Case Study 3

CASE STUDY: PATIENT WITH ENDOMETRIAL HYPERPLASIA General Objectives: This case study aims to gather significant information that contributes to giving nursing care to a patient diagnosed with endometrial hyperplasia. This also intends to help the patient achieve the maximum level of health within his capability. Specific Objectives: • • • • • • • • •

Conduct a comprehensive interview Assess patient from head to toe Know the management of endometrial hyperplasia Correlate patient’s laboratory result with his illnesses Administer medications as ordered Provide health education to patient and patient’s SOs Assist in patient’s mobility Implement nursing care plans Implement a discharge plan

Introduction: ENDOMETRIAL HYPERPLASIA Definition: Endometrial hyperplasia is a condition of excessive proliferation of the cells of the endometrium, or inner lining of the uterus. Most cases of endometrial hyperplasia result from high levels of estrogens, combined with insufficient levels of the progesterone-like hormones which ordinarily counteract estrogen's proliferative effects on this tissue. This may occur in a number of settings, including polycystic ovary syndrome, estrogen producing tumours (e.g. granulosa cell tumour) and certain formulations of estrogen replacement therapy. Endometrial hyperplasia is a significant risk factor for the development of endometrial cancer so careful monitoring and treatment of women with this disorder is essential. Like other hyperplastic disorders, endometrial hyperplasia initially represents a physiological response of endometrial tissue to the growth-promoting actions of estrogen. However, the gland-forming cells of a hyperplastic endometrium may also undergo changes over time which predispose them to cancerous transformation. Several histopathology subtypes of endometrial hyperplasia are recognisable to the pathologist, with different therapeutic and prognostic implications. •

Endometrial hyperplasia (simple or complex) - Irregularity and cystic expansion of glands (simple) or crowding and budding of glands (complex) without worrisome changes in the appearance of individual gland cells. In one study, 1.6% of patients diagnosed with these abnormalities eventually developed endometrial cancer.

•

Atypical endometrial hyperplasia (simple or complex) - Simple or complex architectural changes, with worrisome (atypical) changes in gland cells, including cell stratification, tufting, loss of nuclear polarity, enlarged nuclei, and an increase in mitotic activity. These changes are similar to those seen in true cancer cells, but atypical hyperplasia does not show invasion into the connective tissues, the defining characteristic of cancer. The previously mentioned study found that 22% of patients with atypical hyperplasia eventually developed cancer.

Signs and Symptoms: Heavy menstruation  Extended menstruation  Menorrhagia  Irregular menstruation 

Medical Management: Progestin therapy Because endometrial hyperplasia is estrogendependent, progestins are often used to induce regression. Progestin appears to decrease glandular cellularity in these lesions by triggering apoptosis. In addition, medroxyprogesterone acetate (MPA) significantly inhibits angiogenesis in the myometrium immediately underlying complex endometrial hyperplasia. Gonadotropin-releasing hormone analogues Gonadotropin-releasing hormone (GnRH) analogues suppress the hypothalamicpituitary-ovarian axis, thereby inhibiting estrogen production and, potentially, causing the regression of endometrial hyperplasia. GnRH analogues also appear to have a direct antiproliferative effect on endometrial cells. Laser therapy Vilos and Ettler reported another case in which a patient with complex a typical hyperplasia underwent laser intrauterine thermal therapy. After 13 months of surveillance with transvaginal sonography, there was no evidence of disease. Surgical Management: Thermal balloon ablation The patient initially presented with a complaint of menorrhagia and had a preoperative endometrial biopsy that showed no evidence of hyperplasia. When she subsequently underwent a thermal balloon ablation procedure, a curettage specimen indicated complex hyperplasia with atypia. The patient underwent a hysterectomy 8 months later, at which time no pathologic evidence of persistent hyperplasia or carcinoma was found. Hysterectomy It is best treated surgically with hysterectomy. However, if a patient desires future pregnancy, a trial of hormonal treatment may be given. Nursing Interventions: • • • • • • • •

Assess patient’s bleeding Prepare patient for D/C Stop bleeding Monitor vital signs Promote weight reduction Promote regular aerobic exercise Increase fluid intake Administer medications as ordered

HEALTH HISTORY CHIEF COMPLAINTS: Patient J.D. is a 35 year old woman, married, residing at Basak, Rizal, Maasin City. She was born on March 17, 1975. She is a Filipino citizen and a Mormon. She is a housewife . She was admitted on February 13, 2010 at 10 am for vaginal bleeding. HISTORY OF PRESENT ILLNESS: According to patient, it was 7 days before admission that patient J.D. experienced bleeding. Two days prior to admission, patient had a headache, fever and chills. On the night of February 12, 2010, she experienced heavy bleeding that’s why they brought him at SOYMPH through a van. She was diagnosed with endometrial hyperplasia by Dr. Beneliana Dajao. She was hooked with D5NM 1L@40gtts/min. PAST HEALTH HISTORY: According to patient J.D., she had her first menstruation when she was 13 years old. According to her mother, she was brought to the hospital since she was still 1month old every month due to asthma. She was also brought to the hospital last 2 years due to allergy. She had measles, mumps and chickenpox when she was young. Patient’s mother added that the patient was fully immunized. FAMILY HEALTH HISTORY: According to patient J.D., her paternal side has a history of hypertension and lung disease and her maternal side has a history of heart disease. GENOGRAM: Paternal Side

Maternal Side

Legend: - male

- lung cancer

- hypertension

- female

-bone disease

- gout

- heart disease

- hyperglycemia

- convulsion

- nervous breakdown

- asthma

-deceased

- endometrial hyperplasia

GORDON’S FUNCTIONAL HEALTH PATTERN HEALTH PERCEPTION- HEALTH MANAGEMENT Patient J.D. describes her usual health status as fair. She says she is satisfied with her usual health status. She doesn’t smoke cigarette and doesn’t use any street drugs. She doesn’t drink any alcohol. She rates his living condition at home as fair. She does not exercise on a regular basis. She suggested that she must exercise to lose weight. She does not do breast self-examination. She views health as the absence of illness. NUTRITIONAL METABOLIC PATTERN Patient gains 5 kg weight in the last 6 months. She describes her appetite as good. Her food intolerance is “inun-unan nga isda”. Her average day’s food intake is 3 meals and 2 snacks. His average day’s fluid intake is 5 glasses. He likes to eat barbecue and “humba” and to drink softdrinks and juices. She says she doesn’t have problem with chewing and swallowing. She took vitamins in the previous months. ELIMINATION PATTERN Patient says she usually defecates every morning . Her stool is usually soft, yellow and has no bleeding. She had a history of constipation and diarrhea. She doesn’t have any history of incontinence. She usually void 3 times a day. Her urine is usually yellow. ACTIVITY-EXERCISE PATTERN Patient rates her self-care in feeding as 0, bathing /hygiene as 0, dressing/grooming as 0, toileting as 0 and ambulation as 0 with 0 as completely independent. She has no oxygen use at home. She uses only 1 pillow to sleep. Her works are washing clothes and sweeping the floor. Her way of exercise is walking but not regularly. Her hobbies are listening to music and watching television. SLEEP- REST PATERN Patient’s sleeping hours range from 5 hours per night. She sleeps at 12mn and wakes up at 5 am. She has also a nap during 1 pm. She does not have any difficulty going to sleep. She uses 2 pillows to sleep. Her relaxation technique is watching TV. COGNITIVE-PERCEPTUAL PATTERN Patient J.D. doesn’t have any difficulty in decision-making. She can define what his current problem is that she is having heavy vaginal bleeding. She thinks all will be alright after her stay in the hospital. ROLE-RELATIONSHIP PATTERN Patient’s J.D. live with her family. She has no children. She is the only daughter of the family. She likes to watch TV. She likes being stagnant. SEXUALITY – REPRODUCTIVE PATTERN Patient J.D. has an irregular menstrual cycle which is only once a year. She has also a history of vaginal bleeding. She thinks she has a difficulty of bearing a child. COPING – STRESS TOLERANCE PATTERN Patient J.D. experienced a severe skin allergy at the lower parts in both of his legs 2008. She had a moment of fear then when a certain somebody in the Barangay health station said that her legs would be amputated. She rates his usual handling of stress as average. Her primary way of dealing with stress or problems is consulting her mother. VALUE – BELIEF PATTERN

Patient says she is satisfied with the way her life has been developing because she is a commerce graduate . She is a Mormon. She says her church prohibits drinking coffee because they believe it can damage the cells of the body. PHYSICAL ASSESSMENT General Appearance: Patient J.D. is fat. She is infused with D5NM 1L@40gtts/min at her right arm. Her weight is 80 kgs and her height is 5’. Skull and face • skull are symmetrical round, hard and smooth without lesion • face are symmetric, no abnormal movement noted Hair • thick, evenly distributed • long, curly hair • free from infestation of lice • smooth and firm Eyes • moderately bulging eyes • short eyelashes • eyeballs are symmetrically aligned in sockets without protruding or sinking • eyes and eyelids are free from inflammation and masses • transparent conjunctiva and lens • white sclera • iris is typically round, flat and evenly colored • pupils equally round, reactive to light accommodation Ears • equal in size bilaterally • consistent with facial color • symmetrical with upper attachment • free from lesions and pain • ear wax discharge is present • able to hear words Nose and Sinuses • frontal and maxillary sinuses are non tender • color is the same as the rest of the face • no inflammation of sinuses upon palpation • nasal structure is smooth and symmetric • no mucous discharge Mouth • lips are smooth, moist and pink. without lesions or swelling • gums are pink and moist • teeth is yellowish from the upper portion • tongue pink, moist, a moderate size with papillae (little protuberances) present • no foul-smelling breath • able to open mouth wide Skin • fair dry little pale skin • no lesions • smooth • scars are present because of recent rashes in her feet • temperature is 37.5 °C

Nails • dirty nails in the toes • nail bed is pink • nail base is firm • 160-degree angle between the nail base and the skin Neck • able to move without complaint of pain • symmetric without bulging masses • muscles are symmetrical with head • lymph nodes are not palpable, without enlargement or tenderness Thorax and Lungs • posterior and anterior thorax is free from lesions • respiration is 22 cpm • symmetric chest • slope of the ribs is symmetrical • spine is straight • scapula are symmetric • pitch is low breath sound • no adventitious sound Cardiovascular system • heart rate is 62 bpm • S1 and S2 are audible • absence of visible pulsations • pulses are equal in rate and rhythm Abdomen • protuberant abdomen • 47 inches waistline circumference • non tender and soft • bowel sounds are loud • no lesions • no pain upon palpation External Genitalia, Anus and Rectum • spot bleeding Musculoskeletal system • posture erect • shoulders, arm and elbows are symmetrical, no redness, swelling or deformity • hands and fingers are symmetric, non tender, without nodules • knees are in alignment with each other • feet are in alignment with lower legs • lower leg in alignment with upper leg • toes and feet are in alignment with the lower leg Neurologic • conscious • good eye contact, smiles, and frowns appropriately • speech moderate tone, clear • able to hear • able to swallow • follows directions accurately • recalls recent events without difficulty • her eyes are in coordinated motion in all directions • can identify correct flavor

LABORATORY EXAMINATION Laboratory Exam Hematology the science dealing with the formation, composition, functions and diseases of the morphology of the blood forming organs

Normal Results * Leukocyte # cone : 4.5 - 11.0 x 109 / L * Hemoglobin Mass cone : 139 - 163 g / L * Different Counts → Segmenters : 0.31 - 0.76% → Lymphocytes : 0.14 - 0.44% → Eosinophils : 0 - 0.04% * Erythrocyte vol. fraction : 0.40 – 0.50

Patient’s Results * Leukocyte # cone : 15.1x109/L * Hemoglobin Mass cone : 78g/L * Different Counts → Segmenters : 0.74% → Lymphocytes : 0.26% → Eosinophils : 0.25 * Erythrocyte vol. fraction : 0.48

Indication Increased Normal Normal Normal Normal Normal

Laboratory Exam Urinalysis is a group of manual and/or automated qualitative and semiquantitative test perform on a urine sample.

LABORATORY EXAMINATION Normal Results Patient’s Results *Color: amber to yellow *Color: yellow *Character: clear *Character: turbid *Reaction(ph): *Reaction(ph): adults &children(4.6-8.0) adults: 8.0 newborn(5.0-7.0) *Specific gravity: 1.010-1.025 *Specific gravity: 1.008 *Albumin: negative *Albumin: negative *Sugar: negative *Sugar: negative

Indication *normal * *normal *decreased *normal *normal

LABORATORY EXAMINATION Laboratory Exam Blood chemistry -a group of tests that measures different chemicals in the blood. It is also termed the Chem 7, Chem 8, or Chemistry Panel. These tests usually are done on the fluid (plasma) part of blood. The tests can give doctors information about many organs in the blood, although they are most specific for the kidneys.

Normal Results Total cholesterol :up to 6.17 mmol /L Creatinine : 88-176.88 mmol/L 10-20mg s% Fasting blood glucose: 75-115 mg s / d/ 4.2-6.4 mmol Triglycerides :up to 1.71 mmol /L Uric acid : M=3.4-7 mg s /dL F=2.4 - 5.7 mgs/dL

Patient’s Results Total cholesterol : 2.94 88.4 86 0.46 6.52

Indication Decreased : low fat diet, malabsorption, anemia, liver disorders, carbohydrate sensitivity. Increased : kidney damage Increased : diabetes, liver disease, obesity, pancreatitis, stress Increased : too much carbohydrate intake and hyperlipidism Normal

DRUG STUDY Drug Generic name: Ampicillin Brand name: Ampicin

Date ordered 02-1310 250mg q6h IVTT

Classification Broad-spectrum antiinfective

Mechanism of Action Interfere with the bacterial cell wall synthesis during active multiplication causing cell wall death and resultant bactericidal activity against susceptible bacteria.

Indication Treatment of susceptible bacterial infections.

Side Effects Diarrhea, rash, vomiting, oral candidiasis, severe abdominal pain, encephalophathy, seizures, lymphathic leukemia.

Nursing Implications Assess: -I&O ratio; report hematuria, oliguria, since penicillin in high doses is nephrotoxic. -Culture sensitivity before drug theraphy; drug may be taken as soon as culture is taken. - Bowel pattern before, during treatment. -Skin eruptions after administration of penicillin to 1 wk after discontinuing drug. -Respiratory status: rate, character, wheezing, tightness in chest. -Anaphylaxis: rash, itching, dyspnea facial swelling; stop drug, notify prescriber, have emergency equipment available.

DRUG STUDY Drug Generic name: Cephalexin Brand name: Cefamex

Date ordered 02-1310 500mg cap, q8 PO

Classification

Mechanism of Action Bactericidal Bactericidal Antibiotic antibiotic with mechanism similar to that of penicillins; inhibits mucopeptide synthesis in the bacterial cell wall.

Indication Treatment of susceptible bacterial infections, including those caused by group A beta Hemolytic streptococcus, staphylococcus, klebsiela pneumonia E.coli proteus mirabilis and shigella.

Side Effects Dizziness, fatigue, headache, rash, nausea, vomiting, pseudo membranous colitis, transient neutropenia anemia transient elevation, liver enzymes.

Nursing Implications Give on an empty stomach to increase total absorption; give around the clock rather than 4 times a day to promote less variation in peak and through serum level.

DRUG STUDY Drug

Date ordered Generic 01-11name: 10 paracetamol 500mg 1 tab Brand q4h , name: PO Biogesic

Classification Analgesic and Antipyretic

Mechanism of Action Produce analgesia by blocking pain impulses by inhibiting prostaglandin synthesis in the CNS or of other substances that sensitize pain receptors to stimulation. The drug may relief fever through central action in the hypothalamic heat regulating center.

Indication for the relief of fever, minor aches and pains Contraindications: Anemia, cardiac and pulmonary disease. Hepatic or severe renal disease

Side Effects Paracetamol, when taken within the recommended dose and duration of treatment, has low incidence of side effects. Skin rashes and minor stomach and intestinal disturbances have been reported.

Nursing Implications • • • • •

Assess for fever. Store drug at temp. not exceeding 30°C Assess for hepatotoxicity Assess for allergic reaction Evaluate therapeutic response: reduced fever

DRUG STUDY Drug

Date Classification Mechanism of Indication ordered Action Generic 02-13- Laxatives, Stimulates Treatment of constipation, name: 10 Stimulant peristalsis by colonic e evacuation prior to bisacodyl 2 tab, directly irritating procedures of examination. P.O the smooth Brand muscles of the name: intestine, possibly Dulcolax the colonic intramuscular flexus, alters water and electrolyte secretions producing intestinal fluid accumulation and laxation.

Side Effects CNS: Muscle weakness GI: Nausea, vomiting, anorexia cramps, diarrhea, rectal burning(suppositories) META: Protien- losing enterophathy, alkosis, hypokalemia, tetany, electrolyte, fluid imbalances.

Nursing Implications -Administer tablets 2 hours prior, or 4 hours after antacids, increased PH may dissolve the enteric coating leading to GI distress;do not crush enteric coated during product . ASSESS: -Blood, urine electrolytes if drug is used as often by patient. -I&O ratio to identify fluid loss. -Cause of constipation; identify whether fluids, bulk, or exercise missing from lifestyle -Cramping, rectal bleeding, nausea, vomiting; if these symptoms occur, drug should be disconnected.

DRUG STUDY Drug Generic name: mefenamic acid Brand name: Ponstan

Date ordered 02-13-10 500mg cap, TID

Classification

Mechanism of Action

AntiInhibits inflammatory prostaglandin Nonsteroidal synthesis by decreasing the activity of the enzyme, cyclooxygenase, which results in decreases formation of prostaglandin precursors.

Indication short term relief of mild to moderate pain including primary dismenorrhea. -Increased effect of toxicity with oral anticoagulants, mnethotrexate.

Side Effects Skin rash, dizziness, abdominal cramps, heartburn, indigestion nausea, itching, ringing in ears, fluid retention, headache.

Nursing Implications Take with food, milk or with antacids; extended release capsules must be swallowed intact.

DRUG STUDY Drug Generic name: Brand

Date ordered 02-13-10

Classification

Mechanism of Action

Indication

Side Effects

Nursing Implications

ANATOMY AND PHYSIOLOGY Uterus The uterus (Latin word for womb) is a major female hormone-responsive reproductive sex organ of most mammals, including humans. It is within the uterus that the fetus develops during gestation. The uterus is located inside the pelvis immediately dorsal (and usually somewhat rostral) to the urinary bladder and ventral to the rectum. The human uterus is pear-shaped and about 3 in. (7.6 cm) long. A females uterus can be divided anatomically into four segments: The fundus, corpus, cervix and the internal os.

Regions From outside to inside, the path to the uterus is as follows: • • •

•

Vulva Vagina Cervix uteri - "neck of uterus" o External orifice of the uterus o Canal of the cervix o Internal orifice of the uterus corpus uteri - "Body of uterus" o Cavity of the body of the uterus o Fundus (uterus)

Layers The layers, from innermost to outermost, are as follows: Endometrium The lining of the uterine cavity is called the "endometrium". It consists of the functional endometrium and the basal endometrium from which the former arises. Damage to the basal endometrium results in adhesion formation and/or fibrosis (Asherman's syndrome). In most mammals, including humans, the endometrium builds a lining periodically which is shed or reabsorbed if no pregnancy occurs. Shedding of the functional endometrial lining in humans is responsible for menstrual bleeding (known colloquially as a woman's "period") throughout the fertile years of a female and for some time beyond. In other mammals there may be cycles set as widely apart as six months or as frequently as a few days. Myometrium The uterus mostly consists of smooth muscle, known as "myometrium." The innermost layer of myometrium is known as the junctional zone, which becomes thickened in adenomyosis. Perimetrium The loose surrounding tissue is called the "perimetrium." Peritoneum The uterus is surrounded by "peritoneum." The uterus provides structural integrity and support to the bladder, bowel, pelvic bones and organs. The uterus helps separate and keep the bladder in its natural position above the pubic bone and the bowel in its natural configuration behind the uterus. The uterus is continuous with the cervix, which is continuous with the vagina, much in the way that the head is continuous with the neck, which is continuous with the shoulders. It is attached to bundles of nerves, and networks of arteries and veins, and broad bands of

ligaments such as round ligaments, cardinal ligaments, broad ligaments, and uterosacral ligaments . The uterus is essential in sexual response by directing blood flow to the pelvis and to the external genitalia, including the ovaries, vagina, labia, and clitoris. The uterus is needed for uterine orgasm to occur. The reproductive function of the uterus is to accept a fertilized ovum which passes through the utero-tubal junction from the fallopian tube. It then becomes implanted into the endometrium, and derives nourishment from blood vessels which develop exclusively for this purpose. The fertilized ovum becomes an embryo, develops into a fetus and gestates until childbirth. Due to anatomical barriers such as the pelvis, the uterus is pushed partially into the abdomen due to its expansion during pregnancy. Even during pregnancy the mass of a human uterus amounts to only about a kilogram (2.2 pounds).

PATHOPHYSIOLOGY Precipitating factors:  obesity  age  exposure to unopposed endogenous or exogenous estrogen/tamoxifen  infertility + nulliparity  family history of endometrial cancer

Hyperestrogenism

continuous estrogen stimulation unopposed by progesterone

ASSESSMENT ASSESSMENT S- “sakit akong dapidapi”aho S- “ sakit dapi-dapi” as OSwollenby joints verbalized -bruised left patient buttock O- -Inability Swollen to get to the toilet joints by himself -Bruised left buttock -Inability to get to the toilet by himself

NURSING DIAGNOSIS NURSING Activity DIAGNOSIS intolerance Impaired RT injury of the left physical buttocks. mobility related to pain Scientific Basis: “Activity Scientific basis: intolerance “Impaired reflects physicalthe impact of the mobility… illness Relatedon the client’s ability Factors… to performed Pain/ activities of discomfort” daily living” Nurses’ Pocket Fundamentals of guide by nursing by Doenges, p.458 Delaune and lander, P.813

.

PLANNING PLANNING GOAL: the patient will GOAL: still The be further free from injury patient will after 5 hrs. maintain orof nursing increase intervention. strength and function of affected or compensatory body parts After 5 hours of nursing interventions.

IMPLEMENTATION IMPLEMENTATION 1. Evaluate patient actual act and perceived limitations/degree deficit in of usual status. 1.light Evaluate or continuously monitor degree of joint inflammation or pain. R: Provides comparative baseline and provides information about R: Level of activity or exercise depends on progression and resolution of needed education. inflammatory process. Ascertainbed ability and degree of assistance 2.2. Maintain restto orstand chair and rest more whenabout indicated. Schedule activities necessary. providing frequent rest periods and uninterrupted night time sleep. R: Systemic Determines needs. R: restcurrent duringstatus acute and attacks and important throughout all phases of disease to reduce fatigue and improve strength. 3. Monitor vital signs every 2 hours Provides information or patient’s 3.R:Encourage adequate fluid intake. status. R: To assist with excretion of uric acid and decrease likelihood of stone 4. Provide positive atmosphere formation. R: Helps to minimize frustrations. 4. Assist with active or passive range of motion. 5. Assist withor patient’s mobility R: Maintains improves joint function, muscle strength, and general R:Stamina. Prevents further injury. Provide information about theupright effect of lifestyle on activity 5.6. Encourage patient to maintain and erect posture when sitting, intolerance. Standing or walking. R: Maximizes Educates patient. R: joint function, maintains mobility. Encourage in recreation 6.7..Encourage theparticipation patient to avoid alcohol. R: That Enhances sense of well being. R: can precipitate acute attack. Providefoods assistive 7.8. Review that devices are rich in purines like sardines, anchovies, shell R: Fish Aidsand patient’s mobility. organ meats. R: To avoid foods that precipitate Acute attacks. 8. Provide safety needs. R: Help prevent accidental injuries or falls.

EVALUATION EVALUATION After 5hrs of nursing intervention, is After 5 hourspatient of still free from injury. nursing interventions, the patient was able to maintain or increase strength and function of affected or compensatory Body part.

ASSESSMENT S- “Di ta kalihok-lihok kay sakit atong dapi-dapi” as verbalized by the patient. O- Difficulty to walk. -Patient is always sitting

NURSING DIAGNOSIS Risk for impaired skin integrity R/T impaired circulation Scientific basis: “..At risk for skin being adversely altered… Risk factors Internal impaired circulation”.

PLANNING GOAL: After 5hrs. of nursing interventions, the patient will demonstrate behaviors to prevent skin breakdown.

IMPLEMENTATION 1.Assess skin routinely R: Monitors skin vulnerability. 2. Note presence of conditions that may impair skin integrity R: Prevent further skin alterations.

EVALUATION After 5hrs of nursing interventions, the patient is cooperative with the nursing care rendered.

3. Handle client gently R:prevent skin tears 4. Encourage patient to move. R:Promotes good circulation 5. Avoid exposure to sunlight R: Prevents skin inflammation 6. Increase oral intake R: Keeps the skin moist

Nurses’ Pocket guide by Doenges,p.624

7.Provide adequate clothing R: Prevents hyperthermia 8. Apply herbal oil to patient’s body R: Keeps the skin oily

ASSESSMENT S- “Nakapaus-os gyud ngadto sa 100/80 kining herbal medicine” as verbalized by

NURSING DIAGNOSIS Risk for decreased cardiac output R/T orthostatic hypotension

PLANNING GOAL: After 5hrs. of nursing intervention’s, the patient’s

IMPLEMENTATION 1. Monitor BP and pulse R:Assess patient’s blood flow 2. Encourage client to stop taking unapproved herbal medicines as ordered by the doctor

EVALUATION After 5hrs of nursing intervention, the patient’s BP is 130/70 and pulse is 64.

ASSESSME NT S- “Nahagba man diay kuno ko” as verbalize by the patient O- difficulty of walking -swollen joints -injured scapula

NURSING PLANNING DIAGNOSIS Risk for injury Goal: R/T impaired after 5 hours physical mobility. of nursing interventions, the patient will verbalized Scientific basis: understanding of “Clients who are factors that at risk for injury contribute to may have other possibility of injury. problems… Impaired physical mobility...” Fundamentals of nursing by Deluane and lander,P795

IMPLEMENTATION 1. Note clients decision-making ability R:Assess patient’s ability to protect self 2. Assess mood of aggression R: Monitor patient’s misbehavior 3.Assess client’s muscle strength, gross and fine motor coordination R: Identify risk for falls 4. Maintain bed lowest position. R:Ensure safety 5. place assistive devices R: Prevents further injury 6. Monitor environment R: Identifies contributing factors to injury 7.. Administer medications as ordered R: Aids in clients progress 8. Teach patients S.O.S the importance of railings heading to comfort rooms of their house R:Aids in patient’s mobility

DISCHARGE PLAN 1. Medications Name of drug

Dosage and Frequency

Route

Curative Effects

Side Effects

EVALUATION After 5hrs of nursing interventions, patient understands the value of carefulness.

2. Exercise / Activity Type of Activity Allowed / to be continued:__________________________________ :__________________________________ __________________________________ Procedure or Steps: _________________________________________________________________ _________________________________________________________________ ______________ Use of Equipment (if any):__________________________________________________ Restrictions:_______________________________________________________ ______

3. Treatment (prescribed treatment to be continued at home or to a referred health institution.)

4. Health Teachings (provide a separate sheet on specified health teachings) (

) clinic appointments schedule

(

) use of alternative medicines

(

) follow up laboratory examinations (

) relapse prevention measures

(

) understanding and knowing what to do with side effects of medications

(

) others __________________

5. a.. Observed signs and symptoms that need reporting: ____________________________________________________________________ ____________________________________________________________________ b. Interventions / Home Remedies that may be done immediately prior to seeking consultation:__________________________________________________________ ____________________________________________________________________ ____________

6. Diet (prescribed by the doctor / dietician). a. Prescribed Diet: b. Restrictions:

7. Spiritual and Psychological Needs ( ) Spiritual Counseling ( ) Confession ( ) Supportive Counseling ( ) Grief Work ( ) Family Therapy ( ) Join Organizations/ Church Activities ( ) Anger Management ( ) Reconciliation of Conflicted Relationships A. Discharge Details a. Date and Time of Discharge: __________________________________________________ b. Accompanied by: ___________________________________________________________ c. Mode of Transportation: ______________________________________________________ d. General Condition upon Discharge: _____________________________________________ ____________________________________________________________________ ______ ____________________________________________________________________ ______

August Angelo Asido Ije Bactol Mark Anthony Degamo Jeralden Bolo Mary Jane Lamoste Catherine Rose Macabata Ma. Luisa Mantilla Junalie Verano