Our Lady of Guadalupe College of Nursing Inc.

Case presentation

Adenomyosis

Leader: Degamo, Peter Mem ers: Cu un!ieng, "o#n Paul Del Carpio, $rederic% Del Monte, Carissa Camille &sguerra, Lynn &spanol, '.". $amis, Leslee $ay $arnacio, 'onald Garcia, Geeanne Marie

Clinical Instructor: Ms. (uson '.N. M.A.N.

I. Introduction
Page ) of *+

Last March 6, 2013 at VRPMC 5th floor OB ward, our group chose a 31 r old cl!e"t who has d!ag"ose w!th ade"o# os!s$ %e chose th!s case &ecause we wa"t to ga!" '"owledge a"d u"dersta"d!"g a&out the d!sease process$ (h!s w!ll e"a&le us to g!)e proper heath teach!"gs a"d help ta'e care of people close to us e*per!e"c!"g the sa#e d!sease process$ Adenomyosis !s a co"d!t!o" !" wh!ch the !""er l!"!"g of the uterus +the e"do#etr!u#, &rea's through the #uscle wall of the uterus +the # o#etr!u#,$ -de"o# os!s ca" cause #e"strual cra#ps, lower a&do#!"al pressure, a"d &loat!"g &efore #e"strual per!ods a"d ca" result !" hea) per!ods$ (he co"d!t!o" ca" &e located throughout the e"t!re uterus or local!.ed !" o"e spot$ /t !s co"s!dered a &e"!g" co"d!t!o", the fre0ue"t pa!" a"d hea) &leed!"g assoc!ated w!th !t ca" ha)e a "egat!)e !#pact o" a wo#a"1s 0ual!t of l!fe$ +Bru""er a"d 2uddarth1s (e*t&oo' of Med!cal32urg!cal 4urs!"g, Cause: 5"'"ow"

Contri uting factors: M!ddle 6 aged wo#e" %o#e" w!th !"creased le)els of estroge", a"d usuall d!sappears after #e"opause +12 #o"ths after a wo#a"7s f!"al #e"strual per!od,, whe" estroge" le)els decl!"e$ Mult!parous wo#e" 8a)!"g had uter!"e surger , such as for a cesarea" sect!o" or to re#o)e f!&ro!ds +Ma o,

(igns and symptoms: 8ea) , prolo"ged #e"strual &leed!"g 2e)ere #e"strual cra#ps -&do#!"al pressure a"d &loat!"g Pel)!c pa!" dur!"g !"tercourse

Diagnostic &,am: MR/ 33 #ag"et!c reso"a"ce !#ag!"g 33 ca" &e used to co"f!r# a d!ag"os!s of ade"o# os!s !" wo#e" w!th a&"or#al uter!"e &leed!"g$ pel)!c e*a# 5ltrasou"d of the uterus #a help tell the d!ffere"ce &etwee" ade"o# os!s a"d other uter!"e tu#ors$ MR/ ca" &e helpful whe" ultrasou"d does "ot g!)e def!"!te results$
Page - of *+

.reatment for ade"o# os!s depe"ds !" part o" our s #pto#s, the!r se)er!t , a"d whether ou ha)e co#pleted ch!ld&ear!"g$ M!ld s #pto#s #a &e treated w!th o)er3the3 cou"ter pa!" #ed!cat!o"s a"d the use of a heat!"g pad to ease cra#ps$ Anti/inflammatory medications - 4o" stero!dal a"t!3!"fla##ator drugs +42-/9s, to rel!e)e #!ld pa!" assoc!ated w!th ade"o# os!s$ 42-/9s are usuall started o"e to two da s &efore the &eg!""!"g of our per!od a"d co"t!"ued through the f!rst few of da s of our per!od$ (urgery: O)er 23; of pat!e"ts re0u!r!"g h sterecto# for co"trol of chro"!c se)ere pel)!c pa!" had ade"o# os!s, a"d al#ost half of these wo#e" had a tu&al l!gat!o" perfor#ed$

(tatistics: 20;of wo#e" !" Ca"ada ha)e ade"o# os!s, the e*act rate of !"c!de"ce of ade"o# os!s !s u"'"ow" &ecause a d!ag"os!s ca" & #ade o"l after a patholog!st e*a#!"es the uter!"e wall sa#ples o&ta!"ed dur!"g surger or &!ops $ More tha" <0; of wo#e" w!th ade"o# os!s ha)e other uter!"e d!sorders as well$ 2o#e 50; ha)e assoc!ated f!&rous +&e"!g" s#ooth #uscle tu#ors of the uterus,= appro*!#atel 11; ha)e e"do#etr!os!s +e"do#etr!al t!ssue outs!de of the uterus,= a"d >; ha)e e"do#etr!al pol ps +&e"!g" outgrowths of e"do#etr!al t!ssue,$ (he s #pto#s of these ofte" o&scure the d!ag"os!s of ade"o# os!s$

II. O !ecti0es A. General O !ecti0es -fter the course of the stud , our group a!#s to for#ulate a &as!c case a"al s!s that would pro)!de esse"t!al '"owledge a"d s'!lls !" del!)er!"g 0ual!t health care to pat!e"ts d!ag"osed w!th -de"o# os!s$

1. (pecific O !ecti0es (o co"duct a ph s!cal assess#e"t appropr!ate for the cl!e"t$ (o !de"t!f a"d u"dersta"d the pred!spos!"g a"d prec!p!tat!"g factors that co"tr!&uted to our cl!e"t7s !ll"ess$ (o a"al .e a"d deter#!"e the a"ato# a"d ph s!olog of the affected s ste#s (o pr!or!t!.e pro&le#s a"d de)elop a pla" of care appropr!ate for the pat!e"t (o !#ple#e"t act!o"s accord!"g to the set "urs!"g care pla" to address the "eeds of the pat!e"t

Page * of *+

?)aluate the outco#e a"d effect!)e"ess of the "urs!"g !"ter)e"t!o"s pro)!de$

III. Nursing 2istory ). Personal Data a. Name: Ms$ L$@ . Age: 31 rs old c. (e,: A d. Address: Brg $ 2a" Bose, Ma"dalu o"g C!t e. Occupation: Co#pa" 2ecretar f. 'eligion: Ro#a" Cathol!c g. Date and .ime of Admission: March 02, 2013 #. Admitting P#ysician: 9r$ -$ -. C#ief Compliant: Profuse a"d prolo"ged )ag!"al &leed!"g

*. 2istory of Present Illness: (e" ears pr!or to ad#!ss!o", pat!e"t had profuse a"d prolo"ged )ag!"al &leed!"g co"su#!"g 6 full soa'ed pads last!"g for 2 wee's$ 2he co"sulted a"d was d!ag"osed to ha)e ade"o# os!s w!th ade"o# o#a$ 2he was g!)e" u"recalled p!lls for 6 #o"ths to help regulate her #e"ses &ut fa!led$ 2he was the" g!)e" u"recalled p!lls for 10 da s wh!ch afforded regulat!o" of #e"ses$ 2he ha)e earl ultrasou"d w!th "o !"crease !" #e"ses for 3 rs$ > rs pr!or to ad#!ss!o", there was !"crease !" s!.e of the ade"o# os!s a"d pat!e"t e*per!e"ced se)ere d s#e"orrhea w!th prolo"ged &leed!"g for 10 da s co"su#!"g < pads Cda , she co"sulted a"d was g!)e" (ra"e*a#!c ac!d +he#osta", (/9, Mo&!c, 8e#o&!e" (/9 a"d trust p!lls for 6 #o"ths wh!ch afforded "o regulat!o" of #e"ses$ (wo ears pr!or to ad#!ss!o" she was g!)e" u"recalled p!lls for 10 da s, she was ad)!sed OR &ut refused$ Pat!e"t was lost to follow up u"t!l few hrs pr!or to ad#!ss!o"= she had profuse &leed!"g w!th &lood cloths co"su#!"g #ore tha" 10 pads$ Pers!ste"ce of s #pto#s pro#pted co"sult$ 3. Past medical #istory: +D, !"fa"t: !#perforated a"us 4. $amily medical #istory: 8(4CCard!ac E #other 5. O1 2istory: Menarc#e: 13 Inter0al: 2< 6 30 Duration: > da s Amount: 2 6 < pads (ymptoms: +D,

I6.GO'DON7( $8NC.ION 2&AL.2 PA..&'N

Patterns of $unctioning 1efore 2ospitali9ation After 2ospitali9ation Analysis

Page 3 of *+

2ealt# Perception: 2ealt# Manageme nt

-ccord!"g to the cl!e"t, she had lo"g3t!#e &ee" d!ag"osed w!th -de"o# os!s$ 2he e*per!e"ces alter"at!"g ep!sodes of hea) a"d prolo"ged &leed!"g s!"ce her d!ag"os!s$ Cl!e"t started ta'!"g hor#o"e p!lls !" 2003 a"d stopped 2011 as treat#e"t for her lo"g3 t!#e d!ag"os!s of -de"o# os!s$

Cl!e"t reports feel!"g u"eas $ 2he states "ot feel!"g health at all a"d !s u"prepared for the surger wh!ch she had lo"g t!#e a)o!ded$ 2he co"t!"ues to ha)e ep!sodes of !"ter#!tte"t )ag!"al &leed!"g a"d !s scheduled to ha)e (-8B2O w!th 5rethral 2te"t!"g$

-lthough the cl!e"t has &ee" d!ag"osed to ha)e -de"o# os!s for o)er 10 ears "ow, she st!ll d!spla s hes!ta"c a&out her operat!o"$ Cl!e"t co"t!"ues to e*per!e"ce !"ter#!tte"t )ag!"al &leed!"g "ecess!tat!"g surger $ Nursing Diagnosis: 'is% for $luid 6olume Deficit ':. Adenomyosis A&1 6aginal 1leeding

Nutritional/ Meta olic pattern

(he cl!e"t eats F t!#es a da : &rea'fast, lu"ch, s"ac', a"d d!""er$ 2he prefers to eat f!sh, )egeta&les a"d regularl dr!"'s water +132LCda , a"d ta'es #ult! )!ta#!"s da!l $

Cl!e"t was placed o" 4PO upo" ad#!ss!o" due to poss!&!l!t of surger $ -fter &e!"g sta&!l!.ed, cl!e"t !s "ow o" 9!et as (olerated$

(he cl!e"t was pre)!ousl o" 4PO to pre)e"t co#pl!cat!o"s fro# poss!&le surger $ 4ow that the cl!e"t !s sta&le, cl!e"t #a eat a" th!"g that w!ll suppl her of esse"t!al "utr!e"ts as lo"g as she ca" tolerate !t$ (he cl!e"ts7 a"t!c!pat!o" for her scheduled surger has affected her sleep!"g patter$ (he a&do#!"al d!sco#fort that she7s &ee" e*per!e"c!"g also added to her d!ff!cult sleep!"g$ Nursing Diagnosis: Altered sleep:rest pattern due to anticipated surgery and a dominal pain

(leep: 'est Pattern

(he cl!e"t report ha)!"g "o pro&le# sleep!"g$ 2he sleeps 63< hoursCda $

Cl!e"t has a d!ff!cult t!#e sleep!"g$ 2he reports "ot &e!"g a&le to sleep &ecause she has &ee" th!"'!"g a&out her scheduled surger $ 2he stated that the d!sco#fort fro# a&do#!"al pa!" also co"tr!&utes$

1o;el: 8rinary &limination

Cl!e"t has d!ff!cult !" el!#!"at!o" of &owel a"d reports us!"g her&al #ed!c!"es l!'e dr!"'!"g a#pala a Gu!ce to help her #o)e her &owels$ Cl!e"t reports ha)!"g a pre)!ous perforated a"us a"d chro"!c co"st!pat!o"$

(he cl!e"t st!ll feels co"st!pated a"d was o"l a&le to #o)e her &owel o"ce s!"ce date of ad#!ss!o"$ Cl!e"t ur!"ates 6 t!#es a da $

Cl!e"t has "o pro&le# ur!"at!"g &ut suffers fro# chro"!c co"st!pat!o" #a'!"g #o)!"g &owel d!ff!cult$ 8osp!tal!.at!o" has reduced her act!)!t affect!"g per!stals!s that also co"tr!&utes to &owel el!#!"at!o" pro&le#$

Page 4 of *+

Cl!e"t #o)es &owel e)er other da a"d ur!"ates < t!#es da!l $

Acti0ity: &,ercise Pattern

H2ecretar a'o sa tra&aho 'o 'a a #ara#! a'o"g off!ce wor' "a g!"agawa$ Mah!l!g d!" a'o #ag #all!"g &!la"g wal'!"g e*erc!se pag'atapos 'o pu#aso' sa op!s!"a$I -s )er&al!.ed & the Cl!e"t$ (he cl!e"t graduated fro# Bose R!.al College a"d too' B2BM$ (he cl!e"t co##u"!cates well$

Cl!e"t spe"ds #ost of her t!#e rest!"g !" &ed$

Cl!e"t has l!ttle t!#e to e*erc!se regularl due to de#a"d!"g off!ce hours$ 9ur!"g hosp!tal!.at!o", the cl!e"t !s #ostl co"f!"ed !" &ed due to her co"d!t!o"$

Cogniti0e/ Perceptual pattern

Cl!e"t was a&le to follow !"struct!o"s g!)e" to her & the doctor a"d "urses &ut appears to &e eas!l d!stracted fro# the a&do#!"al pa!" she felt dur!"g our !"ter)!ew$

Cl!e"t has good co##u"!cat!o" s'!lls &ut eas!l gets d!stracted wh!ch !s &rought a&out & the pa!" she !s feel!"g$ Acute pain related to a normal uterine leeding secondary to adenomyosis (he fear a"d the poss!&le after effects of the upco#!"g surger #a'e the cl!e"t to &e hes!ta"t !" )er&al!.!"g her feel!"gs a&out her co"d!t!o"$ $ear ':. 8pcoming (urgery Altered distur ed ody image related to loss of c#ild earing potential. Cl!e"t has a good relat!o"sh!p w!th her pare"ts a"d s!&l!"gs$ (he ser)e as her support s ste# espec!all "ow that she !s hosp!tal!.ed$

(elf/ perception : (elf Concept Pattern

H4oo", o'a "a#a" a'o$ Ja a 'o !3#a"age a"g co"d!t!o" 'o$ %ala "a#a" a'o"g pro&le#a at h!"d! 'o !"!!s!p u"g sa'!t 'o &asta !"!!"o# 'o u"g ga#utI as )er&al!.ed & the cl!e"t$

Cl!e"t !s aware of the fact that she ca""ot ha)e ch!ldre" a" #ore &ut appear to &e !"d!ffere"t a&out the su&Gect dur!"g the !"ter)!ew$ 2he a"swered the 0uest!o" )aguel a"d atte#pted to cha"ge the top!c & co#pla!"!"g a&out d!ffere"t th!"gs$ H2!"o &a "a#a" a"g h!"d! #atata'ot 'apag ala# #o"g ooperaha" 'aI as )er&al!.ed & the cl!e"t$ Cl!e"ts s!ster )!s!ts a"d watches o)er her dur!"g her sta !" the hosp!tal$ 8er s!ster re#a!"ed the cl!e"t7s source of support$

'ole :'elations#i p Pattern

Cl!e"t !s s!"gle a"d l!)es w!th her pare"ts a"d has F s!&l!"gs$ 2he !s the oldest$ Cl!e"t reports &e!"g close w!th her s!sters$ 2he helps her pare"ts f!"a"c!all & pa !"g the house &!lls$

Page 5 of *+

(e,uality/ 'eproducti 0e Pattern

Cl!e"t has #e"struat!o"s e)er 2< da s last!"g >3 < da s$ 2he !s s!"gle a"d reported ha)!"g "o t!#e for o"e$ HBus a'o sa wor' pero h!"d! 'o "a#a" s!"asara a"g sar!l! 'o sa pag'a'aroo" "g relas o" !" the futureI as )er&al!.ed & the cl!e"t$

H4ga o" ala# 'o "a h!"d! "a 'o #ag'a'aa"a' eh &a'!t pa a'o #agrerelas o" d &aKI as )er&al!.ed & the cl!e"t$

(he cl!e"t !s aware of her "eed to u"dergo surger a"d !ts e"d result of loss of reproduct!)e fu"ct!o"$ (e,ual Dysfunction ':. altered reproducti0e function secondary to adenomyosis.

Coping (tress Pattern

HJ!"a'ausap 'o #ga #agula"g at #ga 'apat!d 'o pag #a pro&le#a a'o$ 4ag tutulu"ga" 'a#! sa #ga pro&le#a "a#!"g$I -s )er&al!.ed & the cl!e"t$

Cl!e"t7 s!ster sta s w!th her dur!"g her hosp!tal!.at!o" a"d tr!es to co#fort her whe" she appears co"cer"ed a&out her scheduled operat!o"$

(he cl!e"t has stro"g support s ste# fro# her s!sters a"d has helped her cope w!th hosp!tal!.at!o"$

6alue :1elief Pattern

Cl!e"t !s Ro#a" Cathol!c 9ue to hosp!tal!.at!o" a"d goes to church cl!e"t !s u"a&le to atte"d wee'l $ 2u"da #ass &ut reports pra !"g #ult!ple t!#es a da for stre"gth$

Cl!e"ts7 fa!th re#a!"s the sa#e a"d though hosp!tal!.at!o" has stopped her fro# hear!"g #ass te#porar!l , she st!ll rel!es o" her fa!th for stre"gth$

6. P2<(ICAL A((&((M&N.
9ate a"d (!#e Perfor#ed: March 06, 2013 6 11:00a# 6ital (igns: (e#perature 3 Pulse Rate 3 36$>LC <0 &p#

Resp!rator Rate 3 20 cp# Blood pressure 3 120C60 ##8g

G&N&'AL (8'6&<: (he cl!e"t !s 31 ears of age, secretar !" a co#pa" $ 2he !s well groo#ed a"d h g!e"!c$ 2he !s a&le to a#&ulate w!th ease a"d slouch posture$ 2he !s aware of st!#ul! fro# the e")!ro"#e"t a"d w!th!" the self$ (he cl!e"t was cooperat!)e a"d ca" )er&al!.e ow" thoughts a"d a"swer 0uest!o"s log!call a"d !" se0ue"ce$ 1ody Parts .ec#ni=ue 8sed >IPPA? $indings Analysis

Page + of *+

2'!"

/"spect!o" Palpat!o"

Color: fa!r co#ple*!o" 2 ##etr of color: u"!for# ?de#a: "o ede#a 2'!" (urgor: good 4o les!o"s, a&ras!o"s 2!l' ha!r, (h!" ha!r 4o !"festat!o"s "oted MassCLes!o"s: "o #assCles!o"s o" the scalp 2!.e a"d shape: 4or#ocephal!c Aac!al features: s ##etr!c Aac!al #o)e#e"ts: s ##etr!c 4a!l Cur)ature: co")e* cur)ature (e*ture: s#ooth 4a!l Bed Color: p!"'!sh 2urrou"d!"g (!ssue: !"tact Cap!llar ref!ll: less tha" 2 seco"ds

4o de)!at!o" fro# "or#al

8a!r

/"spect!o"

4o de)!at!o" fro# "or#al (here !s "o fac!al "er)e da#age as e)!de"ced &

8ead

/"spect!o" Palpat!o"

4a!ls

/"spect!o" Palpat!o"

4o de)!at!o" fro# "or#al

? es

/"spect!o"

? e&rows: e)e"l d!str!&uted /t shows that there !s ? elashes: e0uall d!str!&uted "o da#age !" the ? el!ds: !"tact C4 //, ///, /V a"d V/ 4o d!scharge= 4o d!scolorat!o" of the pat!e"t sclera !s wh!te M clear B!lateral &l!"'!"g Ca" a&le to read f!"e pr!"t o" a "ote&oo' P!""a: s ##etr!cal Color: sa#e as s'!" color 8ear!"g acu!t : -ud!&le "or#al )o!ce 4o d!scharge= 4o te"der"ess 4o les!o"s or a&ras!o"s L!ps: dar' p!"' (eeth: co#plete set of teeth +16 upper teeth a"d 16 !" the lower teeth,, sh!" wh!te @u#s: p!"'!sh, #o!st, a"d f!r# (o"gue: at the #!dl!"e, p!"'!sh, a"d #o)a&le 2'!" !"tact, "o les!o"s a"d #asses= 4o red"ess= Breath!"g patter"s: "or#al 2'!": s#ooth a"d !"tact= "o te"der"ess, les!o"s a"d a&ras!o"s shape a"d s ##etr : a"ter!or to tra"s)erse rat!o !s 1:2 sp!"e !s stra!ght, "o lu#ps, "o #asses, full M s ##etr!c chest e*pa"s!o"= 5"!for# !" color, "o les!o"s or a&ras!o"s$ 2to#ach !s d!ste"ded
Page @ of *+

?ars

/"spect!o"

4o de)!at!o" fro# "or#al

Mouth

/"spect!o"

(he to"gue ca" #o)e freel wh!ch !"d!cate that the h poglossal +C4 /N, a"d glossophar "geal cra"!al "er)e +C4 N//, 4o de)!at!o" fro# "or#al 4o de)!at!o" fro# "or#al

4ec'

/"spect!o" Palpat!o" /"spect!o" Palpat!o" -uscultat!o "

(hora*

-&do#e"

/"spect!o"

(he a&do#!"al d!ste"t!o" !s caused

-uscultat!o " Palpat!o" Reproduct!)e /"spect!o" orga" 5pper e*tre#!t!es /"spect!o" Palpat!o"

4or#al &owel sou"d (e"der"ess at the ep!gastr!c reg!o" Vag!"al &leed!"g, l!ght red

& the e"large#e"t of the uterus wh!ch causes pa!" Vag!"al &leed!"g !s due to the slough!"g off of the uterus -ll f!"d!"gs are "or#al

e0ual !" s!.e, 4o !")olu"tar #o)e#e"ts, "o ede#a, p!"'!sh, s ##etr!cal, f!"e ha!r e)e"l d!str!&uted, &oth shoulders, ar#s, el&ows, 2#ooth, well coord!"ated #o)e#e"t /V !"serted 95LR 1L * <0 o" the left dorsu# ha"d$ 4o swell!"g o" the /V s!te

Lower e*tre#!t!es

/"spect!o" Palpat!o"

?0ual !" s!.e, "o les!o"s a"d a&ras!o"s, f!"e ha!r !s e)e"l d!str!&uted$ 2 ##etr!cal, legs, '"ees, a"'les, M toe ca" &e #o)ed !" d!ffere"t ra"ge of #ot!o" w!th relat!)e ease$

3 -ll f!"d!"gs are "or#al

6I. ANA.OM< AND P2<(IOLOG< .#e $emale 'eproducti0e (ystem

(he fe#ale reproduct!)e s ste# !s des!g"ed to carr out se)eral fu"ct!o"s$ /t produces the fe#ale egg cells "ecessar for reproduct!o", called the o)a or ooc tes$ (he s ste# !s des!g"ed to tra"sport the o)a to the s!te of fert!l!.at!o"$ Co"cept!o", the fert!l!.at!o" of a" egg & a sper#, "or#all occurs !" the fallop!a" tu&es$ -fter co"cept!o", the uterus offers a safe a"d fa)ora&le e")!ro"#e"t for a &a& to de)elop &efore !t !s t!#e for !t to #a'e !ts wa !"to the outs!de world$ /f fert!l!.at!o" does "ot ta'e place, the s ste# !s des!g"ed to #e"struate +the #o"thl shedd!"g of the uter!"e l!"!"g,$ /" add!t!o", the fe#ale reproduct!)e s ste# produces fe#ale se* hor#o"es that
Page A of *+

#a!"ta!" the reproduct!)e c cle$ 9ur!"g #e"opause the fe#ale reproduct!)e s ste# graduall stops #a'!"g the fe#ale hor#o"es "ecessar for the reproduct!)e c cle to wor'$ %he" the &od "o lo"ger produces these hor#o"es a wo#a" !s co"s!dered to &e #e"opausal$ (he fe#ale reproduct!)e a"ato# !"cludes !"ter"al a"d e*ter"al structures$ (he fu"ct!o" of the e*ter"al fe#ale reproduct!)e structures +the ge"!tal, !s twofold: (o e"a&le sper# to e"ter the &od a"d to protect the !"ter"al ge"!tal orga"s fro# !"fect!ous orga"!s#s$ (he #a!" e*ter"al structures of the fe#ale reproduct!)e s ste# !"clude:

La ia ma!ora: (he la&!a #aGora e"close a"d protect the other e*ter"al reproduct!)e orga"s$ L!terall tra"slated as Olarge l!ps,O the la&!a #aGora are relat!)el large a"d flesh , a"d are co#para&le to the scrotu# !" #ales$ (he la&!a #aGora co"ta!" sweat a"d o!l3secret!"g gla"ds$ -fter pu&ert , the la&!a #aGora are co)ered w!th ha!r$ La ia minora: L!terall tra"slated as Os#all l!ps,O the la&!a #!"ora ca" &e )er s#all or up to 2 !"ches w!de$ (he l!e Gust !"s!de the la&!a #aGora, a"d surrou"d the ope"!"gs to the )ag!"a +the ca"al that Go!"s the lower part of the uterus to the outs!de of the &od , a"d urethra +the tu&e that carr!es ur!"e fro# the &ladder to the outs!de of the &od ,$ 1art#olin7s glands: (hese gla"ds are located "e*t to the )ag!"al ope"!"g a"d produce a flu!d +#ucus, secret!o"$ Clitoris: (he two la&!a #!"ora #eet at the cl!tor!s, a s#all, se"s!t!)e protrus!o" that !s co#para&le to the pe"!s !" #ales$ (he cl!tor!s !s co)ered & a fold of s'!", called the prepuce, wh!ch !s s!#!lar to the fores'!" at the e"d of the pe"!s$ L!'e the pe"!s, the cl!tor!s !s )er se"s!t!)e to st!#ulat!o" a"d ca" &eco#e erect$

(he !"ter"al reproduct!)e orga"s !"clude:

6agina: (he )ag!"a !s a ca"al that Go!"s the cer)!* +the lower part of uterus, to the outs!de of the &od $ /t also !s '"ow" as the &!rth ca"al$ O0aries: (he o)ar!es are s#all, o)al3shaped gla"ds that are located o" e!ther s!de of the uterus$ (he o)ar!es produce eggs a"d hor#o"es$ $allopian tu es: (hese are "arrow tu&es that are attached to the upper part of the uterus a"d ser)e as tu""els for the o)a +egg cells, to tra)el fro# the o)ar!es to the uterus$ Co"cept!o", the fert!l!.at!o" of a" egg & a sper#, "or#all occurs !" the fallop!a" tu&es$ (he fert!l!.ed egg the" #o)es to the uterus, where !t !#pla"ts to the uter!"e wall$ 8terus >;om ?: (he uterus !s a hollow, pear3shaped orga" that !s the ho#e to a de)elop!"g fetus$ (he uterus !s d!)!ded !"to two parts: the cer)!*, wh!ch !s the lower part that ope"s !"to the )ag!"a, a"d the #a!" &od of the uterus, called the corpus$ (he corpus ca" eas!l e*pa"d to hold a de)elop!"g &a& $ - cha""el through the cer)!* allows sper# to e"ter a"d #e"strual &lood to e*!t$

5terus co"s!sts of three d!)!s!o"s: 1ody or corpus 6 the upper#ost part a"d for#s the &ul' of the orga"$ Ist#mus 6 !s a short seg#e"t &etwee" the &od a"d the cer)!*$ Cer0i, 6 !s the lowest port!o" the uterus$

5ter!"e wall co"s!sts of three la ers:

Page )B of *+

&ndometriun layer 6 a" !""er o"e of #ucous #e#&ra"e$ /t !s the o"e !#porta"t for #e"strual fu"ct!o"$ Myometrium or muscle layer 6 ser)es the !#porta"t fu"ct!o" of co"str!ct!"g the tu&al Gu"ct!o"s a"d pre)e"t!"g regurg!tat!o" of #e"strual &lood !"to the tu&es$ Perimetrium or t#e outermost layer C ser)es the purpose of add!"g stre"gth a"d support to the structure$

6II. Pat#op#ysiology
Predisposing Factor Age (31 y/o)

?"do#etr!al cells !")ade the # o#etr!u# ?"do#etr!al t!ssues depos!ts !" the

@rowth of e"do#etr!al M o#etr!u# &eco#es e"larged

-de"o# os!s

2 #pto#at!c

Prolo"ged !"crease of estroge" le)els

?"larged uterus e*te"d!"g to the @/(

(h!c'e"!"g of ?"do#etr!u# a"d &eco#es h!ghl )ascular!.ed

-&do#!"al swell!"g

(h!c'e"ed e"do#etr!u# sloughs off caus!"g a" !"crease #e"strual &lood flow
Page )) of *+

-&"or#al )ag!"al &leed!"g occurs

6III. LA1O'A.O'<:DIAGNO(.IC &DAMINA.ION ). 1lood .est >Marc# -, -B)*?

Page )- of *+

Examination Hemoglobin

Result 6.1

Reference Values 12.0 16.0 g/dl

Analysis Indicates a decrease of iron containing protein of RBC that carries ox gen to the tiss!e d!e to bleeding. (he res!lt indicates an excessi)e loss of er throc tes d!e to bleeding. ,n indication that the patient is s!ffering from anemia d!e to bleeding. Indicates that the .eight of Hgb in the blood is decrease d!e to blood loss. (he si0e of er throc te become smaller than normal d!e to blood loss. , lo. concentration of Hgb in the blood is d!e to blood loss. Increase prod!ction of 1BC indicates the presence of bacterial infection. In the presence of bacteria4 ne!trophils also prod!ced to help 1BC fight bacteria thro!gh ingestion or phagoc tosis ,n indicati)e of decrease prod!ction of antibodies d!e to infection 2o de)iation from normal 2o de)iation from normal 2o de)iation from normal 2o de)iation from normal

Hematocrit

21."

#$ %& '

RBC

#.*%

%.0 6.0 10+6/!l

-ean Corp!sc!lar Hemoglobin

1&.2

26 #% pg

-ean Corp!sc!lar /ol!me

61."

$0 100 fl

-ean Corp!sc!lar Hemoglobin concentration 1BC

2&."

#1 #& g/dl

##.&&

%.* 11.0 10+#/!l

2e!trophils

"2.&

*0 3&0 '

5 mphoc tes

&.1

20 %0 '

-onoc tes 6osinophils Basophils 7latelet

#.1 %.1 0.0 #2$

0 &' 0.0 *.0 ' 0.0 3 1..0 '

Page )* of *+

1*0 %00 10+# / !l

'emar%s: Platelet -de0uate

-. Acti0ated Partial .#rom oplastine .ime >Marc# -, -B)* E )):B@pm?

&,amination Pat!e"t Co"trol

'esult 2P$F 2P$6

'eference 6alues 25 6 35 seco"ds 2eco"ds

Analysis 4o de)!at!o" fro# "or#al 4o de)!at!o" fro# "or#al

*. 1lood 1an% (ection >Marc# -, -B)* E )-:)4 am?

.est Name Blood ( p!"g: +3,-BO +D,R8

'esult ( pe: H-I Rh +9, Pos!t!)e

Analysis: 5se to '"ow the &lood t pe of the pat!e"t for poss!&le &lood tra"sfus!o"$

3. C#emical &,amination >Marc# -, -B)* E )):4@pm?

&,amination Potass!u# Creat!"!"e B54

'esult 3$3 6>$< 6$>

'eference 6alues 3$5 6 5$1##olCL 50$F 6 P<$1##olCL 2$5 6 6$>##olCL

Analysis 4o de)!at!o" fro# "or#al 4o de)!at!o" fro# "or#al 4o de)!at!o" fro# "or#al

4. 8rinalysis 'eport >Marc# *, -B)* E )-:4+am?

P#ysical C#aracteristics &,amination Color 'esults 9ar' Qellow 'eference 6alues Qellow
Page )3 of *+

Analysis Blood !s #!* !" the ur!"e

that tur"s out a&"or#al result$ (ra"spare"c 8a. Clear Blood !s #!* !" the ur!"e that tur"s out a&"or#al result$ 4o de)!at!o" fro# "or#al 4o de)!at!o" fro# "or#al

React!o" 2pec!f!c @ra)!t

5$0 1$025

F$6 3<$0 1$016 6 1$02P

C#emical &,amination

&,amination Leu'oc tes

'esults 2D +>5 %BCsC5l,

'eference 6alues 4egat!)e

Analysis (he prese"ce of leu'oc tes !" the ur!"e !s due to the prese"ce of &leed!"g fro# the )ag!"a that #a'es a" altered result$ 4o de)!at!o" fro# "or#al 4o de)!at!o" fro# "or#al - prote!" !s prese"t !" the ur!"e due to )ag!"al &leed!"g !t alters the result of the test$ - )ag!"al &leed!"g g!)es a false result !"d!cat!"g a prese"ce of &lood !" the ur!"e$ - prese"ce of 'eto"e !" the ur!"e due to )ag!"al &leed!"g !t alters the result of the test 4o de)!at!o" fro# "or#al 4o de)!at!o" fro# "or#al

4!tr!te 5ro&!l!"oge" Prote!"

4egat!)e 4or#al 2D +100#gCdl,

4egat!)e 4egat!)e 4egat!)e

Blood

1D

4egat!)e

Jeto"e

2D +100#gCdl,

4egat!)e

B!l!ru&!" @lucose

4egat!)e 4egat!)e

4egat!)e 4egat!)e

Page )4 of *+

Microscopic &,amination

&,amination RBC %BC Bacter!a ?p!thel!al cells Casts

'esult 3$0 1F$3 51$0 22$5 0$00

8nit Chpt Chpt Chpt Chpt Chpt

'eference 'ange 062 063 0 6 50 063 033

'esult 16$5 >P$> 2<3$3 125$1 0$00

8nit CuL CuL CuL CuL CuL

'eference 'ange 0 6 11 0 6 1> 0 6 2>< 0 6 1> 031

Analysis: RBC, %BC, Bacter!a, ?p!thel!al cells 6 ?le)ated )alues !"d!cates a co"ta#!"at!o" of RBC !"to the ur!"e due to )ag!"al &leed!"g$

Pregnancy .est: 4egat!)e

5. 1lood Cross Matc#ing >Marc# *, -B)*?

Cross Matc#ing

Pt$ ( pe: H-I R8 Pos!t!)e 9o"ors ( pe: H-I R8 Pos!t!)e

Blood Co#po"e"t: Pac'ed RBC Blood Ba"' 4u#&er: : VRPMC 21336 at 1:35a# : VRPMC 2131F at 6:00a# : 4VB2P 20133001FF56 at P:03a# : PRC R/R-L 20113166326 at

2:3<p# Cross Match!"g: Co#pat!&le !" all Phases Analysis: -ll the &lood suppl!es to &e tra"sfused are co#pat!&le w!th the pat!e"t &lood t pe$

+. C#est D/ray >PA and AP?

Page )5 of *+

Interpretation: Poor /"sp!rator f!l# Lu"gs are clear, pul#o"ar )essels are w!th!" "or#al l!#!t$ 8eart !s "ot e"larged$ 9!aphrag# a"d sulc! are !"tact (he )!sual!.ed &o" a"d soft t!ssue structures are "or#al$

Impression: 4o 2!g"!f!ca"t chest f!"d!"gs Analysis: (o chec' the co"d!t!o" of the lu"g a"d to see' appro)al fro# the card!olog!st that the pat!e"t !s cleared fro# a" co#pl!cat!o" pr!or to surger $

@. 1lood .est >Marc# 3,-B)* E 5:B@am?

&,aminations 8e#oglo&!"

'esults 10$5

'eference 6alues 12$0 6 16$0 gCdl

Analysis (he !ro" co"ta!"!"g prote!" of RBC !s st!ll &elow "or#al )alues !"d!cates &leed!"g st!ll prese"t$ -" !"d!cat!o" that there !s st!ll !"ade0uate &lood due to &leed!"g$ RBC !s alread !" "or#al )alues !"d!cat!"g a reco)er fro# a"e#!a$ (he we!ght of 8g& !s st!ll #ore l!ght or s#aller tha" "or#al$ 2l!ght lower )alues !"d!cate the s!.e of er throc te !s st!ll s#aller fro# "or#al +#!croc t!c,$ (he 8g& co"ce"trat!o" rega!" to "or#al )alue$

8e#atocr!t

32$F

3< 6 F> ;

RBC

F$16

F$0 6 6$0 10S6Cul

Mea" Corpuscular 8e#oglo&!" Mea" Corpuscular Volu#e Mea" Corpuscular

25$2

26 6 3F pg

>>$P

<0 6 100 fl

32$F

31 6 3> gCdl

Page )+ of *+

8e#oglo&!" co"ce"trat!o" %BC 2>$3P F$5 6 11$0 10S3Cul 50 3>0 ; 8!gh )alue !"d!cates &acter!al !"fect!o" !s st!ll prese"t due to &leed!"g$ 2t!ll h!gher a#ou"t produced to help f!ght &acter!a & phagoc tos!s$ /"d!cates that the &od protect!o" fro# !"fect!o" st!ll !"ade0uate /"d!cates the prese"ce of &acter!a does re#o)e de&r!s of fore!g" part!cle fro# the c!rculat!o"$ 4o de)!at!o" fro# "or#al 4o de)!at!o" fro# "or#al 4o de)!at!o" fro# "or#al

4eutroph!ls

<F$6

L #phoc tes

5$>

20 6 F0 ;

Mo"oc tes

P$F

0 6 >;

?os!"oph!ls BasoPh!ls Platelet

0$1 0$2 1>F

0$0 6 5$0 ; 0$0 3 1$$0 ; 150 6 F00 10S3 C ul

'emar%s: Platelet -de0uate

A. 1lood 1an% (ection >Marc# 3,-B)* E )A:*B? Cross Matc#ing Pt$ ( pe: H-I R8 Pos!t!)e 9o"ors ( pe: H-I R8 Pos!t!)e 21305 Cross Match!"g: Co#pat!&le !" all Phases Analysis: (he &lood suppl!es to &e tra"sfused are co#pat!&le w!th the pat!e"t &lood t pe$ Blood Co#po"e"t: Pac'ed RBC Blood Ba"' 4u#&er: VRPMC

)B. C#emical &,amination >Marc# 3, -B)*?

&,amination Potass!u#

'esult 3$5

'eference 6alue 3$5 6 5$1 ##olCL

Analysis 4o de)!at!o" fro# "or#al

Page )@ of *+

Calc!u#

1$P2

2$10 6 2$55 ##olCL /"d!cate a low prote!" le)el !" &lood

)). 1lood .est >Marc# 5, -B)* E )-:-)am?

&,aminations 8e#oglo&!" 8e#atocr!t RBC Mea" Corpuscular 8e#oglo&!" Mea" Corpuscular Vol$ Mea" Corpuscular 8e#oglo&!" co"ce"trat!o" %BC

'esults 12$6 3<$> F$<2 26$1

'eference 6alues 12$0 6 16$0 gCdl 3< 6 F> ; F$0 6 6$0 10S6Cul 26 6 3F pg

Analysis 4o de)!at!o" fro# "or#al 4o de)!at!o" fro# "or#al 4o de)!at!o" fro# "or#al 4o de)!at!o" fro# "or#al

<0$3

<0 6 100 fl 4o de)!at!o" fro# "or#al

32$6

31 6 3> gCdl

4o de)!at!o" fro# "or#al

20$>1

F$5 6 11$0 10S3Cul 50 3>0 ;

8!gh )alue !"d!cates &acter!al !"fect!o" !s st!ll prese"t$ 2t!ll h!gher a#ou"t produced to help f!ght &acter!a & phagoc tos!s$ /"d!cates that the &od protect!o" fro# !"fect!o" st!ll !"ade0uate /"d!cates the prese"ce of &acter!a does re#o)e de&r!s of fore!g" part!cle fro# the c!rculat!o"$ 4o de)!at!o" fro# "or#al 4o de)!at!o" fro# "or#al

4eutroph!ls

<1$P

L #phoc tes

>$1

20 6 F0 ;

Mo"oc tes

P$P

0 6 >;

?os!"oph!ls BasoPh!ls

0$< 0$3

0$0 6 5$0 ; 0$0 3 1$$0

Page )A of *+

; Platelet 2F2 150 6 F00 10S3 C ul 4o de)!at!o" fro# "or#al

ID. Medical Inter0ention

Date F .ime Ordered March 02 2013 11:10 p# Medical Operaions -d#!t u"der the ser)!ce of 9r$Classification (herapeut!c 'ationale (o secure a"d o&ser)e the cl!e"t co"d!t!o", to g!)e proper !"ter)e"t!o" a"d for further e)aluat!o"$ (o #o"!tor!"g the cl!e"t7s co"d!t!o", w!th gradual !"ter)als$ %!ll pro)!de the cl!e"t esse"t!al "utr!e"ts w!th the foods that she ca" tolerate (o #a!"ta!" the cl!e"t7s h drat!o" status -"t!3f!&r!"ol t!c (o co"trol a&"or#al uter!"e &leed!"g %!ll g!)e a rough est!#ate of the a#ou"t of &lood loss of the cl!e"t as well as pro)!d!"g close #o"!tor!"g -ccurate #o"!tor!"g of cl!e"t7s ur!"e output$ %!th decrease !" ur!"e output !"d!cat!"g poss!&le h po)ole#!a caused & prolo"ged &leed!"g (o replace the cl!e"t7s &lood loss as well as !"creas!"g the o* ge"3 carr !"g capac!t of the cl!e"t1s &lood$ 8or#o"e therap to

Mo"!tor )!tal s!g" e)er hour M record

(herapeut!c

9!et as (olerated +9-(,

(herapeut!c

/VAT 1 8 drate 300cc P422 the" re3h drate to 30gttsC#!"$ @!)e (ra"e*a#!c -c!d 1gr# /V e)er < hours

(herapeut!c

(herapeut!c

Pad cou"t

(herapeut!c

/"sert fole catheter M #o"!tor output

(herapeut!c

11:35 p#

Aor &lood tra"sfus!o" of F u"!ts PRBC properl t pe M cross3 #atched N F hours

(herapeut!c

@!)e Pre#ar!"
Page -B of *+

(herapeut!c

0$625#gCta& 2ta&s$ U 6 hours u"t!l feed!"g stop$ @!)e Calc!u# @luco"ate 1a#p$ (/V after 3rd u"!t of PRBC (herapeut!c

co"trol hea)!"g &leed!"g

PRBC co"ta!" traces of c!trate wh!ch &!"ds w!th calc!u# lower!"g !o"!.ed plas#a calc!u# co"ce"trat!o"$ Calc!u# gluco"ate was ordered to pre)e"t poss!&le h pocalce#!a post B( (o chec' !f the tra"sfus!o" !s effect!)e a"d to e)aluate the co#pos!t!o" a"d co"ce"trat!o" of the cellular co#po"e"ts of &lood$ (o pre)e"t !"fect!o"

Repeat CBC 6 hours post tra"sfus!o"

9!ag"ost!c

11:F5p#

@!)e cefuro*!#e +ReGe", 1$5< (/V +3,-42( the" >50#g /V e)er < hours /"crease (ra"e*a#!c ac!d to 2g# (/V e)er < hours

(herapeut!c

March 03,2013 5:F0 a#

(herapeut!c

(o ach!e)e des!red therapeut!c effect of co"troll!"g a&"or#al uter!"e &leed!"g (o ach!e)e des!red therapeut!c effect of co"troll!"g a&"or#al uter!"e &leed!"g

/"crease Pre#ar!" 0$625#gCta& Fta&s "ow the" e)er 6 hours

(herapeut!c

2tart /VA 9582O !L D 20 #?0 JCL V 30gtts *3c cle 6:35a# Aor e"do#etr!al &!ops "ow

(herapeut!c

9!ag"ost!c

(o rule out other poss!&le causes of a&"or#al uter!"e &leed!"g (o assess !f the cl!e"t ca" tolerate such procedure /" preparat!o" for poss!&le h sterecto# that #a !"crease the r!s' of clot for#at!o" /" preparat!o" for poss!&le h sterecto#

Aor CP cleara"ce for poss!&le h sterecto#

9!ag"ost!c

6:F5a#

8old Pre#ar!"

(herapeut!c

4PO

(herapeut!c

Page -) of *+

>:50a#

@!)e o#epra.ole F0#g O9 /V

(herapeut!c

%!ll ser)e as a" a"t!3 reflu* #ed!cat!o" &efore a surger to pre)e"t asp!rat!o" 2 #pto#at!c rel!ef of )o#!t!"g (o deter#!"e the a"ato#!cal patholog of the e"do#etr!al t!ssue o&ta!"ed Co"trol a&"or#al uter!"e &leed!"g /" preparat!o" for poss!&le surger -llow close #o"!tor!"g of the cl!e"t7s co"d!t!o" $ Replace &lood loss thus pre)e"t!"g h po)ole#!a Pro)!de access for future "eed of B( -dGust treat#e"t !" accorda"ce to the cl!e"t7s "eed a"d co"d!t!o" Cl!e"t7s co"d!t!o" !s #ore sta&le that do "ot "ecess!tate #o"!tor!"g fro# M/C5 Aor close #o"!tor!"g of the cl!e"t7s co"d!t!o" 5r!"e output pro)!des a" accurate !"d!cat!o" of the cl!e"t7s h drat!o" status$ 5r!"e output of less tha" 30ccChr #a !"d!cate #ore &leed!"g that #a lead to h po)ole#!a (hese are s!g"s a"d s #pto#s of e#&ol!s# that #a result fro# u"co"trolled &leed!"g

@!)e Plas!l 1a#p$ ?)er < hours for )o#!t!"g Pls$ 2u&#!t e"do#etr!al curett!"g7s for h!stopatholog <a# Resu#e Pre#ar!" 4PO e*cept #eds -d#!t to M/C5 +#ed!c!"e /C5, P:15a# Aor ?C@ M chest N3ra Co"t!"ue B(

(herapeut!c

9!ag"ost!c

(herapeut!c (herapeut!c (herapeut!c 9!ag"ost!c (herapeut!c

/VA to ff: P422 1L at JVO 9ecreased tra*e"a#!c ac!d 500#g /V e)er < hours 6:15p# Ma tra"sfer to roo# V>p#

(herapeut!c

(herapeut!c

(herapeut!c

Pls$ Mo"!tor )!tal s!g" e)er 1 hour M record u"t!l sta&le$ Pls$ Mo"!tor ur!"e output e)er 1 hour M refer !f W 30ccChr

(herapeut!c

(herapeut!c

%atch out for u"toward sCs* such as )ag!"al &leed!"g, d!ff!cult of &reath!"g, palp!tat!o", h pogastr!c pa!"
Page -- of *+

(herapeut!c

Ma ha)e 9-(

(herapeut!c

Pro)!s!o" of "eeded "utr!t!o" w!th foods that the cl!e"t ca" tolerate (o assess le)el of all &lood co#po"e"ts (o assess effect!)e"ess of B( Rel!ef of #oderate to se)ere pa!" assoc!ated w!th -de"o# os!s (o rel!e)e ele)ated &od te#perature (o co"t!"ue s #pto#at!c rel!ef of #oderate to se)ere pa!" assoc!ated w!th -de"o# os!s (o "ote potass!u# le)el post ad#!"!strat!o" of JCL o" 3C3C2013 a$ hor#o"al therap to co"trol &leed!"g &$ cl!e"t !s a&le to tolerate oral #ed!cat!o" to co"trol &leed!"g c$ orga"!c !ro" supple#e"t d$ rel!ef of pa!" assoc!ated w!th -de"o# os!s e$ rel!ef of pa!" assoc!ated w!th -de"o# os!s f$ supple#e"t Cl!e"t !s a&le to tolerate oral #ed!cat!o" "eeded proph la*!s for !"fect!o" /" preparat!o" for poss!&le &lood loss dur!"g the surger thus pre)e"t!"g h po)ole#!a (o treat a"d pre)e"t further &leed!"g -ssess effect!)e"ess of B( as well as &lood co#pos!t!o" a"d the

Aor CBC V6a#

9!ag"ost!c

Refer CBC 6hours post B( ordered 3X2 X 13 Pls$ @!)e "al&uph!"e +4u&a!", 1a#p$ /V

9!ag"ost!c

(herapeut!c

March 0F, 2013 5:F0a#

Paraceta#ol 1a#p$ (/V "ow 2tart arco*!a 120#g O9 M alges!a 1ta&$ (/9 p$o$ Aor potass!u# seru# deter#!"at!o"

(herapeut!c

(herapeut!c

9!ag"ost!c

Meds:

a$ pre#ar!" 0$625#g Fta& O9 /V &$ #a sh!ft tra"e*a#!c /V to 500g 2 ta& p$o e)er 6 hours c$ sa"go&!o" 1 ta&$ O9 d$ arco*!a 120#g O9 * 2da s e$alges!a 1 ta& (9 * 3da s f$ ce"tru# 1 cap$ O9

(herapeut!c

Ma sh!ft cefuro*!#e /V to cefuro*!#e 500g (/9 12:50p# C-R9/O$ 32uggest tra"sfus!o" of 2 #ore u"!t of PRBC pr!or to h sterecto# he#osta" /V 500#g e)er < hours Repeat CBC 12 hours after the 6th u"!t of PRBC
Page -* of *+

(herapeut!c

(herapeut!c

10:00p#

(herapeut!c

9!ag"ost!c

"eed for further B(

March 05, 2013 6:00a#

CBC V <p# post B(

9!ag"ost!c

-ssess &lood co#pos!t!o" a"d the "eed for add!t!o"al B( Pro)!de def!"!te rel!ef of &leed!"g 4PO !" preparat!o" for (-8B2O

Aor (-8B2O >:30 a# #arch 0>,2013 w!th co"se"t 2:25p# -4?2(8?2/-: Pre$ #eds Pre3op order$ 4PO post3#!d"!ght o" the da of operat!o" +3C>C13, a$ "al&uph!"e 10#g &$ d!phe"h dra#!"e 50#g

(herapeut!c

(herapeut!c

(herapeut!c

a$ w!ll prolo"g effect of a"esthes!a dur!"g surger &$ proph la*!s for allerg!c react!o"

Page -3 of *+

ID. Drug (tudy

Generic name

Brand name

Classification

Dosage &*0mg >$ I/

Mechanism of action 8econd3 generation cephalosporin that inhibits cell3.all s nthesis4 promoting osmotic instabilit ? !s!all bactericidal.

Indication 7erioperati)e 7re)ention

Contraindication Contraindicated in patients h persensiti)e to dr!g. @se .ith ca!tion in breast3feeding .omen and in patients .ith histor of colitis or renal s!fficienc .

Adverse Reaction CVA phlebitis4 thrombophlebitis GIA pse!domembrano!s colitis4 na!sea4 anorexia4 )omiting4 diarrhea ematologicA transient ne!tropenia4 eosinophilia4 hemol tic anemia4 thromboc topenia !"inA mac!lopap!lar and er themato!s rashes4 !rticaria4 pain4 ind!ration4 sterile abscesses4 temperat!re ele)ation4 tiss!e slo!ghing at intram!sc!lar inBection site

Nursing Consideration Before administering4 maCe s!re patient is not allergic to penicillins or cephalosporins. ,bsorption of cef!roxime axetil is enhanced b food. High3fat meals increased dr!g bioa)ailabilit .

Cef!roxime Cef!roxime ,ntibiotic 8odi!m cephalosporin 9:inacef ;7arenteral<=

Page -4 of *+

Generic name

Brand name

Classification

Dosage

Mechanism of action 6xerts its antifibrinol tic effect thro!gh the re)ersible blocCade of l sine3binding sites on plasminogen molec!les. Inhibits endometrial plasminogen acti)ator and th!s pre)ents fibrinol sis and the breaCdo.n of blood clots.

Indication

Contraindication

Adverse Reaction

Nursing Consideration

,nti3 (ranexamic Hemostan fibrinol tic4 acid antihemorrhagi c

*00 mg >$ I/

(reating hea) menstr!al bleeding

,llergic reaction to the dr!g or h persensiti)it 1. 7resence of blood clots 9eg4 in the leg4 l!ng4 e e4 brain=4 ha)e a histor of blood clots4 or are at risC for blood clots 2. C!rrent administration of factor ID complex concentrates or anti3inhibitor coag!lant concentrates

2a!sea4 )omiting4 loss of appetite4 headache4 impaired renal ins!fficienc 4 and h potension.

Inform the client that he/she sho!ld inform the ph sician immediatel if the follo.ing se)ere side effects occ!rA8e)ere allergic reactions s!ch as rash4 hi)es4 itching4 d spnea4 tightness in the chest4 s.elling of the mo!th4 face4 lips or tong!e

3 8.allo. (ranexamic ,cid .hole .ith plent of li>!ids. Eo not breaC4 cr!sh4 or che. before s.allo.ing. 3 (he medication can be taCen .ith or .itho!t meals. 3 For .omen .ho are taCing (ranexamic acid to control hea) bleeding4 the medication sho!ld onl be taCen d!ring the menstr!al period.

Page -5 of *+

Generic name ,rcoxia

Brand name 6toricoxi b

Classification 28,IEs

Dosage 120 mg GE x2 da s 7G

Mechanism of action ,nalgesic4 anti3 inflammator

Indication Relief of ac!te pain

Contraindication 6lderl people Histor of disorders affecting the stomach or intestines4 s!ch as !lceration or bleeding Eecreased Cidne f!nction Eecreased li)er f!nction

Adverse Reaction Headache4 Ei00i ness Eist!rbances of the g!t s!ch as diarrhea4 constipation4 na!sea4 )omiting 4 indigestion4 flat! lence or abdominal pain 6xcessi)e fl!id retention in the bod tiss!es4 res!lting in s.elling 9edema= High blood press!re9h perte nsion= 1eaCness or loss of strength 9asthenia

Nursing Consideration (each patient to taCe medicine or medications as ph sicians ordered.

(ell the patient for the possible effects of dr!g prior to its ad)erse reactions and consider s!ch reactions mentioned as normal.

7ro)ide the patient .ith the proper management !pon taCing medications.

(ell the patient to seeC for help if no s!ch effects of dr!g are noted or that if s mptoms prior to his conditions are still noted.

(ell patient to maintain his normal diet and the possible conse>!ences Gf the dr!gs effect concerning on his appetite.

Page -+ of *+

Generic name

Brand name

Classification -"t!3 secretor drug proto" pu#p !"h!&!tor

Dosage F0 #g O9 /V

Mechanism of action @astr!c ac!d3 pu#p !"h!&!tor: 2uppresses gastr!c ac!d secret!o" & spec!f!c !"h!&!t!o" of the h droge" potass!u# -(Pase e". #e s ste# at the secretor surface of the gastr!c par!etal cells= &loc's the f!"al step of ac!d product!o"$

Indication (reat#e"t of heart&ur" or s #pto#s of @?R9

Contraindication 8 perse"s!t!)!t to o#epra.ole or !ts co#po"e"ts 35se caut!ousl w!th preg"a"c , lactat!o"$

Adverse Reaction C42: 8eadache, d!..!"ess, asthe"!a, )ert!go, !"so#"!a, apath , a"*!et , paresthes!a, drea# a&"or#al!t!es 9?RM-(OLO@/ C: Rash, !"fla##at!o", urt!car!a, prur!t!s, alopec!a, dr s'!" @/: 9!arrhea, a&do#!"al pa!", "ausea, )o#!t!"g, co"st!pat!o", dr #outh, to"gue atroph R?2P/R-(ORQ: 5R/ s #pto#s, cough, ep!sta*!s

Nursing Consideration 3(a'e the drug &efore #eals$ 2wallow the capsules whole= do "ot chew, ope", or crush the#$ /f us!"g the oral suspe"s!o", e#pt pac'et !"to a s#all cup co"ta!"!"g 2 ta&le spoo"s of water$ 2t!r a"d dr!"' !##ed!atel , f!ll cup w!th water a"d dr!"' the water$ 9o "ot use a" other l!0u!ds or food to d!ssol)e the pac'et$ 38a)e regular #ed!cal follow up )!s!ts$ 3Report se)ere headache, worse"!"g of s #pto#s, fe)er, ch!lls, se)ere d!arrhea$

Omepra9ol Losec, e

Page -@ of *+

Generic name 7aracetamol

Brand name Biogesic4

Classification ,nalgesics 92on3opiod= ,ntip retics

Dosage 1 tab

Mechanism of action

Indication -ild to moderate pa in

Contraindication H persensiti)it

Adverse Reaction Indigestion 2a!sea ,llergic reactions

Nursing Consideration ,ssess patientHs pain or temperat!re before therap . ,ssess the patientHs dr!g histor and calc!late the total dosage accordingl . (ell the patient not to !se the dr!g for fe)er that is higher than 10#.1F. lasts longer than # da s. 1arn patient that high doses or long term !se can ca!se li)er damage. (ell patient to Ceep tracC of dail dr!g intaCe

7aracetamol red!ces the (IEx#d s nthesis of a s prostaglandin s .hich are PO responsible for the mediation of pain and fe)er.

Fe)er

Hi)es Rash Er!g fe)er

Page -A of *+

Generic name -!lti)ita mins

Brand name Centr!m

Classification /itamins and -inerals

Dosage 1 tab GE 7G

Mechanism of action

Indication

Contraindication H persensiti)it to a )itamin or an mineral 9s!ch as fl!oride4 calci!m4 iron4 0inc and others=

Adverse Reaction (!red"ess, loss of appet!te, !"d!gest!o", "ausea, sta!"!"g of teeth, co"st!pat!o", d!arrhea, &lac' stool

Nursing Consideration %atch for a" s!g"s of allerg!c react!o"s 2hould &e ta'e" w!th food$ (a'e dur!"g or after #eal ?"courage to co#pl w!th ph s!c!a"7s reco##e"dat!o"s$ /"struct to "ot!f s!de effects of #ed!cat!o"s !##ed!atel

(hese For dietar )itamins are s!pplement necessar for normal gro.th and de)elopment. -an act as coen0 mes or catal sts in n!mero!s metabolic processes

Generic

Brand

Classification

Dosage

Mechanism

Indication

Contraindication

Adverse

Nursing Consideration

Page *B of *+

name -!lti)ita mins

name 8angobion /itamins and -inerals/ ,nti 3 anemics 1 tab GE 7G

of action (hese )itamins are necessar for normal gro.th and de)elopment. -an act as coen0 mes or catal sts in n!mero!s metabolic processes . -nemia pr ophylaxis in blood donors. Fe acc!m!lation? disorders in Fe !tili0ation

Reaction Eiarrhea4 constipation4 stomach cramps4 blacC stools

hives; difficulty breathing; swelling of your face lips tongue or throat.

8ho!ld be taCen .ith food. (aCe d!ring or after meals 1atch o!t for an signs of allergic reactions 6nco!rage to compl on medications Instr!ct to notif side effects of medications immediatel

Page *) of *+

Generic name Calc!u# @luco"at e

Brand name Cal3@

Classification -"tac!d ?lectrol te

Dosage

Mechanism of action 4eutral!.es or reduces gastr!c act!)!t $

Indication 9!etar supple#e "t whe" calc!u# !"ta'e !s !"ade0uat e$

Contraindication Co"tra!"d!cated w!th allerg to calc!u#, re"al calcul!, h percalce#!a, )e"tr!cular f!&r!llat!o" dur!"g card!acrescuc!tat !o"a"d pat!e"ts w!th the r!s' of e*!st!"g d!g!tal!s to*!c!t $

Adverse Reaction CV: 2lowed heart rate, t!"gl!"g, Hheat wa)esI+rap!d /V ad#!"!strat!o",= per!pheral )asod!lat!o", local &ur"!"g M?(-BOL/C: 8 percalce#!a +a"ore*!a, "ausea, )o#!t!"g, co"st!pat!o", a&do#!"al pa!", dr #outh, th!rst, pol ur!a,, re&ou"d h perac!d!t a"d #!l' al'al! s "dro#e +h percalce#!a, al'alos!s, re"al da#age w!th calc!u# car&o"ate used as a" a"rac!d,$

Nursing Consideration 9o "ot ad#!"!ster oral drugs w!th!" 132 hr of a"tac!d ad#!"!strat!o"$

8a)e pat!e"t chew a"tac!d ta&lets thoroughl &efore swallow!"g= follow w!th a glass of water or #!l'$

Pre)e"t!o " of h pocalce #!a dur!"g e*cha"ge tra"sfus!o 5se caut!ousl "s$ w!th re"al !#pa!r#e"t, preg"a"c , lactat!o"$

@!)e calc!u# car&o"ate a"tac!d 1 a"d 3 hour after #eals a"d at &edt!#e$

Mo"!tor seru# phosphorus le)els per!od!call dur!"g lo"g ter# oral therap $

Page *- of *+

Nursing Diagnosis ). $ear related to upcoming surgery.

Interpretation 1$ (he fear of the Hu"'"ow"I !s a co##o" co"cer" of a preoperat!)e cl!e"t$ (he #e"tal preparat!o" of a cl!e"t &efore surger should &e a #a!" co"cer" !" pro)!d!"g "urs!"g care$ Ver&al!.at!o"s a"d clar!f!cat!o" of what to e*pect a&out the surger !s )!tal part !" pre)e"t!"g or reduc!"g cha"ce of co#pl!cat!o"s dur!"g surger $ 2$ (he cl!e"t7s d!sease !s affect!"g her 0ual!t of l!fe a"d should &e addressed accord!"gl $ 2urger !s "eeded !" order to stop the &leed!"g$ 8elp!"g the cl!e"t &e prepared for !t !s a #a!" focus of care$

-. (e,ual Dysfunction ':. Altered reproducti0e function secondary to Adenomyosis.

*.

$luid 6olume Deficit ':. Adenomyosis A&1 6aginal leeding

3$ O" ad#!ss!o" cl!e"t suffered fro# profuse uter!"e &leed!"g$ /t was #a"aged to &e 'ept to a #!"!#al &ut cl!e"t st!ll co"t!"ues to ha)e ep!sodes of &leed!"g$ 8er co"d!t!o" should &e sta&!l!.ed &efore u"dergo!"g surger to pre)e"t further co#pl!cat!o"s$

3. Acute pain related to a normal uterine leeding secondary to adenomyosis.

F$ Pa!" fro# the cl!e"t ca" address & co"ser)at!)e #a"age#e"t$ ?"courag!"g )er&al!.at!o" a"d co#fort #easures ca" read!l &e do"e & the cl!e"t$

4. Altered distur ed ody image related to loss of c#ild earing potential.

5$ Post3op co"cer" of the cl!e"t !s her !"a&!l!t to &ear a ch!ld$ (h!s ca" &e address & ha)!"g a support s ste# fro# fa#!l #e#&ers &e !")ol)ed !" e"courag!"g accepta"ce$

Page ** of *+

DIII. Nursing Care Plan

A((&((M&N. N8'(ING DIAGNO(I ( Aear RC( 5pco#!"g 2urger IN$&'&NC & 5"co"trolle d Bleed!"g GOAL O$ CA'& 9ur!"g the sh!ft, cl!e"t w!ll &e a&le to de#o"strate health wa s of deal!"g w!th fear IN.&'6&N.ION 'A.IONAL& &6AL8A.ION

(u !ecti0e Data: H2!"o &a "a#a" a"g h!"d! #atata'ot 'apag ala# #o"g ooperaha" 'aKI as )er&al!.ed & the cl!e"t Ver&al!.ed sleep d!stur&a"ce O !ecti0e Data: ?as!l d!stracted Aac!al te"s!o" ?p!sodes of refus!"g care

/"depe"de"t: /de"t!f!ed the cl!e"t7s percept!o" of the threat prese"ted & the s!tuat!o"

2cheduled for (-8B2O w!th 5rethral 2te"t!"g

?sta&l!shed a therapeut!c relat!o"sh!p w!th the cl!e"t co")e !"g e#path

?"couraged )er&al!.at!o" of fears Aear of the u"'"ow"

?*plored cop!"g s'!lls pre)!ousl used & the cl!e"t to rel!e)e fear M re!"forced these s'!lls

@oal was Aor &etter part!all #et$ u"dersta"d!"g of the 9ur!"g the cl!e"t7s s!tuat!o" a"d sh!ft, the cl!e"t w!ll ser)e as the &as!s was a&le to for other !"ter)e"t!o"s )er&al!.e her feel!"gs a&out (o ga!" the cl!e"t7s trust so that she feels her scheduled safe to )er&al!.e her surger a"d feel!"gs of fear was cooperat!)e (he cl!e"t "eeds to dur!"g our tal' a&out her feel!"gs assess#e"t to &eg!" resolut!o" &ut st!ll reports apprehe"s!o" Methods of cop!"g !" u"dergo!"g w!th fear that ha)e &ee" successful !" the the surger $ past are l!'el to &e helpful aga!"

?*pla!"ed procedures M !ssues that !")ol)es the cl!e"t us!"g "o"3#ed!cal ter#s w!th cal#, slow speech

Cl!e"t w!ll feel less a"*!ous thus decreas!"g fear whe" she '"ows what to

Page *3 of *+

A((&((M&N. 2u&Gect!)e 9ata:

N8'(ING DIAGNO(I(

IN$&'&NC & -de"o# os !s

GOAL O$ CA'& 9ur!"g the sh!ft, the cl!e"t w!ll &e a&le to e*press feel!"gs a&out the alterat!o" !" her se*ual fu"ct!o"

IN.&'6&N.ION /"depe"de"t: Pro)!ded factual !"for#at!o" a&out the cl!e"t7s co"d!t!o" a"d !t7s !#pl!cat!o" to her se*ual!t ?"couraged a"d accepted e*press!o"s of co"cer", a"ger, a"d fear a&out her co"d!t!o" as well as her scheduled operat!o"

'A.IONAL& e*pect

&6AL8A.I ON @oal part!all #et$ Cl!e"t was a&le to partl )er&al!.e her feel!"gs w!th the stude"t "urse &ut re#a!" reser)ed w!th the !"for#at!o" that she pro)!ded$

2e*ual 9 sfu"ct!o" RC( -ltered reproduct!)e H4ga o" ala# fu"ct!o" seco"dar 'o "a h!"d! "a to -de"o# os!s 'o #ag'a'aa"a' eh &a'!t pa a'o #agrerelas o " d!&aKI as )er&al!.ed & the cl!e"t O&Gect!)e 9ata: Prolo"ged )ag!"al &leed!"g 2cheduled for (-8B2O w!th 5rethral 2te"t!"g

5"co"trolle d &leed!"g

B do!"g so, the cl!e"t !s #ade aware that although she do "ot ha)e the capa&!l!t to co"ce!)e, !t does "ot #ea" that she ca""ot ha)e relat!o"sh!ps (he cl!e"t "eeds to tal' a&out these feel!"gs to &eg!" resolut!o"

-ltered reproduct!) e fu"ct!o"

2e*ual 9 sfu"ct!o"

-ct!)el l!ste"ed to the cl!e"t7s e*press!o"s of co"cer" a"d fear

-ct!)e l!ste"!"g supports the cl!e"t w!thout !"trus!)e ad)!ce g!)!"g

Page *4 of *+

A((&((M&N. O&Gect!)e 9ata: Vag!"al &leed!"g Rece!)ed &lood tra"sfus!o" therap of PRBC

N8'(ING DIAGNO(I( R!s' for Alu!d Volu#e 9ef!c!t RC( -de"o# os!s -?B Vag!"al &leed!"g

IN$&'&NC& -de"o# os!s

GOAL O$ CA'& 9ur!"g the < hour sh!ft, the cl!e"t w!ll &e free fro# u"toward co#pl!cat!o"s of &leed!"g

IN.&'6&N.ION Independent: Mo"!tored VC2 rout!"el , !"clud!"g BCP, PR, a"d RR

'A.IONAL&

&6AL8A.IO N @oal #et$ (he cl!e"t re#a!"ed free fro# u"toward co#pl!cat!o" s of &leed!"g

L!"!"g cells of the uterus grows d!rectl !"to the #uscle wall of the uterus

Cha"ges !" VC2 part!cularl BCP, PR, M (e#p #a &e used as a rough est!#ate of &lood loss 5r!"e output g!)es a" accurate p!cture of the cl!e"t7s flu!d status$ 5r!"e output of W30ccChr !s a good !"d!cat!o" of the prese"ce of flu!d )olu#e def!c!t Cha"ges !" these s!g"s #a &e !"d!cat!)e of &lood loss affect!"g s ste#!c c!rculat!o"

Mo"!tored /CO closel as ordered a"d report ur!"e output W30ccChr

%he" l!"!"g cells of the uterus &leed at the t!#e of #e"strual per!od, these #!splaced cells !" the #uscle &leed as well

-ssessed s'!" color a"d #o!sture, ur!"ar output, a"d le)el of co"sc!ous"ess Dependent:

Prolo"ged &leed!"g R!s' for Alu!d Volu#e 9ef!c!t

Blood tra"sfus!o" 6 15 of PRBC properl t ped M crossed #atch

/" replace#e"t of &lood loss fro# the c!rculat!o", pre)e"t!"g h po)ole#!a

Page *5 of *+

 Mo"!tored 8g&, 8tc, RBC le)el as ordered

-!ds !" esta&l!sh!"g &lood replace#e"t "eeds a"d #o"!tor!"g the effect!)e"ess of Blood tra"sfus!o" therap (-8B2O w!th 5rethral 2te"t!"g w!ll pro)!de per#a"e"t cure of the cl!e"t7s co"d!t!o"

2cheduled for (-8B2O w!th 5rethral 2te"t!"g

Page *+ of *+