CHAPTER II

CLIENT PRESENTATION

This is the case of patient , N.CN, a female Franciscan nun, 43 years old,a nulligravid

who was born on 3rd of October 1973, presently residing at Makati City. The patient was

admitted in a selected tertiary hospital in Makati City on 19th of December 2010 for operation

named Exploratory Laparotomy ( Bilateral Salphingo oophorectomy, appendectomy,

adhesiolysis ). Information was obtained through the patient’s medical records.

Two years prior to admission, the patient experienced intermenstrual vaginal spotting

accompanied by left lower quadrant pain. She took Mefenamic acid which afforded relief of

symptoms consult was done and ultrasound showed a myoma about one cm in size. She was then

advised observation. One year prior to admission she was seen for the first time by her attending

physician. Repeat ultrasound showed the same findings. She was then advised to have ultrasound

exam every six months. Eleven months prior to admission, follow up ultrasound showed a small

cyst in the right ovary. She was then advised observation. After ten months, the patient started to

experienced prolonged menses for fifteen days with shortened intervals. Consult with attending

physician was done and she was given primolut for six months which corrected her menses.

Follow-up ultrasound done, one month prior to admission showed increasing in the size of cyst.

She was then advised surgery and hence this admission.

Past History showed the previous hospitalization of patient for three times; on 1997 and

2004 due to dengue fever while on 2009 due to increase cholesterol level. The patient had no
allergies and history of blood transfusion. Current medication taken by the patient were

Paracetamol ; 1 tablet per orem maintained for 2 weeks and Vitamin C; 1 tablet per orem for 1

month., On her laboratory examination; CBC, FBS , Chest X-ray , VDRL, showed normal results

but pelvic ultrasonography showed anteverted uterus , soild mass at left uterine fundus and noted

cystic foci in right ovary. Urinalysis revealed trace of ketones , leukocytes (+2) and blood (+2)

was noted by the researchers.

Past medical history revealed that the patient was diagnosed with hypercholesterolemia

with medication of simvastin taken for three months.Family history revealed the occurrence of

hypertension from maternal side and asthma from paternal side. Personal and social history

showed patient being non- smoker and non alcoholic beverage drinker. Patient had lmited ROM

and dependent for self care. She had no known exercise and had interrupted sleep pattern. Pattern

of elimination was irregular and patient shown no food preferences. Meal pattern was irregular.

On the day of admission, 19th of December 2010 , the patient was received. Patient,

N.C.N, was admitted to the 5th rectangular wing due to prolonged menses . Vital signs were taken

as part of hospital institution’s protocol which revealed a normal body temperature of 36.7 C

(NV: 36.4-37.5 C), respiratory rate of 20 cycles per minute (12-20 cpm), pulse rate of 84 beats

per minute (60-100), blood pressure of 120/70 mmHg. Soft diet was initiated and regulated for

dinner, then NPO. Fleet enema was also done in the morning with IVF fluid transfused to the

patient: 1 L to carun at 32 gtts/min. At 1635 H, patient was given the coamoxiclav 1.2 g/ IV after

negative skin test to be given 30 mins prior to surgery. At 2000H , PHSSIL was started and it

will be given for 8 hours. Physical examination was also accomplished and patient was said to be

conscious, coherent and ambulatory. Review of patient’s system revealed negative of headache,

nausea, vomiting, dyspnea, chest pain, dysuria and change in bowel movement. Physical

Examination also showed symmetric chest expansion with clear breathe sounds , normal rate
and rhythm of heart, adynamic precordium, flabby abdomen with no palpable masses and

normoactive bowel sounds, with pulses regular and equal, moist lips and buccal mucosa and pink

conjunctivae . Extremities were assessed and revealed equal pulses and no signs of edema and

cyanosis.The patient started menarche at age of 12, reported as regular which lasted for 4 days

and which consumes 3 pads per day. She is positive with dysmenorrhea. Her Last Menstrual

period was on last December 10, 2010

On the second day, 20th of December 2010, 0530H, cleansing edema was done with clean

back flow. At 0600H, patient was prepared for abdominal preparation whereas at 0700H, patient

given amoxiclav 1.2 g/IV after negative skin test then at 0900H, patient was put under NPO

status . The patient was fetched from his room to the delivery room for Exploratory Laparotomy

(surgery for bilateral salphingo- oophorectomy s/p appendectomy, s/p adhesiolysis). The patient

received conscious, coherent and awake with negative of bleeding, bladder not distended and

IV fluid of D5MM 11x 8 hours administered , looked patient to oxygen at 21pm via nasal

cannula, looked to cardiac monitor with foley catheter draining to urine bag as seen by Dr.

Fabian. Pre-operation vital signs showed normal results (36.8 C ,20 cpm ,79 bpm ,120/70 mmHg

) . The surgery begun from 0750H .The procedure was successful and ended around 0930

.Specimens removed were left ovary and fallopian tube, right ovary and fallopian tube and

appendix. The patient was monitored at the recovery room, urine output was monitored for

every 24 hours and showed an output 250 ml . Then , abdominal binder was released . At

1100H , patient showed stable vital signs, soft abdomen and adequate output so patient was

transferred to her room. At 2000H, patient awakens with reduced pain , soft nontender abdomen

and stable vital signs but had vomiting episode.

The patient was handled by the researchers and interacted last December 21, 2010 at

0600H until 1400H . At 1220H Patient is negative of nausea, vomiting , flatus and had stable
vital signs (36.5 C ,19 cpm ,89 bpm ,120/70 mmHg ) with adequate output. Foley cathether may

be removed but was advised to continue on IV antibiotics ; coamoxiclav 625 g tablet 2x while on

NPO. At 2130H, patient was hydrated to 200 ml .

Assessment was done 22nd of December 2010, at 0830H and researchers received the

patient, awake, conscious, negative of cardiopulmonary distress but with diminished interaction

and coherence. The researcher noticed that the patient was weak looking, seems serious due to

her procedure and had difficulty in moving in bed. The patient reported of an localized pain at

her epigastric area which was described as burning with pain scale of 5/10. She had the facial

grimace upon reporting. As a relieving factor, CBR and meds were given ; co-amoxiclav

(Augmentin Tablet 625 mg), co-amoxiclav (Augmentin vial 600 mg ),Paracetamol ( Naprex

Amplile 300 mg / 2 ml Toradol ( Ketorolac ampule 30 mg / ml) .With this , Alteration on

comfort; Acute pain related to tissue trauma AEB epigastric pain with pain scale of 5/10

was formulated. Interventions were rendered like; encourage to verbalize feelings of

discomforts, monitor vital signs, Investigate pain reports, noting location, duration, intensity, and

characteristics , provide sleep/rest periods to facilitate comfort, maintain semi-fowler’s position

as indicated and provide optimal pain relief with doctors prescribed analgesics.In urinalysis

results, trace of ketones , leukocytes (+2) and blood (+2) was noted by the researchers. In the

medical records, patient had a history of hospitalization due to Dengue fever on 1997 and

2009. . Besides, patient just had an exploratory laparotomy so there is a positive tissue trauma in

the site of incision at abdominal area . The patient was also observed of having an IVF insertion

at her left hand, with D5MM 1 L to run for 8 hours . In laboratory examination, CBC showed

low RBC results. With above cues, Risk for infection R/t Surgery was formulated. The

following interventions were done as follows: Provide regular perineal care/bed bath, Instruct

caregivers techniques in providing protection of skin integrity, and document skin conditions
around insertion of IV. The site of incision was noticed of swelling and patient reported an

epigastric pain with pain scale of 5/10 with associated irritability, reduced interaction and facial

grimace . Therefore, Impaired Skin Integrity R/t Surgery AEB Surgical Inscisions was

formulated. The following interventions were done like : Keep wound dry and clean and support

incision by using binder and turn the client from side to side whenever possible . The patient was

also put under Nutrional Diet (NPO) then (Hot tea sips) so Risk for imbalanced nutrition r/t

insufficient intake of nutrients was formulated. Interventions done are as follows: Discuss

eating habits, food preference and intolerance and promote adequate fluid intake.

Physical assessment was also done by the researchers. The patient has a short body

structure with symmetrical body parts and no obvious physical deformities. She is fairly

nourished and Her appearance is appropriate for her age with weight of 55.7 kilograms and

height of 149.86 cm . No apparent signs of acute distress but has difficulty in moving the

extremities . Skin was smooth and warm to touch. Nails were intact and good capillary refill (1-2

seconds). Head is normocephalic. Eyes, nose, ears, mouth are all symmetrical without any

discharges , lesions and signs of abnormalities. Lymph nodes are non-palpable.Abdomen has

surgical scars , normoactive bowel sounds and negative of obvious pulsation.

The last interaction of the researchers and the patient was on the 22nd of December 2010

at 0130H. The client was last seen awake and conscious without any signs of distress. Latest

vital signs that day were a body temperature of 36.0 C, respiratory rate of 22 cycles per minute,

pulse rate of 92 beats per minute, and a blood pressure of 110/70 mmHg.