Professional Documents
Culture Documents
I. Introduction
The development of ovarian cysts is a common condition in which one or more cysts f orm on the ovary or ovaries of a woman's reproductive system. An ovarian cyst consists of a sac filled with fluid, blood, or tissue. Ovarian cysts are generally not dangerous and often go away by themselves within weeks to a few months. However, some ovarian cysts can remain and cause serious problems to health or fertility. During ovulation (the process during which the egg ripens and is released from the ovary) the ovary produces a hormone to make the follicles (sacs containing immature eggs and fluid) grow and the eggs within it mature.
I. Introduction
Ovarian cysts can develop due to a woman's changing hormones that normally occur during the monthly menstrual cycle. There are many types of ovarian cysts, including endometriomas, dermoid cysts, and functional cysts. Cysts vary in size, from the size of a pea to the size of a softball.
I. Introduction
But with this case, the patient was diagnosed with ovarian new growth that is benign. Benign cysts can cause pain and discomfort related to pressure on adjacent structures, torsion, rupture, hemorrhage (both within and outside of the cyst), and abnormal uterine bleeding. They rarely cause death. There are often no symptoms of ovarian cysts, but sometimes they can result in abdominal pain, infertility and other health problems.
I. Introduction
The focus of this case is the abdominal pressure made by the growth of the cyst, thus causes epigastric pain, upon the recognition of the person of the pain a diagnostic test, maybe an ultrasound or endoscopy procedure might tell what or how big the affectation of the cyst to the digestion of the person. ON this case, dyspepsia was the associated diagnosis in the ovarian new growth.
I. Introduction
Dyspepsia is derived from Greek word and means difficult to digest. Dyspepsia (indigestion) is best described as a functional disease. Sometimes, it is called functional dyspepsia. It pertains to the muscular organs of the alimentary tract-oesophagus, stomach, small intestine, gallbladder, and colon. It is called functional, because it involves either the muscles of the organs or the nerves that control the organs are not working normally, and, as a result, the organs do not function normally.
I. Introduction
Ulcer like dyspepsia is a type of indigestion that may be caused by peptic ulcer. The symptoms are often similar to dyspepsia caused by ulcers such as bloating and epigastric pain or discomfort. Some causes of this disease is the presence of infection like H. pylori, some are due to other diseases maybe a growth from adjacent internal structures and some are from the persons eating habits like eating too fast or skipping important meals.
Address:
Batangas
Weight: 63 kg
BMI: 22.34 Growth, erosion Admitting Diagnosis: Ovarian New Ulcer like - Dyspepsia Final Diagnosis: Dyspepsia with gastric
Admission date
and time: January 16, 2013, 2:18 PM
The color of the skin is brown and is moist. The patient has good skin turgor. No wounds or lesions are noted.
Eyes
Eyes have symmetrical lids and normal periorbital area. Pink palpebral conjunctiva is noted, and sclera is observed to be anicteric. Dark circles under the eyes were noted
The patient has symmetrical, rounded shape breast with smooth surface. She has a capillary refill time of 2 seconds. Her pericardial area is flat and heart sound is irrregular in rate and rhythm with a rate of 72 bpm.
Nutritional- Metabolic
Elimination
Activity-Exercise
During her hospitalization, she was not Patient M is a housewife and her able to exercise; she would only daily household chores served as her ambulate when she would go to the activities. She sometimes fetches her bathroom. She stays on bed at all daughters from their school. times.
Sleep-Rest
Cognitive-Perceptual Pattern
Role-Relationship Pattern
Coping- Stress
Patient M is a Roman Catholic; she Patient M said that she prays whenever goes to Church with her family. She a procedure would be done to her. She stated that she believes in the power finds strength and courage when she of a superior being. prays and talks to the Lord.
XI. PATHOPHYSIOLOGY
XI. PATHOPHYSIOLOGY
XI. PATHOPHYSIOLOGY
Eosinophils
0.240
0.000-0.060
High
Negative
PUS Cells
2-3
Pus in the urine may indicate urinary tract infection. Normal RBC in the urine is < 5, this can only indicate that the RBC level is increased.
0-1
Squamous
Many
Presence of epithelial cells in the urine indicates the exposure of the specimen with skin flora.
Acute epigastric pain related to abdominal condition (ulcer like dyspepsia) as manifested by positive facial grimace, guarding behaviour, weakness and limited movement and a verbal report of moderate pain, 3/10.
Addressing the acute epigastric pain felt by the patient is the highest priority. In order to intervene well with the patient, it is essential to relieve the patient out of discomfort.
Sleep deprivation related to abdominal pain secondary to underlying condition (ulcer like dyspepsia) as manifested by positive drowsiness, weakness, dark circles under the eyes and a verbal report of desire to sleep.
Deficient knowledge related to unfamiliarity with information resource as manifested by positive weakness, poor eating habits, patient asking questions and colonoscopy report revealed presence of gastric erosion at antrum.
Readiness for enhanced therapeutic regimen management related to underlying condition (ulcer likedyspepsia) as manifested by cooperativeness and willingness to all therapeutic interventions and procedures.
Risk for imbalanced nutrition: less than body requirements related to self impose decrease intake probably secondary to abdominal discomfort.
Acute epigastric pain After 2 hour of Independent: Independent: After 2 hours of related to abdominal nursing interventions, 1. Assessed patients 1. To assess the nursing interventions, condition (ulcer like the patient will be condition. degree of severity. the goal was met, the dyspepsia) as able to report that the patient was relieved manifested by positive pain is relieved as that 2. Reviewed patients 2. For background from her pain as facial grimace, can be evidenced by a chart. information of the evidenced by the guarding behaviour, pain scale of 0-2 out patient. following: weakness and of ten.
NURSING DIAGNOSIS
PLANNING
IMPLEMENTATION
RATIONALE
EVALUATION
3. Rapport building Kirot- kirot na lang reduces anxiety of kaag nagalaw ako, 1 patient during nurse- out of 10 na lang as patient interaction. verbalized by the patient. 4. To know the progression of the pain that affects patient condition.
RATIONALE
EVALUATION
5. Provided quiet and 5. To promote comfortable relaxation and reduce environment. tension. 6. Encouraged 6. To divert the diversional activities attention of patient (watch TV, read from the pain. newspaper, and listen to relaxing music).
IMPLEMENTATION
RATIONALE
EVALUATION
8. To promote vasodilatation that promotes circulation thus 9. Monitored vital signs reduces pain. and documented. 9. To monitor condition of patient through her vitals.
Subjective: Sleep deprivation Hindi pa ako related to nakakatulog, gusto abdominal pain ko matulog as secondary to verbalized by the underlying patient. condition
After 8 hours of Independent: nursing 1. Assessed interventions the patients condition. patient will be able to report improved 2. Reviewed patients chart. sleep that can be evidenced
Independent: After 8 hours of 1. To assess the nursing degree of severity. interventions the goal was met, the 2. For background patient was able to information of the report improved patient. sleep as
Objective: (ulcer like dyspepsia) by a 2-3 hour sleep 3. Establish rapport 3. Rapport building evidenced by the Dark circles under the as manifested by within the shift. with the patient. reduces anxiety of following: eyes positive drowsiness, patient during nurse- Nakatulog ako Weakness weakness, dark circles patient interaction. kanina 9- 12 (3 Drowsy under the eyes and a 4. Instructed patient . hours), okay na Pain scale - 3/10 verbal report of desire to avoid caffeinated 4. Caffeine properties naman, nakapahinga Vital signs: to sleep. substances/ foods. inhibit sleep. kahit papaano as Temperature - 36.8C verbalized by the patient.
Pulse Rate - 72bpm Respiratory Rate - 19 cpm Blood Pressure 110/60 mmHg
5. Promoted physical 5. To increase desire activities during day to sleep. time. 6. Provided calm environment.
Subjective: Deficient Ano ba yung knowledge related gasgas daw sa to unfamiliarity sikmura ko? as with information verbalized by the resource as patient. manifested by
After 8 hours of Independent: Independent After 8 hours of nursing 1. Provided 1. Information can nursing interventions, the explanations decrease anxiety, interventions, the patient will be able of/reasons for test thereby reducing patient was able to to verbalize procedures and sympathetic understand her understanding of preparation needed. stimulation. condition as her condition. evidenced by:
Objective: positive weakness, Asking questions poor eating habits, Weakness patient asking Poor eating habits questions and Colonscopy Report: colonoscopy report Gastric erosion at revealed presence of antrum gastric erosion at antrum.
2. Reviewed disease 2. Provides knowledge Sa pagkain ko pala process/prognosis. base from which ang pinaka patient can make importanteng bagay informed choices. ngayon sa sakit ko, magaagahan na ako at magbabawas ng kape,
3. Encouraged 3. Effective questions, communication expression of and support at this concern time can diminish anxiety and promote healing.
4. Instructed patient to 4. Prevents and limits avoid food/fluids high recurrence of gastric in fats (e.g., whole attacks. milk, ice cream, butter, fried foods, nuts, gravies, pork), gas producers (e.g., cabbage, beans,
5. Recommended resting in semi-Fowlers position after 5. Promotes flow of food meals. and general relaxation during initial digestive process.
6. Suggested patient 6. Promotes gas limit gum chewing, formation, which can sucking on straw/hard increase gastric candy, or smoking distension/discomfort.
7. Monitored patients 7. To monitor vital signs and condition of patient documented. through her vitals.
PLANNING
8. Checked IVF D5 NB 8. To promote 1L x 8 hours and adequate hydration. regulated at desired rate 41- 42 gtts/min.
Collaborative: Collaborative: 1. Reminded patient to 1. To reduce gastric follow soft diet as workload. prescribed by dietician.
IMPLEMENTATION
RATIONALE
EVALUATION
Eat a well balanced diet High fiber diet like vegetables and fruits. Folic Acid and Iron rich foods such as : leafy green vegetables, asparagus, legumes, oranges and orange juice, liver, and whole Avoid gastric stimulants such as: Bell pepper, spicy preservatives ans caffeine and caffeinated foods.
grains sauces,
XVII. PROGNOSIS
Best Case Scenario for Patient M
Patient M, after her discharge was very cautious about her condition. She followed the prescription of her physician about the foods to be eaten and to be avoided. She also took her medications on time and performed activities optimal for her ability. She does not skip her breakfast and only drinks 1-2 cups of coffee per day and increased her intake of water. Upon her follow up check up, the physician encouraged Patient M to continue this healthy food lifestyle and said that Patient M was already well.
XVII. PROGNOSIS
Worst Case Scenario for Patient M
Patient M, after her discharge was very careless about her condition. She skips her meals and eats whenever she wants to. She also drinks the same amount of coffee a day which more than 5 cups. Patient M also forgets to drinks her medications on time and was lying on bed most time of the day. Four days after her discharge she was not able to fetch her children for school and said that she was so sick to get up. She was brought to the hospital and was subjected for another colonoscopy and the gastric erosion found before got worse and bigger. Patient M was again admitted and was subjected surgery to correct the erosion in her digestive tract.