DE LA SALLE HEALTH SCIENCES INSTITUTE College of Nursing and School of Midwifery Dasmarias City, Cavite

NURSING CASE STUDY

Submitted By: Bianca Nicole A. Mangalindan Submitted To: PROF. IAN GENUINO RN, MAN

DE LA SALLE HEALTH SCIENCES INSTITUTE COLLEGE OF NURSING AND MIDWIFERY NURSING CASE STUDY

ADMISSION/FINAL DIAGNOSIS AUB 2o endocervical polyps

I. HEALTH HISTORY
A. DEMOGRAPHIC (BIOGRAPHICAL DATA) 1. Clients Name or Initial (optional): B.D.G.Q 2. Gender (sex): Female 3. Age, Birth date and Birthplace: 39, November 17, 1973, Cavite city 4. Marital (Civil) Status: Married 5. Race and Nationality: Filipino 6. Religion: Catholic 7. Address, Telephone Number, E-mail Address: 252 Anuling Lejos II, Mendez Cavite 8. Educational Background/Other Significant Framing : College Graduate 9. Occupation (usual and present): Office employee 10. Usual Source of Medical Care: Hospital

B. SOURCE AND RELIABILITY OF INFORMATION The client was conscious and able to respond coherently. Fully aware and oriented of the time, date and place; Capable of responding very audibly and giving out adequate and reliable information clearly, cleverly and properly on her own.

C. REASONS FOR SEEKING CARE OR CHIEF COMPLAINTS (top 3) 1) Medyo matagal na kasing parang may masakit dito banda sa may tyan ko na di ko maintindihan, hindi ko naman agad pinacheck up. 2) Tapos nung kumailan lang nagpacheck up na rin ako eventually kasi hindi regular yung mens ko at marami. 3) Nung mga isang araw ba yun, ayun dinugo nalang ako ng marami

D. HISTORY OF PRESENT ILLNESS/OR PRESENT HEALTH The patient stated that she is experiencing pain in the abdominal area for a month or so, and also some irregular menstruation and bleeding between menstrual periods. She went to the doctor eventually and have her tested. It was found out that there are small lumps/polyps on her cervix which then the doctor decided the best way for it is to remove the uterus. On April 19 in the morning she was admitted due to vaginal bleeding again, when she was at home that time, which caused her for a TAH. She mentioned that the pain was at the grade of 8-9 out of 10 during that time. She also experienced DOB because she was anxious about what might happen. Especially when she was told that surgery was needed. Despite the fear, she perceived this operation very helpful because it is a relief for her to know that the mass is removed. E. PAST MEDICAL HISTORY OR PAST HEALTH According to the patient, she only had chicken pox at the age of 6 then it re-occurred again at the age of 34 but less severe. Other than that, she only experienced fevers due to flu. She stated that she never had any accidents or injuries. At the year 1999, 2000, 2006 she was hospitalized because she gave birth through CS. June 19, 2013 she was admitted due to vaginal bleeding and was scheduled for operation (TAH). Her Obstetric history is G3P3 (3003), the patient is complete in immunization together with TT and HPV vaccine. No allergies are present. According to the patient, she is not taking any medications other than pain relievers such as Mefanamic Acid. Last Examination Date was June 9, 2013.

F. FAMILY HISTORY (Family tree or genogram/roster)

The patients family has history of Cancers in the maternal side while there is HTN in the father side. As can be seen above, there are different kinds of CA present which puts the patient in a high risk of acquiring CA as well. Also, the patient is also at risk in acquiring HTN since her father is hypertensive and so are her relatives. This means the patient must be well aware on how to prevent such and must practice healthy lifestyle to decrease chances in acquiring CA and HTN.

G. SOCIO-ECONOMIC

FAMILY MEMBER/ RELATIONSHIP TO THE PATIENT J.Q (Mother) L.Q (Father) B. Q ( Husband)

SOURCE OF INCOME

MONTHLY INCOME

Housewife Business man Corporation Employee

Not disclosed Not disclosed Not disclosed

Both the patient and her husband is an employee in a company. She stated that both of their income can sustain their familys needs including health matters. Though there are times that they need some help from her parents. They are fortunate enough compared to others because they have PhilHealth and enough money to provide for their healthcare. In case one of their family members gets sick, their financial status is enough for their health needs. H. DEVELOPMENTAL HISTORY Intimacy VS Isolation of Erik Eriksons Developmental stage. This stage takes place during young adulthood between the ages of approximately 19 and 40. During this period of time, the major conflict centers on forming intimate, loving relationships with other people. Being a 39 year old, the patient has already succeeded this stage because she has already found intimacy with his husband. Finally now stable with her 3 children. Success in this stage leads to stronger relationship. Erikson believed that it is vital to develop close and committed relationship with other people. As for the patient reaching almost the end of young adulthood, she found that sense of intimacy with her family.

I. REVIEW OF SYSTEMS AND PHYSICAL EXAMINATION 1. ROS AND PE (6-20-13) Systems ROS (includes history of illness or complaints) -all subjective a. General/Overall Health Status Hindi naman masyado nagbago yung timbang ko eh. Ayos naman hindi ako nanghihina. PE (includes assessment via IPPA) -all objective Awake, conscious and coherent Ambulatory with minimal assistance With good muscle strength T= 36.8oC PR= 81 bpm, regular and equal in strength bilaterally RR= 23 cpm BP= 110/70 mmHg

Skin: b. Integument Wala naman akong history ng skin disease. Uhm medyo numipis yug buhok ko kesa dati tapos tumutubo na mga putting buhok. Laging ma-pink yung mga kuko ko naman tsaka regular kong ginugupit. Dry skin on both upper and lower ex Good skin turgor Warm to touch Hair: Normal hair distribution Black with some gray, thin hair, no parasites evident Nails: Round, hard, nails with pink nail beds Capillary refill <3 sec

c. Head

Hindi naman madalas sumakit ulo ko, pa minsan minsan lang.

Symmetrical, smooth, firm (-) Lesions on the scalp Normocephalic Full ROM

d. Eyes

Malinaw pa naman mga mata ko. Hindi ko na matandaan last check-up ko eh. Okay naman ang pandinig ko, nakakarinig pa ako ng maayos. Cotton buds panglinis ko mga every week. Dati madalas ako magkasipon pero ngayon hindi na.

Symmetrical blinking Round and equal iris PERRLA (-) Discharges on external ear (-) Tenderness (-) Nasal discharges (-) Nasal flaring Nontender nasal sinuses Sinuses clear upon illumination

e. Ears

f. Nose and sinuses

g. Mouth and Throat

Wala naman akong problema dyan, di madalas sumakit lalamunan ko. Bihira din ako mapaos. Wala naman masakit kapag ginagalaw. Di pa ako nagkakakulani ever. Hindi naman siya sumasakit, tingin ko naman walang abnormal. Wala naman akong nakakapa Ay hindi ako nag b-BSE.

(-) Hoarseness Dry lips No lesions Pharyngeal tonsils not inflammed (+) Full ROM No cervical lymph node enlargements

h. Neck

i. Breast and axilla

j. Respiratory

Yung tito ko namatay yun sa lung cancer eh. Pero so far, wala naman problema sakin. Minsan lang ako ubuhin. Hindi pa naman ata ako nakakapag-ECG kasi okay naman ako walang problema sa puso.

Normal breathing Symmetrical thoracic expansion (+) Apical pulse felt at 5th ICS Identical apical and radial pulse @ 81bpm Normal heart rate sounds Regular rate, normal rhythm

k. Cardiovascular

l. Gastrointestinal

Regular naman akong nakakadumi tapos tama lang yung kain ko. Hindi naman ako masyadong matakaw na eh hindi katulad dati. Pero minsan nacoconstipate ako siguro depende sa kinain ko. Hindi naman masakit kapag umiihi ako. Usually color yellow. Umiihi ako mga 4-5 beses sa isang araw siguro depende sa iniinom ko. Nagkaron ako ng 11 years old. Hindi ko na matandaan kelan huli kong mens eh hindi kasi siya regular. Pag nagkaroon ako mga 5-6 days. Hindi naman ako ina-arthritis,

Round abdomen (-) rashes, lesions (-) mass and tenderness

m. Urinary

Urine color: amber yellow (-) Bladder distention

n. Genitalia

q. Musculoskeletal

Steady gait

bihira naman sumakit mga muscles ko depende nalang kapag pagod talaga sa trabaho. r. Neurologic Ay hindi wala naman akong problema jan.

(+) Full ROM and muscle strength

Responds to questions and statements Oriented to time, place and person Able to smell odor properly and correctly Sensation to light touch and pain Able to raise eyebrows, wrinkle forehead, clench teeth Able to identify taste Able to shrug shoulders, able to move neck with ease

s. Hematologic

Dati lagi ako nagkakapasa pero ngayon hindi na. Nakainom nako ng gamut para dun eh so okay na. Wala naman akong history. Wala rin diabetic sa pamilya ko. Uh hindi ako pawisin as in, yung tama lang.

(-) Bleeding and bruising

t. Endocrine

(+) Heat and cold tolerance

2. LABORATORY STUDIES/DIAGNOSTICS Procedure/Date Indication Normal Values/Findings Actual Findings Nursing Responsibilities/ Implications (PRE, INTRA, POST) Urinalysis 6-9-13 To assess overall health, to diagnose a Color: Pale to amber yellow Character: Clear Clear Yellow PRE: - Check doctor's order - Validate patients name 1.015 - Explain the procedure to the 5.0 Trace (-) 0-1 HPF 0-1 HPF pt INTRA: - Give sterile specimen bottle, clean perineal, instruct pt to catch midstream urine

medical condition, to lightly hazy to monitor a medical condition Specific Gravity:1.005 1.025 pH:4.6-8.0 Albumin: (-) Sugar: (-) WBC 0-4 RBC 0-2

- Write the
information in the specimen container - Observe standard precautions POST: - Deliver the specimen to the laboratory or refer

CBC 6-9-13

Used to diagnose and manage numerous diseases. It can reflect problems with fluid volume (such as dehydration) or loss of blood. It can show abnormalities in the production, life span, and destruction of blood cells. It can reflect acute or chronic infection, allergies, and problems with clotting.

Hgb: 123-153 Hct: 0.36-0.45 % Wbc: 5-10X10^9L Segmenters: 0.36- 0.66 Lymphocytes: 0.22-0.40 Eosinophils: 0.010.040 Monocytes: 0.040.08 Stab cells: 0.020.05

130 0.40 7.7

PRE: - Check doctors order - Verify patient

0.68

- Explain test procedure. -

0.26

Explain that slight discomfort may be

0.02

felt when the skin is punctured.

0.03

- Encourage to avoid stress if

0.01

possible because altered physiologic status influences and changes normal hematologic values. - Explain that fasting is not necessary. However, fatty meals may alter some test results as a result of lipidemia. INTRA: - Provide support while the CBC test is in process POST:

-Monitor the puncture site for oozing or hematoma formation. - Instruct to resume normal activities and diet.

3. OTHER ASSESSMENT TOOLS (Scale, Sheet, Grade, Level, etc.) Date(s) Taken Comprehensive Actual Content/Legend 6-20-13 Numeric pain scale 0-no pain 1-3 Mild pain (Nagging, annoying, interfering little with ADLs) 4-6 Moderate pain (interferes significantly with ADLs) 7-10 Severe pain (disabling, unable to perform ADLs) 7 Severe pain, impaired physical mobility, but able to walk short distances Actual Result

J. FUNCTIONAL ASSESSMENT 1. Health Perception/Health Management Pattern According to the patient, she seems to be fine most of the time except the time before the surgery when she knew that something wrong is going on. She hadnt had any colds in the past. She eats fruits and vegetables often but does not exercise because she usually has no time. She uses her weekends for rest. The patient verbalized that its not hard for her to follow what nurses or doctors suggest her to do because she knows this is whats best for her. She doesnt know what caused her illness; she went to the doctor and have her checked after suspecting that something is wrong with her. With this, she was diagnosed with uterine endometrial polyp that is why the best solution is to have the surgery.

2. Self-esteem, Self-concept/Self-perception Pattern The patient sees herself as a fine, happy woman with a great family. She feels good most of the time although there are stressors that come her way. Since the illness started, she felt the need to be more aware of her health so that she can prevent more illnesses. Although, the patient mentioned that she is a bit low today because of the change in situation and lifestyle.

3. Activity/Exercise Pattern As a working mother, the patient perceives that she has sufficient energy for her duties as an employee and a mother as well. Although there are times that she feels really tired, depending on the severity of her work. As mentioned above, she has no time to exercise anymore. She uses her spare time with her family and to rest. The patient can still do any normal person can do. She can still feed, bath, dress, cook, etc. properly on her own which places her to Level 0 full self-care.

4. Sleep/Rest Pattern The client usually sleeps 6-7 hours a day. Sometimes when she wakes up she feels that she still lacks sleep but still thankful for her day and make the most out of it. She doesnt need any medication to put her to sleep. Her sleep patterns are regular; she sleeps soundly most of the time and has no hard time sleeping since she has no daytime naps.

5. Nutrition/Elimination Typical daily Filipino meal is her usual food intake. She eats pork, fish, beef and vegetables most of the time. She has no problem with her appetite and no sudden changes with her weight. Problems with food or any food allergies are not experienced by the patient. She stated that she cannot remember what she ate for the last 24 hours and that she was NPO for the last hours. No dental and skin problems, only a little dryness of her skin. She confirmed that she doesnt use any lotion or any moisturizer often. Her bowel elimination pattern is normal. She defecates every morning before going to work and usually hard. For the urinary elimination pattern, she urinates at least 4 times a day. No discomfort and abnormalities seen or felt.

6. Sexuality/Reproductive She cannot remember when her LMP was because it was irregular and it was hard to track. Her Obstetric history is G3P3 (3003). She mentioned that she and her husband uses condom for contraceptives

7. Interpersonal Relationships/Resources The patient is an employee in a company and gets along with her coworkers well. She describes her family as a loving and a close one. As a mother and a wife, shes very happy and contented with her life today. She told me that she is thankful with her loved ones/relatives because of the support they give her especially in times of needs and difficulties in life. The patient also mentioned that she is very close with her family/relatives and has close connection with them. Her time alone, she said, is relaxing because she gets to rest.

8. Coping and Stress management/Tolerance Pattern The patient encountered many stressors in life already such as family, friends and financial. She believes that there will be a change in her lifestyle now since she will take care of herself more because she doesnt want to get ill anymore, knowing also that she is capable of acquiring her familys illnesses. During difficult and tense times, she usually looks up to her husband or her family and friends to cope up with her problems. This way, they help her relieve her anxiety about her stressors in life. Or sometimes, she uses her alone time to alleviate stress by going to the malls or watching movies to get distracted for awhile. And she revealed that it actually helps her.

9. Personal Habits The patient confessed that she only drinks occasionally; her last was during the celebration of New Year. She clearly stated that she never had drinking problems or smoking because she is well aware of the consequences.

10. Environmental Hazards The client is living in a peaceful subdivision with her family. She said she is well aware of her neighbors and that their subdivision is safe. Also, there are enough utilities to use and easy access for transportation for her to go to work.

II. PROBLEM LIST

A. ACTUAL or Active Problem No. Problem Date Identified Date Resolved/Remarks 1 2 3 Acute pain Low self esteem Sexual dysfunction 6-20-13 6-20-13 6-20-13 6-20-13 6-20-13 6-20-13

B. HIGH RISK or Potential Problem No. 1 2 Problem Infection Fluid volume deficit Date Identified 6-20-13 6-20-13

IV. ANATOMY AND PHYSIOLOGY

Uterus, also called womb, an inverted pear-shaped muscular organ of the female reproductive system, located between the bladder and rectum. It functions to nourish and house the fertilized egg until the unborn child, or offspring, is ready to be delivered. 6 to 8 cm (2.4 to 3.1 inches) long; 2 to 3 cm (0.8 to 1.2 inches) thick. The uterus has 4 major regions: the fundus is the broad, curved upper area in which the fallopian tubes connect to the uterus; the body, the main part of the uterus, starts directly below the level of the fallopian tubes and continues downward until the uterine walls and cavity begin to narrow; the isthmus is the lower, narrow neck region; and the lowest section, the cervix, extends downward from the isthmus until it opens into the vagina.

V. PATHOPHYSIOLOGY
The normal menstruation takes place every 28 days on a womans menstrual cycle. It normally occurs for 4-6 days with an amount of 30 cc. To start off, the main point is the irregular menstruation caused by the endocervical polyp. Causes of this according to research are still unknown. But some may relate it to changes in hormone levels or blocked blood levels. Risk factors are divided to modifiable and non-modifiable factors. Age, history, number of child born, menopause and unknown are under the non-modifiable factors. While medications such as Tamoxifen, hormone replacement therapy, obesity and hypertension are the modifiable factors. Patient may or may not experience signs and symptoms. But it is usually asymptomatic at early parts. Symptoms of this include Menorrhagia or heavy menstrual bleeding, abnormal uterine bleeding which can occur between menstrual period, after menopause, after sexual intercourse and after douching (washing or cleaning out the vagina (birth canal) with water or other mixtures of fluids. And lastly, Leukorrhea, a yellow/white mucus which may be inflamed and rarely can become infected causing vaginal discharge. Several methods of lab and diagnostics include pap smear, vaginal UTZ, hysteroscopy, D&C and hysterosalpingogram. Results can actually identify abnormalities that can be found which cause AUB such as small lump or nodule. This may be malignant or benign, but usually benign. It ends up with diagnosing AUB secondary to endocervical polyp.

Normal menstruation occurs every 28 day, with duration of 4-6 days, 30 cc volume

Irregular menstruation

CAUSE: unknown, hormone levels, blocked blood vessels

NON MODIFIABLE FACTORS: Age History Unknown #of child Menopause

MODIFIABLE FACTORS: Medications (Tamoxifen) Hormone Replacement Therapy Obesity HTN

Asymptompatic

Pt may or may not experience any symptoms

Symptomatic

Menorrhagia

AUB

Leukorrhea Yellow/white mucus

Abnormally heavy and prolonged menst rual period at regular intervals.

- Bet. Menstrual period - After menopause - After sexual intercourse -After douching

May be inflamed & rarely can become infected causing vaginal discharge

AUB 2 endocervical polyp

Several laboratories for finding out whether endocervical polyp is present

May be malignant or benign

Abnormalities found that can cause AUB such as small lump or nodule

Pap smear Vaginal UTZ routine pelvic exam, hysteroscopy D&C

VI. MEDICAL-SURGICAL MANAGEMENT (Curative) 1. Procedure (USN, Gavage, CPT, Surgery, etc.) Procedure/Date Indication/Analysis Nursing Responsibilities (PRE, INTRA, POST) TAH 6-20-13 AUB secondary to endocervical polyp with endocervical grandular PRE: - Check doctors order - Ensure patient has signed the Informed consent - Make sure that preop lab tests are performed and review lab results - Explain to the patient the procedure clearly preoperatively, intraoperatively and postoperatively. - Night before surgery, administer enema and tell pt she is in NPO - Administer IV, Antibiotics or any medicines according to the doctor - Instruct and show patient on postoperatively measures such as deep breathing, coughing exercises. - Tell patient what to expect after surgery - Provide support - Transfer pt to the OR INTRA: - Get VS for baseline data - Count sponges, needles, instruments with the

circulating nurse - Insert IFC - Skin preparation according to Anesthesiologist prefers. - Helps in draping the patient - Pass instruments to the surgeon accordingly and correctly (Scrub nurse) - Maintain asepsis - Clean pt after surgery - Provide abdominal binder - Transfer to PACU POST: - Get VS - Monitor respiratory status - Encourage patient to have deep breathing, coughing, turning and extremity exercise - Administer and regulate IV fluids, monitor I&O - Auscultate for bowel sounds. Still NPO until peristalsis has returned and the doctor has ordered that she can resume oral intake - Provide pain medications and other meds needed - Keep pt in supine position without pillow for at least 6 hours - Assess vaginal discharge and perineal pads, Assess incision site for drainage and bleeding. Provide wound care

2. Pharmacotherapeutics/Medicines (IV Fluids, Drugs) GN (BN) Classification Stock Cefuroxime (Zinacef) 2nd Gen Cephalosporin Skin and skin suture infections, 500 mg/cap, q8 x 7 days Indication (client-specific) Dosage and Frequency Nursing Responsibilities/Implication s (PRE, INTRA, POST) PRE: - Check doctors order - Follow 10 Rs in drug administration INTRA: - Make sure pt drinks it and Explain indications - Give oral drug with food to decrease GI upset and enhance absorption. - Have vitamin K available in case hypoprothrombinemia occurs. - Discontinue if hypersensitivity reaction occurs. POST: Teaching points - Take full course of therapy even if you are feeling better. - You may experience these side effects: Stomach upset or diarrhea. - Report severe diarrhea with blood, pus, or mucus; rash; difficulty breathing; unusual tiredness, fatigue; unusual bleeding or bruising; unusual itching or irritation.

Amlodipine (Norvasc), calcium channel blockers

Angina, Decrease BP 5 mg/tab, OD

PRE: - Check doctors order - Follow 10 Rs in drug administration INTRA: - Make sure pt drinks it - Explain indications - Monitor patient carefully (BP, cardiac rhythm, and output) while adjusting drug to therapeutic dose - Monitor cardiac rhythm regularly during stabilization of dosage and periodically during long-term therapy. - Administer drug without regard to meals. POST: Teaching points - You may experience these side effects: Nausea, vomiting (eat frequent small meals); headache - Report irregular heartbeat, shortness of breath, swelling of the hands or feet, pronounced dizziness, constipation. PRE:

Epidural Morphine, Narcotic Analgesics

Relieve pain following a major surgery 8cc Q12 x 4

- Check doctors order - Follow 10 Rs in drug administration INTRA: - Make sure pt drinks it

- Explain indications - Dilute and administer slowly IV to minimize likelihood of adverse effects. - Keep opioid antagonist and facilities for assisted or controlled respiration readily available during IV administration. - Reassure patients that they are unlikely to become addicted; most patients who receive opiates for medical reasons do not develop dependence syndromes. POST: - You may experience these side effects: Nausea, loss of appetite (take with food, lie quietly); constipation (use laxative); dizziness, sedation, drowsiness, impaired visual acuity (avoid driving or performing tasks that require alertness and visual acuity). - Report severe nausea, vomiting, constipation, shortness of breath or difficulty breathing, rash.

Mefanamic Acid (Ponstan) NSAID

Relieve mild to moderate pain, 500mg/cap, q6

PRE: - Check doctors order - Follow 10 Rs in drug administration INTRA: - Make sure pt drinks it

- Explain indications POST: - Discontinue drug promptly if diarrhea, dark stools, hematemesis, ecchymoses, epistaxis, or rash occur and do not use again. Contact physician. - Notify physician if persistent GI discomfort, sore throat, fever, or malaise occur. - Do not drive or engage in potentially hazardous activities until response to drug is known. It may cause dizziness and drowsiness.

D5LR, hypertonic

Treatment for persons needing extra calories who cannot tolerate fluid overload, treatment of shock. 1000cc X 30gtts/min

- Check doctors order, if the solution is clear and undamaged - Properly label the IV bottle - Observe proper aseptic techinique when changing

VII. PROGRESS NOTES (Narrative) phase form Day No. Existing Cues/Problems Interventions Actually Done (Nursing and Collaborative) Clients Response

Day 1

The patient is alert, oriented of the date, time and place. Standing beside the bed and has been ambulating short distances with a little assistance from a relative. The patient is still NPO. Abdominal binder attached. Client has complaints of incisional tenderness. Nursing interventions were done such as wound care and analgesics were given to relieve pain. She also has other concerns about her situation now. She manifested situational low esteem. Enough support system was given for relief. The patient was given a full explanation about her clinical condition and all her questions were answered. She was satisfied with the interventions and increased comfort and increased self-esteem were achieved.

Day 2 The patient is alert, oriented of the date, time and place. Sitting on the bed and has been ambulating slowly more often by herself or with assistance if pain is present. Abdominal binder attached. The patient is now on a clear diet to allow the stomach to rest. Wound care and analgesics are still given if pain occurs. Risk for infection is still possible that is why health teachings on how to prevent it were given. Since there are no complications, IFC was removed but IV still continues. Patient now understands more about her condition and starts to accept the changes.

VIII. DISCHARGE HEALTH TEACHING PLANS Content 1. Compliance - Compliance to all health teaching plans Strategy - Explain very well, simple and clear so that the pt would be able to understand the importance of the teachings Medication - Pain medications are - Emphasize the need to drink

prescribed such as analgesics and anti-inflammatory - Wound care

it with meals - Indicate important points such as: Try getting up and moving around if she is having some pain. This may ease it. And press a pillow over incision when she cough or sneeze to ease discomfort and protect your incision. In the first couple of days an ice pack may help to relieve some of the incisional pain. - Importance of wound care to prevent infection and how to do wound care

Diet

- Well balanced diet including protein and fruits & vegetables - Fluids

- Emphasize the importance of eating healthy diet, to help in healing. - Encourage to drink 8-10 glasses a day to keep hydrated and from constipation

Exercise

- Balance exercise with rest (walking is the best) - No heavy lifting

- Explain very well that Walking is one of the best ways to recover and heal more quickly. And prevent heavy lifting to prevent wound dehiscence

Activity/Lifestyle Changes

- Driving after two weeks - No sexual intercourse for 8 weeks - Slowly increase daily activities - No menstrual periods

- Tell the pt that it is important to comply with the teachings in order to recover quickly - Explain very well the changes in order to accept the situation more easy

- Unable to get pregnant 2. Follow up/ check up - 6-12 weeks to check progress - Enumerate the things she should know when to call the doctor and importance of follow up

IX. SUMMARY OF CLIENTS STATUS OR CONDITION AS OF LAST DAY OF CONTACT (Narrative Form) Date: 6-20-13 As of last day of contact, the patient is coherent and communicative. Oriented to time, place and date. Ambulatory with minimal assistance. Primary concern is the pain on the incision site. Nursing interventions such as wound care and analgesics could be given to relieve pain. Concerns are also emotional which is situational low esteem and sexual dysfunction. Provided time to listen and educate for further knowledge about the situation. Enough teachings on how to prevent infection, discharge plans and follow up care.

__________________________ Signature over PRINTED NAME