plastic bag or waste bag where soiled. e.do after care of the instruments and work place after the procedure. 3.detrmine the materials Materials: to be used in wound care. a. cotton balls lecture 5 mins. Fundame Determined ntals of the materials 8 mins. Fundame Enumerated ntals of the ways proper and

Nursing by : Kozier, Barbara 7th Edition.

guidelines in proper wound care.

44

b. gloves c. alcohol d. betadine e. OS dressing f. bandage g. bandage scissor 4. demonstrate beginning 1st do hand washing demonstra 15

Nursing by : Kozier, Barbara 7th Edition.

to be used in wound care.

Fundame the ntals

family

skill on proper wound 2nd clean the area with tion care. sterile water or hydrogen return peroxide.

& mins.

of member demonstrated on wound

Nursing by : Kozier, Barbara 7th Edition.

demonstra

3rd clean the area with tion. dry and clean cotton balls. 4th apply betadine

dressing.

solution and spread to the wound site.(from inner to outer circular motion/one direction only.) 5th do apply dressing & secure with bandage. 6th do after care. 7th do hand washing. 5. show awareness on the topic discuss. Questioni ng 10

asked questions

& mins.

45

answer.

regarding wound care.

Name of Patient: Mrs. Gemma Lawas Chief Complaints: Abdominal mass Hospital No.: 893835 Attending Physician: Dr. Marrisa Agudo

Room No.: Annex 49

46

Name of Patient: Mrs. Gemma Lawas Chief Complaints: Abdominal mass Hospital No.: 893835 Attending Physician: Dr. Marrisa Agudo

Room No.: Annex 49

SOAPIE #1 S sakit gihapon ako tahi dongas verbalized by the patient. O seen patient lying on bed; coherent; a febrile; with the IVF # 1 D5LR 1L @ 20 gtts/mins hooked at the right arm, infusing well; pain occurs intermittently; located at sutured wound at the suprapubic region of the abdomen, duration of 30-60 seconds; gnawing pain; aggravated by sudden body movement; relieved by resting in a comfortable position; and with treatment of tramadol 50mg slow IVTT; pain scale of 7 in which 10 is the highest and 1 is the lowest; temperature of 37.3 C. A Alteration in comfort: pain related to surgical sutured wound. P To alleviate patients manifestations of pain. I monitored and charted vital signs and intake and output every 4 hours; encouraged patient to verbalized feelings and needs; encouraged patient to sleep/rest; instructed patient to splint affected area with pillow when about to cough or sneezed; repositioned patient carefully every 2 hours; placed patient properly and comfortably in bed; monitored the affected site frequently; provide adequate lighting and ventilation area; assisted patient in her self-care needs; administered analgesic as prescribed for pain. E The patient was able to manifest a relief in pain as evidenced by the patients pain scale of 4 from 7.

47

Name of Patient: Mrs. Gemma Lawas Chief Complaints: Abdominal mass Hospital No.: 893835 Attending Physician: Dr. Marrisa Agudo

Room No.: Annex 49

SOAPIE #2 S Sakit gihapon ako tahi dong as verbalized by the patient. O Seen patient lying in bed; coherent; afebrite; with IVF #1 dslr 1 liter @ 20

gHs/minute hooked at the right arm, infusing well; pain occurs intermittently; located at the sutured wound at the suprapubic region of the abdomen duration of 30 60 seconds; gnawing pain; aggravated by sudden body movement; relieved by resting in a

comfortable position; and with treatment of tramadol 50 mg slow IVIT; pain scale of 7 of which 10 is the highest and 1 is the lowest; temperature of 37.3 0 C. A Alteration in comfort; pain related to surgical sutured wound. P To alleviate patients manifestation of pain. I monitored and charted vital sign and intake and output every 4 hours; encouraged patient to verbalized feelings and needs; encouraged patient to sleep/rest; instructed patient to splint affected area and pillow when about to cough or sneeze; repositioned patient carefully every 2 hours; placed patient properly and comfortably in bed; monitored the affected site frequently; provide adequate lighting and ventilation area; assisted patient in her self-care needs; administered analgesic as prescribed for pain. E The patient was able to manifest a relief in pain as evidenced by the patients pain scale of 4 from 7.

48

Name of Patient: Mrs. Gemma Lawas Chief Complaints: Abdominal mass Hospital No.: 893835 Attending Physician: Dr. Marrisa Agudo SOAPIE #3

Room No.: Annex 49

S Dako jud ang gitahi kay gikuha man ako ovary dong.as verbalized by the patient. O seen patient lying on bed; coherent; a febrile; with the IVF # 1 D5LR 1L @ 20 gtts/mins hooked at the right arm, infusing well; pain occurs intermittently; located at sutured wound at the suprapubic region of the abdomen, duration of 30-60 seconds; gnawing pain; aggravated by sudden body movement; relieved by resting in a comfortable position; and with treatment of tramadol 50mg slow IVTT; pain scale of 7 in which 10 is the highest and 1 is the lowest; temperature of 37.3 C. A Impaired skin integrity; Disrupted tissue related to sutured surgical incision secondary to post abdominal surgery. P demonstrate behaviors of wound healing & prevention of complication such as infection. I - inspect wound daily for changes.(eg. Sign of infection/complication; practice aseptic technique cleansing the wound; provide devices such as dressings and splints like pillow; avoid sheaning of tissue with dressings, clothing or splints; keep skin free for pressure; avoid constrictive clothing; provide position changes, active/passive & assistive exercises; promote good nutrition with adequate protein and calorie intake, and vitamins and minerals supplements as indicated.

49

E The patient was able to manifest a relief in pain as evidenced by the patients pain scale of 4 from 7.

50

EVALUATION AND RECOMMENDATION

Prognosis:

In the case of Mrs. Lawas, the operation she had undergone which is the Pelvic Laparatomy Salphingo Oophorectomy (removal of fallopian tube and ovary_ improved her condition very much from the onset of the signs and symptoms and after the surgery conducted. The increasing growth of endometrial cancer leads to the occurrence of several physiologic changes such as profuse vaginal bleeding, nausea and total body weakness that unable the patient to function well.

After the condition of conduction of the operation, the mentioned above physiologic changes subsided and gradually diminished. The operation was great help to Mrs. Lawas in the relief of her condition. Now, mrs. Lawas is taking enough rest to recover as much as possible as to what the doctor advised.

Based on Mrs. Lawas physical condition, she has a high positive prognosis to achieve her optimum level of functioning since the patient shows positive attitude towards the treatment regimen being rendered to her.

51

RECOMMENDATION TO PROMOTE EARLY RECOVERY AND REHABILITATION:

Mrs. Lawas who had undergone, a surgery focused on her health goal on would healing. The patient and also the significant others should be able to understand on caring the surgical incision to prevent complication such as infection on the site. Together with would healing, the patient should adjust her behavior and lifestyle to prevent recurrence and promote early recovery. She adjust her behavior. She should take follow-up diagnostic tests to ensure or rule out the possibility of malignancy. She should not also forget to submit herself for regular consultation to her physician.

With these recommendations and health teaching the patient and her familys knowledge on her condition will be improved and will have assurance of maintaining good health.

52

EVALUATION AND IMPLICATION OF THIS CASE STUDY

1. Nursing Practice

In nursing practice, this enable the student to apply what she has learned in her field of study. She is trying to implement the theories and skills that client manifested or gained from the client. Giving holistic nursing care to the client from the day the patient was received is the most significant way in applying nursing practice. It also include full assessment of the client and most of all giving emotional support since this time anxiety may be felt more or less by patient who undergo Pelvic Laparatomy Salphingo Oopherectomy.

2. Nursing Education

Through the study of the case, the student achieves excellence though the knowledge of the scientific basis of medical-surgical nursing. Nursing has contributed a lot to a better expansion of the students knowledge. She makes it as a foundation of her knowledge\j, attitude and skill towards better care for client as well as better understanding of the clients condition.

3. Nursing Research

With this case study, she can update knowledge attitude and skills in nursing through the existence of nursing research. She can utilize many revised theories that would enhance our education and practice in nursing as well as the knowledge of scientific basis and pathophysiology of the disease that would further lead to more progress in the field of nursing practice.

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REFERRAL AND FOLLOW-UP:

The nurse is responsible for the coordination to the community health cancer for a continuous monitoring and care of the patient while the nurse is into home care setting. It includes the special care endorsement for the patient to the community health officers and to the family. It is also essential for the nurse to inform the patient for follow-up care to prevent possible complications and awareness on current health conditions. Consultation to the doctor should be emphasized by the nurse to the patient and family.

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BIBLIOGRAPHY Bare, Brenda G. and Suzanne c. Smeltzer. Brunner and Suddarths Textbook of MedicalSurgical Nursing Vol. 1 and 2 10th Edition. Lippincott Williams and Wilkins and Wilkins Inc. 2000. Block, Joyuce M. and Jane Hokanson Hawks. Medical-Surgical Nursing: Clinical Management for Positive Outcomes Vol. 1 and 2 7th Edition. W.B. Saunders Company 1999. Burke, Karen and Priscilla Lemone. Medical-Surgical Nursing: Critical Thinking in Client Care 3rd Edition. Pearson Education South Asia PTE Ltd. 2004. Doenges, Marilynn E., Mary-Frances Moorhouse and Alice c. Murr. Nurses Pocket Guide: Diagnoses, Intervention and Rationales 9th Edition. F.A. Davis Company. 2004. Fischbach, F.T. Nurses Quick References to Common Laboratory and Diagnostic Test 2nd Edition. Philadelphia; JB. Lippincott Co. 1998. Kozler, Barbara et. Al. Fundamentals of Nursing 7th Edition Pearson Education South Asia PTE Ltd. 2000. Luckmann, Joan and Karen Creason Sorensen. Medical-Surgical Nursing: A Psychophysiologic Approach 3rd Edition Vol. 1 and 2 W.B. Saunders Company. 1987. Marieb, Elaine N. Essentials of Human Anatomy and Physiology 7th Edition. Pearson Education South Asia PTE LTD. 2004. Monahan and Sands. Phipps Medical-Surgical Nursing Clinical Management for Positive Outcomes 7th Edition Vol. 1 and 2 Mosby Yearbook Inc. 2002. Nursing 2008 Drug handbook 26th 28th Edition. Lippincott William and Wilkins. The Merck Manual of Medical Information Home Edition. Mercks and Co. Inc. 1997. Udon, Josie. Medical-Surgical Nursing: Concepts and Clinical Application 1st Edition. Educational Publishing House. 2002.

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