Final Case Study Output

VELEZ COLLEGE COLLEGE OF NURSING F. RAMOS ST. CEBU CITY PHILIPPINES PERIOPERATIVE NURSING A CASE STUDY ON PATIENT C.M. WITH A POST-OPERATIVE DIAGNOSIS OF INTRAMURAL LEIOMYOMA WITH SUBMUCOUS COMPONENTS, ENDOMETRIAL POLYP IN DEGENERATION, STATUS POST FRACTIONAL CURETTAGE WITH CERVICAL PUNCH BIOPSY WITH FROZEN SECTION TOTAL ABDOMINAL HYSTERECTOMY – BILATERAL SALPHINGO OOPHORECTOMY AND PERITONEAL FLUID CYTOLOGY

CLINICAL INSTRUCTORS Ms. Anne Caroline Mendez RN Mr. Mark Anthony Longinos RN MAN SUBMITTED ON: November 25, 2009 SUBMITTED BY: Grant Rainiere Young Redentor Durano II Kier Escario Jeff Benjamin Go

INTRODUCTION

Alisteir Montecillo Jabe Gica Michelle Anne Sabellano

LEIOMYOMA A leiomyoma (plural is 'leiomyomata') is a benign smooth muscle neoplasm that is not premalignant. They can occur in any organ, but the most common forms occur in the uterus, small bowel and the esophagus. Uterine fibroids are leiomyomata of the uterine smooth muscle. As other leiomyomata, they are benign, but may lead to excessive menstrual bleeding (menorrhagia), often cause anemia and may lead to infertility. Uterine leiomyomas originate in the myometrium and are classified by location:  Submucosal - lie just beneath the endometrium.  Intramural - lie within the uterine wall.

 Subserosal - lie at the serosal surface of the uterus or may bulge out from the myometrium and can become pedunculated. Signs and Symptoms: Fibroids may cause no symptoms, or they may produce abnormal vaginal bleeding. Other symptoms are due to pressure on the surrounding organs and include:  Pain  Backache  Pressure  Bloating  Constipation  Urinary problems  Menorrhagia  Metrorrhagia Risk Factors:  Race  Age  Sex  History of Leiomyoma Diagnostic Tests:  Pelvic Examination  Ultrasound  Hysteroscopy  Papanicolaou (Pap) Smear  Endometrial Biopsy  MRI and CT Scanning: These can be useful, showing, for example, whether the ureter is obstructed and ruling out bowel involvement Management  Surgical • Myomectomy- removal of large tumors • Hysterectomy- removal of the uterus • Hysteroscopic resection of myomas- a laser is used through a hysteroscope passed through the cervix • Laparoscopic myomectomy- a removal of fibroid through a laparoscope inserted through a small abdominal incision • Laparoscopic myolisis- a laser or electrical needles are used to cauterize and shrink the fibroid • Laparoscopic cryomyolysis- electric current is used to coagulate the fibroid • Uterine artery embolization (UAE)  Pharmacological • GnRH analogs- induce a temporary meopause-like environment • Antifobrotic agents

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Birth Control Pill/Progestins: While these will not shrink fibroids, they may be effective enough in controlling the symptoms (particularly bleeding) that the patient can make it through to menopause.

ENDOMETRIAL POLYP Endometrial polyps are small, soft, growths in the lining of your uterus. Endometrial polyps grow very slowly. You may have 1 or many endometrial polyps. Sometimes endometrial polyps protrude through the vagina, causing cramps. The cramps occur because when the endometrial polyps protrude through the vagina, they impinge on the opening of the cervix. If the polyps become twisted and lose their blood supply, they can become infected. Polyps only rarely turn cancerous. However, some women with endometrial polyps will have difficulty becoming pregnant. Symptoms: Sometimes, symptoms don’t occur. Often, symptoms do not occur when the polyps are small. When symptoms do occur, the most common symptoms are: • spotting between menstrual periods • pelvic cramps • heavy or prolonged menstrual periods • bleeding during hormonal therapy Risk Factors: • obesity • high blood pressure • history of cervical polyps • intake of tamoxifen or hormone replacement therapy Diagnostic Exams: Diagnosing endometrial polyps involves looking inside the uterine cavity. A regular ultrasound (also called a sonogram) usually does not diagnose polyps, because the pressure inside the uterus flattens the polyps, making them very hard to see. A special ultrasound, called a sonohysterogram (water ultrasound), allows doctors to see inside the uterus after a few drops of sterile water is carefully infused into the uterus through the vagina. The water opens the uterine cavity, allowing the doctor to see if any polyps are present. Another diagnostic test is a hysterosalpingogram (HSG), which uses dye under pressure to open the uterus and tubes. A quick X-ray is then taken to see if any polyps are in the uterus. Finally, gynecologists are becoming more skilled at using the hysteroscope to look inside the uterus. This is a small, lighted tube that goes into the vagina then the uterus, to look around inside the uterus. Hysteroscopy using small tubes can be performed in the office, but larger tubes (used to remove large polyps or fibroids) usually require anesthesia in the hospital. Complications: Rarely, once the growths are removed, they may return -- this usually occurs years later, if at all. Most polyps grow very slowly. Rarely is major surgery needed for polyps, unless they are found to be precancerous or cancerous. In some women, if the polyp(s) interfere with the egg and sperm, it may make it hard to get pregnant. It is unknown at the time of writing how common this is. It is also possible that they may lead to a slightly higher chance of miscarriage, but this is also unknown. Most gynecologists will remove polyps if they are found in women with a history of miscarriage. If a polyp is diagnosed one of the first questions is, "Could this be cancer?" Although some polyps are thought to turn gradually into cancer, fortunately they rarely do. The risk does increase slightly as a patient passes age 50: polyps that appear during menopause may put the woman at greater risk. Usually, postmenopausal bleeding caused by the polyps will warn women to seek care Treatment: The old-fashioned way was to perform a D&C (dilatation and curettage). This involves a gentle scraping of the uterine lining. Unfortunately, this may miss the polyp completely, since this procedure is done solely by feel. As the scraping instrument goes by, it will likely just push the polyp out of the way without grabbing it. Hysteroscopes now allow us to look right at the polyp as we grasp it or cut it away from the uterine lining. This ensures that the polyp (or, in some cases, multiple polyps) is removed. TOTAL ABDOMINAL HYSTERECTOMY – BILATERAL SALPHINGO OOPHORECTOMY This is the removal of the uterus including the cervix as well as the tubes and ovaries using an incision in the abdomen.  Hysterectomy is the surgical removal of the uterus. Hysterectomy may be total, as removing the body and cervix of the uterus or partial, also called supracervical.

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Salphingo refers specifically to the fallopian tubes that connect the ovaries to the uterus. Oophorectomy is the surgical removal of an ovary or ovaries.

Hysterectomy is also referred to as surgical menopause. Operative Position: Supine Indications: • Cancer • Dysfunctional uterine bleeding • Endometriosis • Non- malignant growths • Persistent pain to the Pelvis • Previous injury to the uterus • Postpartum obstetrical hemorrhage Risk and Side Effects: • Increased bladder function problems • Greater risk of developing Cardiovascular problems such as atherosclerosis • Risk for developing osteoporosis Preoperative Management: • The lower half of the abdomen and the pubic and perineal regions may be shaved. • These area are cleaned with Povidine iodine. • To prevent contamination and injury to the bladder or intestinal tract, the intestinal tract and the bladder need to be empty. An enema and antiseptic douche may be prescribed the evening before the surgery. • Preoperative meds may be administered before the surgery. Postoperative Management: • Monitor closely peripheral circulation Rationale: To prevent thrombophlebitis and DVT ( noting varicosities, promoting circulation, using elastic compression stockings) • Monitor Input and Output Rationale: Voiding problems may occur due to the fact that the surgical site is close to the bladder • Indwelling catheter may be inserted Potential Complications: • Hemorrhage • Deep Vein Thrombosis and Pulmonary Embolism • Bladder Dysfunction Nursing Interventions: • Relieving Anxiety Rationale: Explanations are given about the physical preparations and procedures that are performed • Improving Body Image Rationale: Patient may have strong emotional reactions to having a hysterectomy and strong personal feelings related to the diagnosis. Nurse who exhibits interest, concern, and willingness to listen to the patient’s fears will help the patient progress through the surgical experience • Relieving Pain Rationale: Assess intensity of pain and administer analgesia as prescribed

Health Teachings: • Diaphragmatic Breathing Exercise • Foot and leg exercise • Incentive Spirometry • Coughing • Turning • Tell patient to resume activity gradually • Avoid straining and lifting • Early ambulation • General Liquid Diet post op PERITONEAL FLUID CYTOLOGY Peritoneal fluid analysis is a test to examine fluid accumulated in the peritoneal space (the abdominal space that houses the gastrointestinal organs). The sample is obtained by an abdominal tap. Procedure: A sample of fluid is obtained by abdominal tap. The physicians will sterilize and numb a small area of your abdomen with a small needle. Next, a larger needle will be inserted into the peritoneal space and the fluid will be withdrawn. Occasionally, vacuum bottles are used to draw off large amounts of fluid. The fluid is typically examined in the laboratory for appearance, red and white blood cell counts, protein and albumin, bacteria and fungi. Occasionally, tests for glucose, amylase, ammonia, alkaline phosphatase, LDH, cytology, and other substances are performed. Preparation: You must sign a consent form. Immediately before the abdominal tap, empty your bladder. Purpose: The test is performed to determine the cause of fluid in the abdomen, to detect whether trauma has caused internal bleeding, to detect a hole in the bladder, and to detect peritonitis. Interpretation: Milk-colored peritoneal fluid may indicate disease such as carcinoma, lymphoma, tuberculosis or infection. Bloody fluid may indicate tumor or trauma. Bile-stained fluid may indicate gallbladder problems. High white blood cell counts may indicate peritonitis or cirrhosis. Other laboratory abnormalities may indicate problems in the intestines or abdominal organs. Large differences between the concentration of albumin in the peritoneal fluid and in your blood serum may point to heart, liver, or kidney failure as the cause of the fluid collection. Small differences may point more towards cancer or infection. Risks: There is a slight chance of the needle puncturing the bowel, bladder, or a blood vessel in the abdomen. If a large quantity of fluid is removed, there is a slight risk of low blood pressure and even shock. There is also a slight chance of infection. FRACTIONAL DILATATION AND CURETTAGE Description: D and C, also called uterine scraping, may be performed in the hospital or in a clinic while you are under general or local anesthesia.The health care provider will insert an instrument called a speculum into the vagina. This holds open the vaginal canal. Numbing medicine may be applied to the opening to the uterus (cervix).The cervical canal is widened using a metal rod, and a curette (a metal loop on the end of a long, thin handle) is passed through the opening into the uterus cavity. The doctor gently scrapes the inner layer of tissue, called the endometrium. The tissue is collected for examination. Purpose This procedure may be done to: • Diagnose conditions such as uterine cancer • Remove tissue after a miscarriage

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Treat heavy menstrual bleeding or irregular periods (See: Bleeding between periods) Perform a therapeutic or elective abortion Investigate infertility Your doctor may also recommend a D and C if you have: • Endometrial polyps • Thickening of the uterus • An embedded intrauterine device (IUD) • Bleeding after menopause • Abnormal bleeding while on hormone replacement therapy This list may not be all-inclusive. Risks: Risks related to D and C include: • Puncture of the uterus • Tear of the cervix • Scarring of the uterine lining Risks due to anesthesia include: • Reactions to medications • Problems breathing After the Procedure: D and C has relatively few risks, can provide relief from bleeding, and can help diagnose infection, cancer, infertility, and other diseases. Prognosis: You may return to normal activities as soon as you feel better, possibly even the same day. There may be vaginal bleeding, as well as pelvic cramps and back pain for a few days after the procedure. Pain can usually be managed well with medications. Tampon use is not recommended for a few weeks, and sexual intercourse is not recommended for a few days. CERVICAL PUNCH BIOPSY A cervical biopsy is a test in which tissue samples are taken from the cervix and examined for disease or other problems. Procedure: You will lie on your back with your feet in stirrups. As in a regular pelvic examination, an instrument (speculum) will hold the vaginal canal open for the doctor to look inside. It will be inserted into the vagina and opened slightly so that the cervix is visible.The health care provider will place a small low-power microscope (colposcope) at the opening of the vagina and cervix to examine the area. The colposcope magnifies the surface of the vagina and cervix. The cervix is swabbed with a vinegar solution (acetic acid), which removes the mucus to help highlight abnormal areas. Photographs may be taken.Another method is the Schiller's test, which uses an iodine solution to stain the cervix. The stain is inserted through the speculum. The iodine solution stains the normal portions of the cervix, but does not stain abnormal tissues.If the health care provider finds abnormal tissue, a sample (biopsy) may be taken using a small biopsy forceps or large needle. More than one sample may be taken.Cells from the cervical canal may be used as samples as well. This is called an endocervical curettage or biopsy (ECC), and it may further help find abnormal cervical cells. When the procedure is done, the health care provider will remove all of the instruments. Preparation: There is no special preparation. Before the procedure, you should empty your bladder and bowel for your comfort. Do not douche or have sexual intercourse for 24 hours before the exam. Purpose: A cervical biopsy is usually done when the health care provider sees an abnormal area on the cervix during a routine pelvic examination. The biopsy can be done if the abnormal area is big enough for the health care provider to see. A colposcopy may be needed for small abnormal areas, or if a Pap smear is abnormal.

Normal Results: A specialist called a pathologist will examine the tissue sample from the cervical biopsy and will report to your doctor whether the cells appear normal or abnormal. Interpretation: Abnormal biopsy results may indicate problems, such as: • Abnormal tissue or cell growth in the cervix (cervical intraepithelial neoplasia) • Cancer Colposcopy may be used to keep track of precancerous cells and look for abnormalities that come back after treatment. Problems that may be biopsied or monitored include: • Abnormal patterns in the blood vessels • Areas that are swollen, worn away, or wasted away (atrophic) • Whitish patches on the cervix Other findings may be signs of cervical polyps. Risks: You may have some bleeding after the biopsy for up to 1 week. If bleeding is very heavy or lasts for longer than 2 weeks, or if you notice any signs of infection (fever, foul odor, or discharge), call your health care provider. Considerations: If the examination or biopsy does not show why the Pap smear was abnormal, your health care provider may suggest that you have a more extensive biopsy. To allow the cervix to heal, for 1 week after the biopsy avoid: • Douching • Sexual intercourse • Using tampons

ANATOMY AND PHYSIOLOGY THE FEMALE REPRODUCTIVE SYSTEM

The female reproductive system is designed to carry out several functions. It produces the female egg cells necessary for reproduction, called the ova or oocytes. The system is designed to transport the ova to the site of fertilization. Conception, the fertilization of an egg by a sperm, normally occurs in the fallopian tubes. After conception, the uterus offers a safe and favorable environment for a baby to develop before it is time for it to make its way into the outside world. If fertilization does not take place, the system is designed to menstruate (the monthly shedding of the uterine lining). In addition, the female reproductive system produces female sex hormones that maintain the reproductive cycle. During menopause the female reproductive system gradually stops making the female hormones necessary for the reproductive cycle to work. When the body no longer produces these hormones a woman is considered to be menopausal. What parts make-up the female anatomy? The female reproductive anatomy includes internal and external structures. The function of the external female reproductive structures (the genital) is twofold: To enable sperm to enter the body and to protect the internal genital organs from infectious organisms. The main external structures of the female reproductive system include:

EXTERNAL FEMALE GENITALIA The external organs of the female reproductive system include the mons pubis, labia majora, labia minora, vestibule, perineum, and the Bartholin's glands. As a group, these structures that surround the openings of the urethra and vagina compose the vulva, from the Latin word meaning covering. a. Mons Pubis. This is the fatty rounded area overlying the symphysis pubis and covered with thick coarse hair. b. Labia Majora. The labia majora run posteriorly from the mons pubis. They are the 2 elongated hair covered skin folds. They enclose and protect other external reproductive organs. c. Labia Minora. The labia minora are 2 smaller folds enclosed by the labia majora. They protect the opening of the vagina and urethra. d. Vestibule. The vestibule consists of the clitoris, urethral meatus, and the vaginal introitus. The clitoris is a short erectile organ at the top of the vaginal vestibule whose function is sexual excitation. The urethral meatus is the mouth or opening of the urethra. The urethra is a small tubular structure that drains urine from the bladder. The vaginal introitus is the vaginal entrance. e. Perineum. This is the skin covered muscular area between the vaginal opening (introitus) and the anus. It aids in constricting the urinary, vaginal, and anal opening. It also helps support the pelvic contents. f. Bartholin's Glands (Vulvovaginal or Vestibular Glands). The Bartholin's glands lie on either side of the vaginal opening. They produce a mucoid substance, which provides lubrication for intercourse.

INTERNAL FEMALE ORGANS The internal organs of the female consists of the uterus, vagina, fallopian tubes, and the ovaries a. Uterus. The uterus is a hollow organ about the size and shape of a pear. It serves two important functions: it is the organ of menstruation and during pregnancy it receives the fertilized ovum, retains and nourishes it until it expels the fetus during labor. Location: The uterus is located between the urinary bladder and the rectum. It is suspended in the pelvis by broad ligaments. Divisions of the uterus: The uterus consists of the body or corpus, fundus, cervix, and the isthmus. The major portion of the uterus is called the body or corpus. The fundus is the superior, rounded region above the entrance of the fallopian tubes. The cervix is the narrow, inferior outlet that protrudes into the vagina. The isthmus is the slightly constricted portion that joins the corpus to the cervix. Walls of the uterus: The walls are thick and are composed of three layers: the endometrium, the myometrium, and the perimetrium. The endometrium is the inner layer or mucosa. A fertilized egg burrows into the endometrium (implantation) and resides there for the rest of its development. When the female is not pregnant, the endometrial lining sloughs off about every 28 days in response to changes in levels of hormones in the blood. This process is called menses. The myometrium is the smooth muscle component of the wall. These smooth muscle fibers are arranged. In longitudinal, circular, and spiral patterns, and are interlaced with connective tissues. During the monthly female cycles and during pregnancy, these layers undergo extensive changes. The perimetrium is a strong, serous membrane that coats the entire uterine corpus except the lower one fourth and anterior surface where the bladder is attached. b. Vagina. Location: The vagina is the thin in walled muscular tube about 6 inches long leading from the uterus to the external genitalia. It is located between the bladder and the rectum. Function: The vagina provides the passageway for childbirth and menstrual flow; it receives the penis and semen during sexual intercourse. c. Fallopian Tubes Location: Each tube is about 4 inches long and extends medially from each ovary to empty into the superior region of the uterus. Function: The fallopian tubes transport ovum from the ovaries to the uterus. There is no contact of fallopian tubes with the ovaries. Description: The distal end of each fallopian tube is expanded and has finger-like projections called fimbriae, which partially surround each ovary. When an oocyte is expelled from the ovary, fimbriae create fluid currents that act to carry the oocyte into the fallopian tube. Oocyte is carried toward the uterus by combination of tube peristalsis and cilia, which propel the oocyte forward. The most desirable place for fertilization is the fallopian tube. d. Ovaries Functions: The ovaries are for oogenesis-the production of eggs (female sex cells) and for hormone production (estrogen and progesterone). BLOOD SUPPLY

The blood supply is derived from the uterine and ovarian arteries that extend from the internal iliac arteries and the aorta. The increased demands of pregnancy necessitate a rich supply of blood to the uterus. New, larger blood vessels develop to accommodate the need of the growing uterus. The venous circulation is accomplished via the internal iliac and common iliac vein.

FACTS ABOUT THE MENSTRUAL CYCLE Menstruation is the periodic discharge of blood, mucus, and epithelial cells from the uterus. It usually occurs at monthly intervals throughout the reproductive period, except during pregnancy and lactation, when it is usually suppressed. a. The menstrual cycle is controlled by the cyclic activity of follicle stimulating hormone (FSH) and LH from the anterior pituitary and progesterone and estrogen from the ovaries. In other words, FSH acts upon the ovary to stimulate the maturation of a follicle, and during this development, the follicular cells secrete increasing amounts of estrogen. b. Hormonal interaction of the female cycle are as follows: Days 1-5. This is known as the menses phase. A lack of signal from a fertilized egg influences the drop in estrogen and progesterone production. A drop in progesterone results in the sloughing off of the thick endometrial lining which is the menstrual flow. This occurs for 3 to 5 days. Days 6-14. This is known as the proliferative phase. A drop in progesterone and estrogen stimulates the release of FSH from the anterior pituitary. FSH stimulates the maturation of an ovum with graafian follicle. Near the end of this phase, the release of LH increases causing a sudden burst like release of the ovum, which is known as ovulation. Days 15-28. This is known as the secretory phase. High levels of LH cause the empty graafian follicle to develop into the corpus luteum. The corpus luteum releases progesterone, which increases the endometrial blood supply. Endometrial arrival of the fertilized egg. If the egg is fertilized, the embryo produces human chorionic gonadotropin (HCG). Thehuman chorionic gonadotropin signals the corpus luteum to continue to supply progesterone to maintain the uterine lining. Continuous levels of progesterone prevent the release of FSH and ovulation ceases. OVULATION Ovulation is the release of an egg cell from a mature ovarian follicle. Ovulation is stimulated by hormones from the anterior pituitary gland, which apparently causes the mature follicle to swell rapidly and eventually rupture. When this happens, the follicular fluid, accompanied by the egg cell, oozes outward from the surface of the ovary and enters the peritoneal cavity. After it is expelled from the ovary, the egg cell and one or two layers of follicular cells surrounding it are usually propelled to the opening of a nearby uterine tube. If the cell is not fertilized by union of a sperm cell within a relatively short time, it will degenerate. HORMONES Estrogen Estrogens are a group of steroid compounds functioning as the primary female sex hormone. Like all steroid hormones, estrogens readily diffuse across the cell membrane. Once inside the cell, they bind to and activate estrogen receptors which in turn up-regulate the expression of many genes.

The three major naturally occurring estrogens in women are estrone (E1), estradiol (E2), and estriol (E3). Estradiol (E2) is the predominate form in nonpregnant females, estrone is produced during menopause, and estriol is the primary estrogen of pregnancy. Estrogens are produced primarily by developing follicles (Graafian follicles) in the ovaries, the corpus luteum, and the placenta. Follicle-stimulating hormone (FSH) and luteinizing hormone (LH) stimulate the production of estrogen in the ovaries. Some estrogens are also produced in smaller amounts by other tissues such as the liver, adrenal glands, and the breasts. These secondary sources of estrogens are especially important in postmenopausal women. While estrogens are present in both men and women, they are usually present at significantly higher levels in women of reproductive age. They promote the development of female secondary sexual characteristics, such as breasts, and are also involved in the thickening of the endometrium and other aspects of regulating the menstrual cycle. • Structural  promote formation of female secondary sex characteristics  decelerate height growth  accelerate metabolism (burn fat)  reduce muscle mass  stimulate endometrial growth  increase uterine growth  increase vaginal lubrication  thicken the vaginal wall  maintenance of vessel and skin  reduce bone resorption, increase bone formation  morphic change (endomorphic -> mesomorphic -> ectomorphic) • protein synthesis  increase hepatic production of binding proteins • coagulation  increase circulating level of factors 2, 7, 9, 10, plasminogen  decrease antithrombin III  increase platelet adhesiveness • Lipid  increase HDL, triglyceride  decrease LDL, fat deposition • Fluid balance  salt (sodium) and water retention • Hormones  increase cortisol, SHBG • Gastrointestinal tract  reduce bowel motility  increase cholesterol in bile • Cancer  support hormone-sensitive breast cancers

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Lung function  promotes lung function by supporting alveoli (in rodents but probably in humans). Progesterone Progesterone acts with estrogen to bring about the menstrual cycle. During pregnancy, it quiets the muscles of the uterus so that an implanted embryo will not be aborted and helps prepare breast tissue for lactation. Progesterone is produced by another glandular structure in the ovaries, the corpus luteum. The corpus luteum produces both estrogen and progesterone, but progesterone is secreted in larger amounts Ovaries are stimulated to release their estrogens and progesterone in a cyclic way by the anterior pituitary gonadotropic hormones. Progesterone is sometimes called the "hormone of pregnancy", and it has many roles relating to the development of the fetus: • Progesterone converts the endometrium to its secretory stage to prepare the uterus for implantation. At the same time progesterone affects the vaginal epithelium and cervical mucus, making it thick and impermeable to sperm. If pregnancy does not occur, progesterone levels will decrease, leading, in the human, to menstruation. Normal menstrual bleeding is progesterone-withdrawal bleeding. • During implantation and gestation, progesterone appears to decrease the maternal immune response to allow for the acceptance of the pregnancy. • Progesterone decreases contractility of the uterine smooth muscle. • In addition progesterone inhibits lactation during pregnancy. The fall in progesterone levels following delivery is one of the triggers for milk production. • A drop in progesterone levels is possibly one step that facilitates the onset of labor. • It raises epidermal growth factor-1 levels, a factor often used to induce proliferation, and used to sustain cultures, of stem cells. • It increases core temperature (thermogenic function) during ovulation. • It reduces spasm and relaxes smooth muscle. Bronchi are widened and mucus regulated. (Progesterone receptors are widely present in submucosal tissue.) • It acts as an antiinflammatory agent and regulates the immune response. • It reduces gall-bladder activity. • It normalizes blood clotting and vascular tone, zinc and copper levels, cell oxygen levels, and use of fat stores for energy. • It may affect gum health, increasing risk of gingivitis (gum inflammation) and tooth decay. • It appears to prevent endometrial cancer (involving the uterine lining) by regulating the effects of estrogen. PATHOPHYSIOLOGY See Appendix D

OUTCOME PRESENT STATE TEST MODEL CLIENT IN CONTEXT GORDON’S FUNCTIONAL HEALTH PATTERNS C.M., is a 47 yr old female, Filipino, Roman Catholic, married, housewife from Tuba, Dalaguete, Cebu, born on November 14, 1962 in Lumbang Dalaguete, Cebu, was admitted for the first time in Cebu Velez General Hospital last November 12, 2009 at 10:25 AM accompanied by her sister and son, for complaints of vaginal bleeding under Dr. Velez House (Dr. Belinda Panares) with a case number of 083841, to PPW 4th Floor room number 408B. History of Present Illness February of 2006 PTA, patient started to feel that her right lower quadrant of her abdomen was hardening but there was no pain. Her menstrual cycle was still regular and normal consuming 3-4 napkins per day. No consultation was done. May of 2006 PTA, patient had her menstrual flow for 2 weeks, but with inconsistent amounts of discharges that sometimes she could consume 3 diapers per day and lumps were not noted. Hardening of the RLQ of the abdomen was still noted and no pain was felt. She then consulted Dr. Clarita Andrades of Argao Cebu and an ultrasound was ordered. It was found out that she had uterine myoma. No drugs were given. The doctor advised the patient to undergo surgery but the patient refused to take the advice due to financial constraints but she still wants to be cured. With her sister’s influence, they went to Tabunok Cebu City, to see a faith healer. For a year, they went to see the faith healer for 5 times. The patient states that, what the faith healer did was

PRESENT STATE TEST EMERGENCY ROOM BLOTTER Date: November 12, 2009 Time in: 10:25 AM Time out: 11:40 AM Vital Signs: • BP = 130/70 mmHG • PR = 60 bpm • T = 36.7 oC • R = 20 cpm • Height = 5’2”

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Weight = 115 lbs. BMI = 21.21 (Normal) Admitted on November 12, 2009 Admitted at 11:20 AM DOCTOR’S ORDER November 12, 2009 Please admit to OB-GYNE under the service of Dr. Velez/House • TPR q 4H • DAT • Problem G3P3003 menometrorrhagia • Labs  CBC  UA  Pregnancy Test  TUS at CUPSI PHYSICAL ASSESMENT DAY 1 (PRE-OPERATIVE PHASE) Date of Assessment: November 16, 2009 • Height: 5’2”

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Weight: 115 lbs. BMI: 21.21

General appearance: Examined sitting on bed, awake, conscious, responsive, coherent, afebrile and with an

INTERVENTIONS

OUTCOME

to place a cigarette foil with unrecalled herbs and plants on the site of the hardening RLQ of the abdomen. Patient claimed that she felt better verbalized that”mura man kog naayo ato dong, day kay ni au akong pamati dayun nihumok – humok ang gahi nakong pus.on ug wala na nibalik ang dugay na pag-agas sa akong dugo.” Patient claimed that her menstrual cycle became normal again. No other interventions were done as claimed by the patient. 2 months PTA, the patient had her menstrual flow for the entire month but with regular amounts consuming 3-4 napkins per day. Patient claims that it was not accompanied with pain and no lumps were noted. Patient claimed that there are no alterations in her physiologic functions. No interventions were done. 1 day PTA, on the 5th day of her menstrual cycle, the patient experienced severe vaginal bleeding with lumps noted while taking a bath. She felt sudden weakness and sister claimed that she became very pale. She was rushed to the nearest health care facility in Argao Cebu. The sister of the patient claimed that the amount of blood loss was about 1-2 liters. IVTT was administered. The doctor prescribed Hemostan capsule #15, 3x a day for 5 days and Hemorin capsule #1, 2x a day for 5 days but was taken for 1 day only. The doctor referred the patient to Cebu Velez General Hospital for further recommendations and assessment. Past Health History Patient claimed that when she was born there were no problems. Childhood illnesses include chicken pox, measles, fever and the common cough and colds. She had no accidents or serious injuries. Patient has no allergies. Previous

ease in respiration with an IVF of (5) D5LR at 10 gtt/min, infusing well at left arm with the following vital signs: • Blood Pressure = 130/70 mmHg • Pulse Rate = 61 bpm

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Respiratory Rate = 19 cpm Temperature = 36.9oC/axilla

Skin: Brown in color, skin is evenly distributed, no discolorations and infestations, warm, moist skin with the presence of IV line on left arm, and no edema noted. Nails: Pinkish nailbeds, clean, trimmed nails, no signs of clubbing and with a CRT < 2 seconds. Head: Symmetrical, round, normocephalic, located at midline, no involuntary movements, no swelling, tenderness or crepitations with movement on the Temporo-mandibular joint. Eyes: Eyeballs are round, symmetrical, sclera is white and moist, no unusual discharges noted, brown iris, eyes are able to move gaze at the 6 cardinal gazes, pupils are equally round, react to light and accommodation. Ears: Symmetrical with lateral canthus aligned with pinna, external ear same color with face, no lesions, presence of moist, yellow, odorless cerumen on both ears, able to hear whispered word “Hello” at a distance of 2 feet. Nose and Sinuses: Septum is midline; nostrils are patent, with

hospitalization was on 1973 in Cebu City Medical Center (CCMC) for the excision of cyst on her right breast. She stayed in the hospital for 1 month due to bleeding in the incision. Unrecalled drugs were given and no consultations done after. Health Perception and Health Management Pattern The patient describes health as “ang kawal-on ug sakit”. She is currently concerned with her condition is excited but anxious about the surgery that she states “Nahadlok man ko dong, pero normal raman siguro na dong, pero ganahan nako ma-operahan para maayo nako”. Before hospitalization, she rates her health as 9, 1 as the lowest and 10 as the highest. Before the surgery, she rates her health as 5 then rates it as 8 after the surgery and verbalized “Nalipay kaau ko na nahuman na ang operation ug na tangtang ang mayoma”. She does not smoke, drink alcohol and has no history of drug abuse. She usually self medicates when she has cough and colds, fever and headache and takes Neozep and Biogesic at an unrecalled dose. She does not take any maintenance medication. She usually drinks 2 – 3 cups of “salabat’ when she has cough. She doesn’t have any yearly checkups done. After her breast excision surgery, she has no correct knowledge in performing breast self-examination and only palpates her breast once in a while. She recalled that she had been immunized with BCG. Her family lives in an old 2 storey house and there are 7 of them. It is made with mixed materials. There are 2 doors, 6 windows, 3 bedrooms and 1 bathroom. There kitchen is outside their house. There toilet is water sealed. They get there water

no discharges transillumination.

noted

and

clear

Mouth and Throat: Symmetrical lips, uvula at midline, no nasopharyngeal congestion, no discharges and lesions noted in the buccal mucosa. Neck: Trachea is at midline, no lesions and lymph nodes are non-palpable. Chest and Lungs: Equal chest expansion, clear breath sounds, no retractions, no rales, no wheezes and deep inspiration noted. Heart: Distinct S1 and S2 sounds, regular paced heartbeats, CRT < 2 seconds and with the following pulse rates at the different sites: • Brachial = 61 bpm • Radial = 62 bpm

• •

Apical = 61 bpm Temporal = 61 bpm

Abdomen: Symmetric, umbilicus at midline, brown in color, NABS 20 clicks per 5 minutes, no tenderness upon palpation, and uterus palpated with the enlargement noted to be dominantly at the right side. Genito-Urinary: Grossly female, and claims of having no lesions and discharges upon assessment. Rectum: Patent and free of any lesions and hemorrhoids as claimed by the patient upon assessment. Breast:

source from the faucet and the artesian well and store it in a pail and pitcher for drinking. They take care of animals in their home. They have cats, dogs, pigs, cows and goats. There house is 5 meters away from their house. Nearest grocery, drugstore and hospital is 30 minutes away.

Breasts are saggy and no lumps palpated, scar is present at the bottom part of the right areola.

Nutritional – Metabolic Pattern Patient doesn’t weigh herself so weight 3 months ago is unknown. But, she states that there was no significant change in her weight. She currently weighs 115 lbs. or 52.27 kg and is 5 feet 2 inches tall. Her ideal body weight is 51.74 kg., and her BMI is 21.21 and is categorized of having a normal weight. She states that her weight is appropriate for size and feels good about it. She states that she does not lose or gain weight easily. She has good appetite before and during hospitalization. She was ordered not to take any food and any liquid (NPO) 11 hours before surgery. And after the surgery and passing flatus, the patient only took crackers and water as the doctor ordered general liquid diet and crackers with no carbonated drinks. She doesn’t have any vitamin supplements taken. Her 24 hour diet recall includes 1 pc longganisa, banana and 1 cup rice for breakfast, egg soup, beef and 1 cup rice for lunch and spaghetti, a single meatball and 1 serving of vegetables and I cup of rice for dinner. Her usual daily meals include I cup coffee which is preferred sweet in regards to her coffee by the patient, egg, fish and rice for breakfast, 1 serving each of vegetables and fish for lunch and dinner. She claims that she drinks 8 glasses a day. They seldom eat pork and beef at home, about 2 times a week. She is also fond of drinking coke, about 3 8oz bottles a week. She is not fond of eating snacks. She has no specific likes

NEUROLOGIC ASSESSMENT Mental Status: Awake, alert, conscious, follows direction accurately, patient follows instructions properly and performs tasks right away. Instructions are told once and are understood right away. Speech is somewhat moderate in volume and can be heard easily, moderately paced, oriented to person (able to recognize the student nurse), place (able to identify Cebu), time (able to recognize that it’s afternoon), able to recall last day of operation (remote memory) and date of yesterday (current memory).

Extremities: Pinkish nail beds, with a steady gait, no edema noted, extremities are symmetrical.

Motor-Cerebellar Function: (+) rapid alternating movements, (+) fingerthumb test, (+) finger-nose test, (+) buttonunbutton shirt and open-close zipper, (+) Romberg’s test and was able to do the tandem walk. Sensory Function: Able to feel light touch, able to differentiate between sharp and dull object (The difference between pressing with a finger and with a ballpen), (+) stereognosis (ballpen), (+) kinesthesia (able to recognize movement and direction of finger) and (+) graphesthesia (The number 7). Cranial Nerve Testing:  Olfactory - Able to identify the scent of Bambini cologne.  Optic – Is able to see clearly, read

and dislikes and religion does not affect her diet. When she gets stressed, she usually eats less. She and her sister are the ones who shop for food, prepare them and cook it. She verbalized that there income is sufficient for a decent meal. Elimination Pattern Before hospitalization, she voids around 3-5 times a day around 1-1.5 liters. She claims that it is clear and yellowish in color. During her hospitalization, she voided around 1430ml but with normal characteristics. After the surgery, she was catheterized and she voided 1200ml. She doesn’t drink any diuretics and drinks at least 1 cup of coffee a day. She has not experienced urinary incontinence and dysuria. Before hospitalization, she passes stool once a day. She claims that it is brown and formed stool. She usually voids in the morning and usually doesn’t postpone it. There was no change in her bowel movement during hospitalization. After surgery, the patient claimed that she has yet to pass stool. She seldom experiences diarrhea and constipation. Activity – Exercise Pattern Patient is a housewife but from 1990 to 2002 she worked as a ticket seller in a movie house. Her typical day includes cleaning her house, cooking, feed their animals and watches over there sari - sari store. She usually talks to her costumers and watches TV as her leisure activity. She doesn’t have any exercise but she states that cleaning her house and doing the laundry as her exercise. Before and during hospitalization, she does not need assistance in dressing, bathing, toileting and eating. After the surgery, her sister is the one who feeds her and perform

  

 

    

things from afar and at a close distance in regards to the student’s nameplate. Occulomotor – (+) PERRLA and Cardinal gazes for both eyes. Trochlear – (+) PERRLA and Cardinal gazes for both eyes. Trigeminal – (+) Corneal sensitivity test and patient can clench teeth and masseter and temporal muscle contracted bilaterally upon biting tongue depressor. Abducens – (+) PERRLA and Cardinal gazes for both eyes. Facial – Able to smile, frown, show teeth, raise eyebrows and close eyes tightly. Able to identify the taste of banana as sweet. Vestibulococchlear – Can hear whispered word “Hello” at a distance of 2 feet and has a sense of balance. Glossopharyngeal – (+) Gag reflex Vagus – (+) Gag reflex Spinal Accessory – Able to shrug shoulders against resistance and able to turn head side to side. Hypoglossal – Able to stick the tongue out and move it side to side and up and down.

Range of Motion: • Elbows: full • Wrist: full

•

Shoulders and arms: left arm slightly limited due to the presence of an IV line • Hips: full

•

Knees, feet, ankles: full No bony deformities, crepitus and fasciculations noted.

hygienic procedures as she difficulty in ambulating. She didn’t feel any pain in doing her everyday activities back then. Patient was observed to grimace, and presented guarding behavior through splinting of the wound. The patient was not able to perform her daily activities such as housekeeping or laundry since admission. Cognitive – Perceptual Pattern The patient’s highest educational attainment was grade 6. Patient is oriented to time, place and person. He has no eye problem and can read a nameplate 2 feet away. She has no ear examinations done. She cleans her ears with cotton buds 2 times a week. She could hear watch tick test 5 inches away. She does not have any problem in the sense of taste, touch and smell based on the result of the physical examination. She doesn’t have recurring problems like headache, vertigo and dizziness. Postoperatively, the patient was able to demonstrate the abilities she could perform preoperatively. Sleep – Rest Pattern Before hospitalization, the patient sleeps 10 hours a day. She sleeps mostly around 8 pm and wakes up around 6 pm and does not nap. During hospitalization, patient claims that “Sige ko mata mata dong kay sige ug sulod ang mga nurse sa room”. She verbalized that before hospitalization, she feels refreshed after sleeping but now she feels that she didn’t regain her energy as she verbalized “La-ay man gihapon akong lawas”. After surgery, the patient always stays in bed and wakes up when she needs to eat and when the nurse enters the room to get the vital signs. She verbalized that she could sleep with a small amount of noise and light. She does not have any nighttime awakenings

Muscle Strength: R

L

5/5

5/5

5/5

5/5

SCALE FOR GRADING MUSCLE STRENGTH 5 – Full ROM against gravity, full resistance 4 – Full ROM against gravity, some resistance 3 – Full ROM with gravity 2 – Full ROM with gravity eliminated (passive motion) 1 – Slight Reaction 0 – No Reaction Deep Tendon Reflexes: LEFT: (+2) biceps reflex, (+2) triceps reflex, (+2) brachioradialis reflex, (+2) patellar reflex, (+2) Achilles reflex RIGHT: (+2) biceps reflex, (+2) triceps reflex, (+2) brachioradialis reflex, (+2) patellar reflex, (+2) Achilles reflex SCALE FOR GRADING REFLEX RESPONSES: 0 – No Reflex Response +1 – Minimal Activity +2 – Normal Response +3 – More Active than Normal +4 – Maximal Activity (Hyperactive) DAY 2 (INTRA-OPERATIVE PHASE) Date of Assessment: November 17, 2009 • Height: 5’2”

and does not have any nightmares. Before she retires, she washes up her face, brushes her teeth and prays. Postoperatively, the patient was not able to perform her daily rituals. At home, she sleeps in a medium sized bed with her husband. She sleeps with one pillow which is placed in her head and a blanket. She usually sleeps in a supine and side lying position. Self Perception and Self Concept Pattern The patient views herself as a kind and loving person. She also thinks positively. Her sister describes her as a caring person and very responsible. She states that she is very happy with her life today. She states that she thinks that there is nothing wrong with her body and that her illness didn’t change the way she looked at her self. After the surgery, the patient was asked about the essence of her womanhood and replied “Okay raman dong, tiguwang naman pud ko.” She believes that her strength is her good cooking skills and the way she keeps the house clean and organized. She claims that raising her 3 sons well is her greatest achievement in life. Role – Relationship Pattern In her family, she takes the maternal role as a full time mother to her children and as the loving wife of her husband. She states that it usually her husband who makes the decision in the home but she always trust her husband’s decisions because it works out for the best. She states that her sons are very responsible that they usually brought no problem to the family. She is the third among all the 7 siblings. She verbalizes that she has a good and loving relationship

• •

Weight: 115 lbs. BMI: 21.21

General appearance: Examined lying on a stretcher, awake, conscious, responsive, coherent, afebrile and eupneic with an IVF of (5) D5LR infusing well at 10 gtt/min at left arm with the following vital signs: • Blood Pressure = 130/70 mmHg • Pulse Rate = 63 bpm

• •

Respiratory Rate = 19 cpm Temperature = 36.6oC/axilla

Skin: Presence of IV line noted at the left arm. Heart: Distinct S1 and S2 sounds, heart rate of 63 bpm. Abdomen: Uterus palpated with the enlargement noted to be dominantly at the right side. NEUROLOGIC ASSESSMENT Mental Status: Patient was awake, alert, and conscious. Responds to questions asked and speech is understandable, moderately paced and smiles. Oriented to person (able to recognize the student nurse), place (able to identify Cebu Velez General Hospital), and time (able to recognize time: morning). Sensory function: Patient is able to see things at a distance and at close proximity, able to hear and understand speech, able to smell and feel touch applied to skin. DAY 3 (POSTOPERATIVE PHASE)

with her mother. She is closest to her eldest sister and the sister next to her as she verbalized “ maau jud kaau ni ako igsoon kay iya jud ko gi ubanan”. Her present status brought their family closer, helping her financially and even sacrificed their job in order to accompany her to the hospital and always there to support her. Patient verbalized “Gi-tumor man sad sa matres akong duha ka mga iya-an.” Patient claimed that her father has a history of cardiovascular disease, hypertension and diabetes mellitus and her mother has hypertension. Genogram See Appendix B Ecomap See Appendix C Sexuality – Reproductive Pattern Patient has a female orientation. She had her menarche when she was 15. Her first sexual contact was with her husband when she was 20 yrs old and was her only sexual partner as well as her partner. She states that she is still sexually active. She claims that she doesn’t use any contraceptives. She claims that before and after the onset of illness, she had not experienced pain, burning and discomfort during intercourse and loss of libido. She has no history of sexually transmitted diseases. Patient is a G3P3003. She has 3 sons born through normal spontaneous vaginal delivery and all assisted by a doctor in a hospital in Angeles City in 1985, 19863, and 1987. She had her first baby when she was 23 years old and claims that each was delivered full term. She claims that she was checked by a doctor during her pregnancies but was not regular. She claims that she had no illness during the

Date of Assessment: November 18, 2009 • Height: 5’2” • Weight: 115 lbs.

•

BMI: 21.21

General appearance: Examined lying on bed, awake, conscious, responsive, coherent, afebrile and with ease in breathing with an IVF of (6) D5LR (1 L) infusing well at 30 gtt/min at left arm with the following vital signs: • Blood Pressure = 1600/90 mmHg

• • •

Pulse Rate = 61 bpm Respiratory Rate = 18 cpm Temperature = 36.7oC/axilla

Skin: Presence of IV line on left arm. Abdomen: A presence of a binder covering a bandage estimated to be 12 inches long, in turn this bandage covers a horizontal incision estimated to be 7 inches long located below the umbilicus. NEUROLOGIC ASSESSMENT Mental Status: Awake, lethargic, responsive and conscious, follows direction accurately, patient follows instructions properly and performs tasks right away. Instructions are told once and are understood right away. Speech is somewhat moderate in volume and can be heard easily, moderately paced, oriented to person (able to recognize the student nurse), place (able to identify Cebu), time (able to recognize that it’s afternoon), able to recall last opeeration (remote memory) and date of yesterday (current memory). Motor-Cerebellar Function:

entire course of all her pregnancies and no complications during and after birth. She states that every baby gave joy to her and her husband’s lives. When asked whether the operation will affect her womanhood, she replied “ ok ra man dong, tigulang naman sad ko, wala nakoy plano manganak”. She states that she has not undergone mammogram and Pap smear. Coping – Stress Pattern When asked about her stressors and problems, patient states that “ pasalamat ko sa ginoo dong kay kani ra jud ako sakit ang pinaka dako na problema karon, maau ra man ang akong pamilya bisan kulang usahay ang kita sa ako bana”. But sometimes, she has small fights with her neighbors and sometimes with her husband in which she says is normal. It doesn’t really affect her life in a way that it alters her daily activities and well being. When she has problems, she always goes to her sister and her husband but when she thinks it is irrelevant, she usually keeps it to herself. She believes that her hospitalization is not a huge stressor because it is for her own welfare. Value – Belief Pattern The patient is a Roman Catholic. She values her family and she always keeps the family together. Before and during the onset of illness, patient fervently prays everyday, goes to church every Sunday, prays the rosary, attends procession and joins prayer meetings. She states that her illness is not a punishment of God. She states that because of her strong belief in God, the operation will be successful and after the surgery she verbalized, “Nagpasalamat jud ko sa Ginoo na maau ra an gang akong operasyon”. She doesn’t believe in superstitions.

(+) rapid alternating movements, (+) fingerthumb test, (+) finger-nose test, (+) buttonunbutton shirt, Romberg’s test and tandem walk not done as it might endanger the patient. Sensory Function: Able to feel light touch, able to differentiate between sharp and dull object (The difference between pressing with a finger and with a ballpen), (+) stereognosis (ballpen), (+) kinesthesia (able to recognize movement and direction of finger) and (+) graphesthesia (The number 6). Cranial Nerve Testing:  Olfactory - Able to smell the Bambini cologne with eyes closed  Optic – Is able to see clearly, read the nameplate of the student nurse  Occulomotor – (+) PERRLA and Cardinal gazes for both eyes  Trochlear – (+) PERRLA and Cardinal gazes for both eyes  Trigeminal – (+) Corneal sensitivity test and patient can clench teeth and masseter and temporal muscle contracted bilaterally upon biting tongue depressor.  Abducens – (+) PERRLA and Cardinal gazes for both eyes.  Facial – Able to smile, frown, show teeth, raise eyebrows and close eyes tightly  Vestibulococchlear – Can hear whispered word “Hello” at a distance of 2 feet.  Glossopharyngeal – (+) Gag reflex  Vagus – (+) Gag reflex



Spinal Accessory – Able to turn head side to side.

INDEPENDENT INTERVENTIONS: 1.Continually assessed patient’s perception of cause of sleep difficulty and possible relief measures R: To facilitate treatment and to improve sleep with the identification of relief measures 2.Determined usual sleep habits and changes that are occurring R: Assess need for and identifies appropriate interventions 3.Organized plan of care R:To promote minimal

interruption

in

DESRIED OUTCOME: Within 8 hours of nursing intervention, client will be able to achieve optimal amount of sleep as evidenced by a rested appearance and verbalization of feeling rested and to recognize the importance of bedtime routines and practices as evidenced by using these measures in order to promote sleep ACTUAL OUTCOME: After a day of nursing intervention, client appeared rested and with the verbalization of “maka tarong-tarong



Hypoglossal – Able to stick the tongue out and move it side to side and up and down.

Range of Motion: • Elbows: full

• •

Wrist: full Shoulders and arms: left arm slightly limited due to the presence of an IV line No bony deformities, crepitus and fasciculations noted.

Muscle Strength: R

L

4/5

4/5

4/5

4/5

SCALE FOR GRADING MUSCLE STRENGTH 5 – Full ROM against gravity, full resistance 4 – Full ROM against gravity, some resistance 3 – Full ROM with gravity 2 – Full ROM with gravity eliminated (passive motion) 1 – Slight Reaction 0 – No Reaction LABORATORY FINDINGS See Appendix A

sleep/rest 4.Promoted relaxation by providing a darkened, quiet environment, ensuring adequate room ventilation, following bedtime routines, and avoid banging doors R: Hospital environment can interfere with relaxation and sleep. Using established bedtime rituals increases relaxation 7.Instructed client measures to promote sleep such as DBE R: Sleep is difficult unless client is relaxed 8.Assisted in elevating head in a reclining bed R: To reduce shortness of breath and increased rest 9. Asked to verbalize needs before going to sleep R: Promotes bedtime routines and attends to client’s need 11.Instructed in relaxation measures like reading magazines R: Helps induce sleep 12. Encouraged comfortable position and assisted in turning R: Repositioning alters areas of pressures and promotes rest INDEPENDENT INTERVENTIONS: 1. Acknowledged awareness of patient’s anxiety. R: communicated acceptance of the feeling. 2. Conversed with patient R: to promote relaxation and encourage expression of feelings.

KEY ISSUES

nkog tulog day ky wala naman kaau manulod nga mukuha ug tests.”

DESIRED OUTCOME: Within 3 hours of nursing intervention, patient will appear relaxed and verbalize reduction of anxiety to manageable level. ACTUAL OUTCOME: After 3 hours of nursing intervention, patient still showed anxiousness by verbalization of “Mahadlok gihapon ko gamay day sa akong operasyon maong d au ko maka tog sa sigeg huna-huna”.

DAY 1 (Pre-operative Phase) (November 16, 2009)

3. Stayed by patient’s side. R: to assure patient of security and safety.

1. SLEEP DEPRIVATION related to discomfort and unfamiliar environment as manifested by daytime drowsiness, lack of energy and patient’s verbalization “Sige ko og mata-mata dong, kay sulod ang mga nurse sa room” and when asked about what she felt when she wakes up she answered “Lain man gihapon ako lawas.”

4. Encouraged deep-breathing exercises. R: to promote relaxation.

SCIENTIFIC BASIS: Hospitalization affects the quality of nocturnal and other sleep time especially for older adults. The hospital environment often lacks light and dark cues. Confinement curtails activity or exercise that normally causes fatigue. In addition, unfamiliar sights and sounds and frequent awakenings for the assessment for vital sing and other interventions can disturb sleep. SOURCE: Black, Joyce and Jane Hokanson Hawks. Medical-Surgical Nursing & 7th edition vol. 1, p. 439 Clients with sleeping problems have difficulty falling asleep or difficulty staying asleep. Various factors may be involved. This includes frequent changes in sleep time, changes in sleep environment or bedtime rituals. SOURCE: Fundamentals of Nursing, 7th edition by Barbara Kozier, page 1122)

5. Provided a quiet and peaceful environment. R: feelings of anxiety decrease in a calm atmosphere. 6. Conducted a preoperative teaching about his condition and the surgery she would undergo R: to reduce the level of anxiety, client has the right to receive necessary information regarding his diagnosis and treatment INDEPENDENT INTERVENTIONS: 1. Determined client’s ability to learn R: to assess readiness to learn individual learning needs

and

DESIRED OUTCOME: Within 30 minutes of nursing intervention, patient will verbalize understanding of procedures. ACTUAL OUTCOME: After 30 minutes of nursing intervention, patient verbalized “ah, mao diay na akong angay buhaton… salamat day”.

2. Provided pre-operative health teachings including hygiene, NPO after midnight, emptying bladder and bowel, changing into OR gown and taking off of jewelry. R: to orient patient to surgical procedures. 3. Maintained an atmosphere of openness. R: to encourage patient to express opinions about his situation and to voice out areas of doubt. 4. Provided positive reinforcement R: encourages continuation of efforts 5. Provided an environment conducive to learning R: To facilitate learning

that

INDEPENDENT INTERVENTIONS:

is

DESIRED OUTCOME: Within 3 days of nursing intervention, the client will be able to: • report improved sense of energy • perform ADLs and participate in desired activities at level of ability

1. Determined the ability to participate in activities. R: Fatigue can limit the person’s level of mobility. 2. Lessened environmental stimuli. R: Over stimulation increases fatigue. 2. MILD ANXIETY related to the perceived possible complications during and after the surgery as manifested by verbalization of “hadlok ko gamay sa operasyon kay mahadlok ko ma-ingato sauna” and presence of poor eye contact with the nurse and a worried face. SCIENTIFIC BASIS: Anxiety disorders are very common among primary care patients. However, similar to depression, anxiety is poorly recognized by the patient and requires a high degree of suspicion for diagnosis. Patients with anxiety may present with a complaint of excessive worrying but they are more likely to report various somatic complaints, such as palpitations, insomnia or exhaustion, or gastrointestinal disturbances. SOURCE: www.sh.lsuhsc.edu

3. Assess vital signs R: to evaluate cardiopulmonary response to activity

ACTUAL OUTCOME: After 3 days of nursing intervention, the client was able to: • report that her energy was restored but not fully • perform some ADLs with assistance such as walking and going to the bathroom without feeling tired

4. Obtain client’s description of fatigue R: to assist in evaluating impact on client’s life 5. Scheduled activities with frequent rest periods in between. R: To conserve energy. 6. Instruct in methods to conserve energy such as delegating task and sitting instead of standing in doing daily care/ other activities R: to conserve energy and to assist client to cope with fatigue 7. Assist with self-care needs and ambulation as indicated R: to client cope with fatigue 8. Promote overall health measures such as adequate nutrition and fluid intake R: to promote wellness

3. PARTIAL KNOWLEDGE DEFICIT related to the unfamiliarity of the operation to be done as manifested by client’s verbalization “unsa diay mahitabo ana day? Aron ma kahibaw pd ko.” SCIENTIFIC BASIS: The preoperative client may not be completely knowledgeable about surgical procedures.

9. Advised patient to get enough rest and sleep R: to restore energy level

INDEPENDENT INTERVENTIONS: 1. Reviewed client’s history, noting age, weight and height, physical limitations,

DESIRED OUTCOME: Within the duration of the operation, the client will experience no aspiration. ACTUAL OUTCOME: Within the duration of the operation, the client was not able to experience aspiration.

SOURCE: p.1309, Medical-Surgical Nursing by Black and Hawk)

preexisting conditions R: Affects choice of perioperative positioning and affects skin/tissue integrity during surgery. 2. Noted anticipated length of procedure and customary position R: to increase awareness of potential postoperative complications. 3. Assessed individual’s response to operative sedation/medication, noting level of sedation and/or adverse effects and report to surgeon as indicated. R: Each person has different responses to different kinds of anesthesia.

4. FATIGUE related to altered blood chemistry as manifested by lab results as of Nov.16,2009 (HGB = 11.5 and HCT = 34.6) and verbalation “gikan ko matulog kapoy ghapon akong lawas”. SCIENTIFIC BASIS: Fatigue may be the result of one or more environmental causes such as inadequate rest, improper diet, work and home stressors, or poor physical conditioning, or one symptom of a chronic medical condition or disease process in the body. SOURCE: www.healthatoz.com

DESIRED OUTCOME: Within the duration of the operation, the client will be free of injury related to perioperative disorientation. ACTUAL OUTCOME: Within the duration of the operation, the client remained unharmed and free from injury.

INDEPENDENT INTERVENTIONS: 1. Locked patient in place; support client’s body and limbs; use adequate numbers of personnel during transfers R: to prevent shear and friction injuries. 2.Determined specific position reflecting procedure guidelines R: to avoid having injury to the patient. 3.Maintained body alignment as much as possible using pillows/padding/safety straps R: to reduce potential for neurovascular complications associated with compression, overstretching or ischemia of nerve/s.

DESIRED OUTCOME: Within the duration of the operation, the client will not manifest any signs and symptoms of infection or excessive blood loss. ACTUAL OUTCOME: Within the duration of the operation, the client did not manifest any signs and symptoms of infection or excessive blood loss.

INDEPENDENT INTERVENTIONS: 1. Noted skin color, texture and turgor.

R: to asses extent of involvement and injury 2. Maintained sterility of the field. R: to prevent contamination 3. Made sure that the instruments that are soiled are not mixed with the sterile instruments. R: to prevent contamination and infection DAY 2 (Intra-operative (November 17, 2009)

Phase)

1. RISK FOR ASPIRATION related to administration of anesthesia Cues: Use of Anesthesia (Tetracaine) Adverse Effects of Tetracaine: Respiratory arrest SCIENTIFIC BASIS: One of the general adverse effects of local anesthetics, esters and specifically tetracaine is respiratory arrest. SOURCE: p.248, Pharmacology for Nurses by Michael Patrick Adams et. al.

2. RISK FOR PERIOPERATIVE POSITIONING INJURY related to position requirements and loss of consciousness secondary to administration of Tetracaine Cues: decreased level of consciousness caused by induction of Tetracaine SCIENTIFIC BASIS: As the patient breathes in the anesthesia mixture, warmth, dizziness, and a feeling of detachment may be experienced. SOURCE: Brunner and Suddarth’s Medical-

4. Ensured complete sponge count as done by the scrub nurse and participated by the student nurse. R: to ensure that no instruments are left inside the operative site. 5. Noted poor hygiene/health practices R: Hygiene may have a big impact on tissue health 6. Assessed blood supply and sensation (nerve damage) of affected area. Evaluate pulses/calculate ankle/brachial index R: to evaluate actual/potential for impairment of circulation of lower extremeties. 7. Determined and Noted degree/depth of injury/damage to integumentary system, extent of tunneling/undermining, if present. R: to note how deep and how the extent of impairment is 8. Maintained sterility in the area of operation. R: to prevent transmission of microorganisms to enter the incision site. INDEPENDENT INTERVENTIONS: 1. Stressed proper hand washing techniques by all caregiver between

DESIRED OUTCOME: Within the duration of the operation, the client will not manifest any signs and symptoms of infection or excessive blood loss. ACTUAL OUTCOME: Within the duration of the operation, the client did not manifest any signs and symptoms of infection or excessive blood loss.

Surgical Nursing. “General Anesthesia, Stage I: beginning anesthesia”. 11th ed, Vol1, p.509.

therapies and client. R: a first-line defense against nosocomial infections or cross contamination. 2. Observe for localized signs of infection at surgical incision and wound such as swelling, inflammation and unusual discharges R: to assess contributing factors.

3. IMPAIRED SKIN AND TISSUE INTEGRITY related to mechanical trauma secondary to total abdominal hysterectomy with bilateral salphingo-ooparectomy as manifested by to midline abdominal surgical incision SCIENTIFIC BASIS: A wound can be infected by microorganisms at the time of injury, during surgey and post operatively. SOURCE: Kozier Fundamentsls of Nursing

3. Instructed client and SO in techniques such as strict hand washing before touching R: to promote wellness and prevent cross contamination. 4. Instructed patient not to touch site frequently R: reduce risk of infection 5. Instructed to keep site clean and dry R: to reduce risk of infection and promote healing

DESIRED OUTCOME: Within 1 hour of nursing intervention, patient will be able to maintain a body temperature ranging from 36.5 °C to 37.5 °C. ACTUAL OUTCOME: After 1 hour of nursing intervention, patient’s temperature was 36 °C.

6. Discussed importance of not using other persons prescribed drugs and avoid self medication. R: inappropriate use can lead to development of drug-resistant strains.

INDEPENDENT INTERVENTIONS: 1.Monitored vital signs especially temperature R: to prevent occurrence of temperature deviations 2. Provided adequate covering. R: to promote warmth and prevent unnecessary heat loss. 3. Adjusted air-cooling device.

DESIRED OUTCOME: Within 3 days of nursing intervention, the client will be able to: • report pain is relieved, controlled or decreased • follow prescribed

R: to prevent unnecessary heat loss by convection. 4. Maintained surgical asepsis at all times. R: To prevent the spread of microorganisms and prevent infection 4. RISK FOR INFECTION related to possible intrusion of pathogens secondary to invasive procedure (total abdominal hysterectomy with bilateral salphingoooparectomy) Cues: presence of midline abdominal incision SCIENTIFIC BASIS: the nature, number and duration of physical and emotional stressors can influence susceptibility to infection. Stressors elevate the blood cortisone. Prolonged elevation of blood cortisone decreases anti-inflammatory responses, depletes energy stores, leads to a state of exhaustion, and decreases resistance to infection. For example, a person recovering from a major operation or injury is more likely to develop an infection than a healthy person. SOURCE: Kozier and Erb’s Fundamental’s of Nursing. “Factors increasing susceptibility to infection”, 8th ed, p. 675 SCIENTIFIC BASIS: A wound can be infected with microorganisms at the time of injury, during surgery or postoperatively. Surgery involving the intestines can also result in infection from the microorganisms inside the intestine. Surgical infection is most likely to become apparent 2 to 11 days postoperatively. SOURCE: Kozier and Erb’s Fundamental’s of Nursing. “Infection”, 8th ed, p. 912 5.

RISK

FOR

IMBALANCED

BODY

5. Assess for blood loss R: to much blood loss can decrease the temp 6. Monitor I&O R: to note unusualities in the drains

INDEPENDENT INTERVENTIONS: 1. Assessed onset, location, duration, characteristics, aggravating and relieving factors, severity (1-10 scale) & frequency of pain. R: to determine quality of pain

•

pharmacological regimen verbalize nonpharmacologic methods that provide relief

ACTUAL OUTCOME: After 3 days of nursing intervention, the client was able to: • report a decrease in pain from 5 to 2 with 10 as the highest and 1 as the lowest • follow prescribed pharmacological regimen • demonstrate deep breathing exercise as a nonpharmacological method to relieve pain

2. Observe nonverbal cues/ pain behaviors R: Observations may be the only indicator present when client is unable to verbalize 3. Monitor vital signs R: Vital signs is usually altered in acute pain though not always 4. Note when pain occurs R: To medicate prophylactically, as appropriate 5. Provide comfort measures R: To promote nonpaharmacological pain management 6. Instruct in/ encourage the use of relaxation techniques like DBE R: to distract attention and reduce tension

DESIRED OUTCOME: Within 3 days of nursing intervention, the client will be able to: • Maintain optimal nutrition/ physical well-being • Participate in methods to decrease the risk for infection • Be infection-free ACTUAL OUTCOME: After 3 days of nursing intervention,

TEMPERATURE related to body’s exposure to cold environment. Cues: Lack of clothing for the patient. Air-conditioned operating room.

7. Encourage verbalization about the pain R: To slightly relieve pain using a nonpharmacologic method to alleviate pain. 8. Encourage adequate rest periods R: to prevent fatigue

the client was: • Able to participate in methods to decrease the risk for infection such as hand washing • Noted to have no post op infection

COLLABORATIVE INTERVENTIONS: 1. Administered Nalbupine (C: opioid analgesic; I: moderate to severe pain; A: decrease pain) INDEPENDENT INTERVENTIONS: 1. Determine depth of damage of the integumentary system R: to assess the extent of the injury 2. Assess blood supply and sensation R: to evaluate actual/ potential for impairment of circulation to lower extremities DAY 3 (Postoperative Phase) 1. ACUTE PAIN related to surgical incision at the hypogastric region secondary to total abdominal hysterectomy with bilateral saplphingo-oophorectomy onset of continuous sharp gnawing pain at incision site noted hours after surgery at hypogastric region aggravated by sudden movement relieved by analgesics and rest with a pain scale of 6 with 1 as the lowest and 10 as the highest as manifested by facial grimacing when moving and guarding behavior. SCIENTIFIC BASIS: Nociceptive pain is caused by an injury to the body tissues. The injury may be a cut, a bruise, bone fracture, crush injury, burn or anything that damages tissues. This type of pain is typically aching,

3. Performed hand washing before and after contact with the client R: to prevent contamination 4. Taught patient and SO proper way of hand washing R: hand washing is the most effective way to prevent infection 5. Note presence of compromised vision, hearing, or speech R: Skin is a particularly important avenue of communication for this population and, when compromised, may affect responses. 6. Note for signs of infection such as fever, chills, redness, swelling and purulent drainage R: these may indicate post op infection

DESIRED OUTCOME: Within 3 days of nursing intervention, the client will be able to: • Identify individual areas of

sharp, or throbbing. Most pain is nociceptive pain. Pain receptors for tissue injury (nociceptors) are located mostly in the skin or in the internal organs. The pain almost universally experienced after surgery is nociceptive pain. SOURCE: The Merck Manual, p.404

7. Keep area clean/ dry R: to aid in the body’s natural process of repair 8. Reposition every 2 hours R: to prevent ulcers 9. Encourage early ambulation R: promotes circulation and reduces risk associated with immobility 10. Encouraged patient to eat a well balanced and protein- rich diet once on full diet R: to provide a positive nitrogen balance to aid in tissue healing and to maintain general good health 11. Assist client to learned stressed reduction activity and techniques R: To control feelings of helplessness and deal with situation.

IMPAIRED SKIN INTEGRITY related to mechanical trauma secondary to total abdominal hysterectomy with bilateral salphingo-oophorectomy as manifested by presence of surgical incision on the hypogastric region. SCIENTIFIC BASIS: Skin, the flexible tissue enclosing the body of vertebrate animals. In humans and other mammals, the skin operates a complex organ of numerous structures serving vital protective and metabolic functions. Surgical incision is a medical procedure involving an incision with instruments; performed to repair damage or arrest disease in a living body. Wound healing is a complex sequence of events initiated by injury to the tissues. The

•

weakness/ needs Perform self-care activities within level of own ability

ACTUAL OUTCOME: After 3 days of nursing intervention, the client was able to: • Identify her weakness/ needs such as her difficulty in getting out from the bed • Perform some self-care activities such as toileting without assistance

INDEPENDENT INTERVENTION: 1. Evaluate current limitations of client in doing usual activities R: To obtain baseline data 2. Performed physical examination R: To assess client’s motor functions 3. Perform/ assist with meeting client’s needs when he or she is unable to meet own needs R : to assist in correcting or dealing with situation 4. Practice and promote short-term goal setting and acheivement R : accepting ability to do one thing at a time ; boost self-esteem

DESIRED OUTCOME: Within 3 days of nursing intervention,

components are coagulation of bleeding, inflammation, epithelization, fibroplasias and collagen metabolism, collagen maturation, scar remodeling and wound contraction SOURCE: http://www.answers.com/topic/skin

5. Provide privacy and equipment within easy reach during personal care activities R : to assist in correcting/ dealing with the situation 6. Allow sufficient time for client to accomplish tasks to the fullest extent of ability R : to assist in correcting/ dealing with the situation 7. Advised patient to set time to rest, especially after ADLs. R: Increase patient’s strength and tolerance for activity; to provide comfort and relaxation. 8. Encouraged patient participation in random activities (ambulating, daily exercises). R: Promotes independence, enhances selfesteem Independent interventions 9. Encouraged client to increased exercise levels gradually R: To help client increased level of activity of client 10. Encouraged client to participate in recreational activities & hobbies appropriate for the situation R: To enhance sense of well-being

INDEPENDENT INTERVENTIONS: 1. Observe for localized signs of infection at insertion sites of invasive lines, sutures, surgical incisions/ wounds R: to assess causative/ contributing factors PARTIAL SELF CARE DEFICIT: BATHING, DRESSING, & TOILETING; related to postoperative pain at the hypogastric region

2. Stress proper hand hygiene by all caregivers and SOs R: a first line of defense against infections

the client will be able to: • Identify interventions to prevent/ reduce risk of infection • Understand the importance of keeping the incision site clean/ dry ACTUAL OUTCOME: After 3 days of nursing intervention, the client was able to: • Identify interventions to prevent/ reduce risk of infection like proper hand washing • Understand the importance of keeping the incision site clean/ dry by nodding

as manifested by difficulty in performing ADLs as manifested sister’s assistance in performing ADLs. SCIENTIFIC BASIS: Self care is personal health maintenance. It is any activity of an individual with the intention of improving or restoring health, or treating or preventing disease. Self care includes all health decisions people (as individuals or consumers) make for themselves and their families to get and stay physically and mentally fit. Self care is exercising to maintain physical fitness and good mental health. Self care is also taking care of minor ailments, long term conditions, or one’s own health after discharge from secondary and tertiary health care. . To enable people to do enhanced self care, they can be supported in various ways and by different health service providers. SOURCE: http://en.wikipedia.org/wiki/Selfcare

3. Change surgical/ other wound dressings, as indicated, using proper technique for changing/ disposing of contaminated materials R: to reduce/ correct existing factors 4. Cover perineal/ pelvic region dressings/ casts with plastic when using bedpan R: to prevent contamination 5. Encourage early ambulation, teach deep breathing, coughing, position changes R: for mobilization of respiratory secretions and prevention of aspiration/ respiratory infections 6. Maintain adequate hydration, stand/ sit to void, and catheterize, if necessary R: to avoid bladder distention/ urinary stasis 7. Administer/ monitor medication regimen and note client’s response R: to determine effectiveness of therapy/ presence of side effects 8. Emphasize necessity of taking antibiotics as directed (dosage and length of therapy) R: premature discontinuation of therapy when client begins to feel well may result in return of infection and potentiate drug resistant strains 9. Include information about ways to reduce potential for postoperative infection (wound/ dressing care, avoidance of others with infection) R: to promote wellness

DESIRED OUTCOME: Within 3 days of nursing intervention, the client will be able to regain and maintain usual pattern of elimination. ACTUAL OUTCOME: After 3 days of nursing intervention, the client still wasn’t able to pass stool.

RISK FOR INFECTION related to inadequate primary defenses and tissue destruction secondary to total abdominal hysterectomy with bilateral salphingooophorectomy Cues: surgical incision on hypogastric region SCIENTIFIC BASIS: The location and extent of the surgical site and incision put the patient at risk for contamination of the site and infection and sepsis. The patient is monitored closely for local and systemic signs and symptoms of infection: purulent drainage, redness, increased pain, fever, and an increased white blood count. SOURCE: Medical Surgical Nursing, Brunner, p. 1434 SCIENTIFIC BASIS: A wound can be infected with microorganisms at the time of injury, during surgery or postoperatively. Surgical infection is most likely to become apparent 2 to 11 days postoperatively. SOURCE: Kozier and Erb’s Fundamental’s of Nursing. “Infection”, 8th ed, p. 912

INDEPENDENT INTERVENTIONS: 1. Review medical/ surgical history R: to identify conditions commonly associated with constipation 2. Discuss usual elimination pattern and use of laxatives R: to obtain baseline data & identify individual risk factors or needs 3. Ask the patient if he has "passed gas" within 24 hours of return to the ward from the recovery room. R: this indicates the return of peristalsis 4. Ambulate patient as early as possible R: ambulation assists in peristalsis 5. Discuss acceptable variations in elimination R: may help reduce anxiety about situation 6. Promote adequate fluid intake, including water and high- fiber fruit juices or foods rich in fiber such as cereals, beans, peas and cabbage, grain products like whole grain breads R: promotes soft stool and stimulates bowel activity 7. Encouraged client to increase activity/exercise within limits of capability. R: Stimulates contractions of the intestines.

RISK FOR CONSTIPATION related to immobility secondary to s/p total abdominal hysterectomy with bilateral salphingooophorectomy Cues: Always staying on her bed SCIENTIFIC BASIS: Anesthesia slows or stops the peristaltic action of the intestine, which results in constipation. Nausea and vomiting may cause fluid imbalance. Abdominal distention/flatus may also be present. SOURCE: http://www.tpub.com/content/armymedical/ md0915/md09150067.htm APPENDIX A LABORATORY & DIAGNOSTIC FINDINGS COMPLETE BLOOD COUNT Performed on: August 25, 2009 Purpose: A complete blood count serves a clinical purpose, through which it serves by diagnosing certain diseases and evaluates the stage of a particular disease. The cells that generally circulate the body are divided into three and are counted, and thus gives a general health status about the client. Component Patient’s Values Normal Values 11 – 16 – 2009 11 – 14 – 2009 11 – 12 – 2009 White Blood Cells 7.98 7.99 7.07 4.10 – 10.9 k/uL Neutrophils 5.56 5.75 5.18 2.50 – 7.50 Lymphocytes 1.31 1.54 1.44 1.00 – 4.00

Monocytes Eosinophils Basophils

0.769 0.262 0.081

0.496 0.178 0.034

0.337 0.081 0.030

0.10 – 1.20 0.0 – 0.5 0.0 – 0.1

Red Blood Cells Hemoglobin Hematocrit Mean Corpuscular Volume Mean Corpuscular Hematocrit Mean Corpuscular Hemoglobin Concentration Red Blood Cell Distribution Width

4.77 11.5 34.9 73.2 24.1 32.9 29.1

4.21 9.14 28.8 68.5 21.7 31.8 38.1

3.15 5.27 17.8 56.4 16.7 29.7 23.4

4 – 5.20 m/uL 12 – 16 g/dL 36 – 46% 80 – 100 fL 26 – 34 pg 31 – 36 g/dL 11.6 – 18%

Platelets Mean Platelet Volume

289 8.33

327 8.25

455 7.78

140 – 440 k/uL 0 – 100 fL

Implications: The amount of hematocrit and hemoglobin are below the normal range which indicates anemia.

URINALYSIS Performed on: November 12, 2009 Purpose: Urinalysis are usually used to as a general health screening test to detect renal and metabolic diseases diagnosis of diseases or disorders of the kidneys or urinary tract monitoring of patients with diabetes In addition, quantitative urinalysis tests may be performed to help diagnose many specific disorders, such as endocrine diseases, bladder cancer, osteoporosis, and porphyrias (a group of disorders caused by chemical imbalance). Macroscopic Microscopic Color: Yellow RBC/hpf: 1 – 2 Appearance: Cloudy WBC/hpf: 1 – 3 pH: 7.0 Epithelial Cells: 5 – 8/hpf Specific Gravity: 1.018 Phosphates: Abundant Protein: Negative Bacteria: Abundant Glucose: Negative Ketones: Negative Reducing Substances: Negative Blood: Moderate Heat and Acetic Acid Test: Negative

Implications: There were no significant findings noted. BLOOD CHEMISTRY Performed on: November 12, 2009 Purpose: In the body, the important ions of electrolytes are sodium, potassium, calcium, magnesium, chloride, hydrogen phosphate, and hydrogen carbonate. Humans must regulate these electrolytes in order to optimally function. Such gradients affect and regulate the hydration of the body, blood pH, and are critical for nerve and muscle function. Liver Function Tests – ALT/SGPT Creatinine Patient’s value: 10 u/L Patient’s value: 0.8 mg/dL Normal value: 0 – 39 Normal value: 0.6 – 1.5 mg/dL Potassium Sodium Patient’s value: 3.2 mmol/L Patient’s value: 139 mmol/L Normal value: 4.0 – 5.6 mmol/L Normal value: 136 - 142 mmol/L Implications: Low blood potassium levels can be caused by high levels of aldosterone (hyperaldosteronism) made by the adrenal glands.

CLOTTING & BLEEDING TIME Performed on: November 12, 2009 Purpose: Clotting Time- are used to determine the integrity of the coagulation pathways, and platelet function. In general, the common tests for the intrinsic or common pathways are the activated partial thromboplastin time (APTT) and activated coagulation time (ACT). One-stage prothrombin time (OSPT) is usually used to evaluate the extrinsic or common pathways, and platelet count, clot retraction, bleeding time and activated coagulation time reflect platelet numbers and function. Bleeding Time- This test measures the time taken for blood vessel constriction and platelet plug formation to occur. No clot is allowed to form, so that the arrest of bleeding depends exclusively on blood vessel constriction and platelet action. Clotting Time Bleeding Time Patient’s value: 3 minutes and 28 seconds Patient’s value: 1 minute and 50 seconds Normal value: 2 – 6 minutes Normal value: 1 -3 minutes Implications: No significant findings found. PLATELET & PROTHROMBIN TIME Performed on: November 12, 2009

Purpose: These tests will detect most coagulation protein problems. A relation between thrombocytopenia and time on bypass also was reported. The clinical picture, bleeding time, prolonged partial thromboplastin time test, and plasma prothrombin time test lead to the diagnosis. Platelet and Prothrombin Time Patient’s value: 11.3 Control value: 12.3 Implications: No significant findings found. PREGNANCY TEST Performed on: November 12, 2009 Purpose: to determine whether or not a woman is pregnant. Pregnancy Test β - HCG Patient’s value: Positive Implications: Increase HCG which is released by the trophoblastic cells of the fertilized ovum is a reliable marker of pregnancy. CHEST PA Performed on: November 12, 2009 Purpose: Chest X-rays can also reveal fluid in your lungs or in the spaces surrounding your lungs, enlargement of your heart, pneumonia, emphysema, cancer and many other conditions. Some people have a series of chest X-rays done over time, to track whether a particular health problem is getting better or worse. Findings: Examination reveals there is irregular calcific density noted in the right lowe lung. The cardiac silhouette is not enlarged, no bony abnormalities. Conclusion: Benign calcification of the right lower lung

TUMOR MARKER TEST Performed on: November 13, 2009 Purpose: The majority of tumor markers are used to monitor patients for recurrence of tumors following treatment. In addition, some markers are associated with a more aggressive course and higher relapse rate and have value in staging and prognosis of the cancer. Most tumor markers are not useful for screening because levels found in early malignancy overlap the range of levels found in healthy persons. The levels of most tumor markers are elevated in conditions other than malignancy, and are therefore not useful in establishing a diagnosis. β – HCG II Tumor Marker Patient’s value: 49.41 mIU/ml Control value: PreMP < 1, PostMP < 7 Implication: HCG is a glycoprotein consisting of subunits a e b, which are nonconvalently linked. The hormone is normally produced by the syncytiotrophoblastic cells of the placenta and is elevated in pregnancy. It’s most important uses as a tumor marker are in gestational trophoblastic disease and germ cell tumors. ULTRASOUND Performed on: November 12, 2009 Purpose: Ultrasound is performed routinely during pregnancy. Early in the pregnancy (at about seven weeks), it might be used to determine the size of the uterus or the fetus, to detect multiple or ectopic pregnancy, to confirm that the fetus is alive (or viable), or to confirm the due date.

Uterus: 16.1 x 11.6 x 7.4 cm anteverted Cervix: 4.2 x 3.8 x 3.1 cm without Nabothian cyst Endometrium: 2.3 cm Right ovary: not visualized Left ovary: 4.1 x 2.8 x 2.8 cm lateral Others: no free fluid from the cul – de – sac Remarks: • The uterus is anteverted with regular contour and inhomogenous myometrium. • Well circumiscribed heterogenous structure noted within posterior myometrium measuring 7.0 x 7.2 x 5.5 cm suggestive of an intramural myoma with submucous component. • Cervix is closed and homogenous. • Endometrium is thickened and heterogenous suggestive of blood clots. Impression: • Enlarged anterverted uterus with thickened endometrium • Uterine myoma Implications: Results of the ultrasound suggest that the patient has a myoma described to be intramular and at the same time with submucous components. By intramural, it means that the myoma is located within the uterine wall, while having submucous components suggests that it lies just beneath the endometrium, the inner most layer of the uterus.

ELECTROCARDIOGRAM Performed on: November 12, 2009 Purpose: Electrical impulses in the heart originate in the SA node and travel through the intrinsic conducting system to the heart muscle. The impulses stimulate the myocardial muscle fibers to contract and thus induce systole. The electrical waves can be measured at selectively placed electrodes (electrical contacts) on the skin. Electrodes on different sides of the heart measure the activity of different parts of the heart muscle. An ECG displays the voltage between pairs of these electrodes, and the muscle activity that they measure, from different directions, also understood as vectors. This display indicates the overall rhythm of the heart and weaknesses in different parts of the heart muscle. It is the best way to measure and diagnose abnormal rhythms of the heart, particularly abnormal rhythms caused by damage to the conductive tissue that carries electrical signals, or abnormal rhythms caused by levels of dissolved salts (electrolytes), such as potassium, that are too high or low. Rate: Atrial: 89 Ventricular: 89 Rhythm: Sinus Axis: +30o PR Interval: 0.16 seconds QRS: 0.08 seconds QT Interval: 0.32 seconds

P wave: upright ORS: normal R wave progression Transitional zone: V3 – V4 T Wave: upright ST segment: isoelectric Interpretation: Sinus rhythm, within normal limits Implications: There were no significant findings noted. LIPID PANEL Performed on: November 13, 2009 Purpose: The lipid panel checks the lipid levels in blood, which can indicate a person's risk for heart disease or atherosclerosis which is the hardening, narrowing, or blockage of the arteries. Component Glucose Implications: There were no significant findings noted.

APPENDIX B GENOGRAM

Patient’s Values 100

Flag

Normal Values 75 – 115 mg/dl

- Female - Male - Cardiovascular Disease, Hypertension and Diabetes Mellitus - Uterine Myoma and History of Hysterectomy - Hypertension - Patient

APPENDIX C ECOMAP

DRUG STUDY 1.) Benadryl (Diphenhydramine) Class: Antihistamine, Anti-motion sickness agent, Sedative/hypnotic, Anti-parkinsonian agent, Cough suppressant Action: Competitively blocks the effects of histamine at H1-receptor sites have atropine-like, antipruritic, and sedative effects. Indications: Relief of symptoms associated with perennial and seasonal allergic rhinitis; vasomotor rhinitis; allergic conjunctivitis; mild, uncomplicated urticaria and angioedema; amelioration of allergic reactions to blood or plasma; dermatographism; adjunctive therapy in anaphylactic reactions. Active and prophylactic treatment of motion sickness; Nighttime sleep aid Contraindications: Hypersensitivity to any anti-histamine; Third trimester of pregnancy; lactation. Side Effects: Drowsiness, sedation, dizziness, disturbed coordination, fatigue, confusion, restlessness, excitation, nervousness, tremor, headache, blurred vision, diplopia, Hypotension, palpitations, bradycardia, tachycardia, extrasystoles, Epigastric distress, anorexia, increased appetite and weight gain, nausea, vomiting, diarrhea or constipation, Urinary frequency, dysuria, urinary retention, early menses, decreased libido, impotence, Hemolytic anemia, hypoplastic anemia, thrombocytopenia, leukopenia, agranulocytosis, pancytopenia, Thickening of bronchial secretions, chest tightness, wheezing, nasal stuffiness, dry mouth, dry nose, dry throat, sore throat, Urticaria, rash, anaphylactic shock, photosensitivity, excessive perspiration Nursing Considerations: • Advise patient to take drug with food to decrease GI upset • Advise patient to take drug as prescribed by the doctor • Inform patient about the drug she is receiving and its side effects • Monitor client’s response • Advise patient to avoid alcohol because serious sedation could occur

• Instruct patient to report to health care provider if difficulty breathing, hallucinations, tremors, loss of coordination, unusual bleeding or bruising, visual disturbances, irregular heartbeat occurs 2.) Atropine Sulfate Classes: Anti-cholinergic, Anti-muscarinic, Parasympatholytic, Anti-parkinsonism drug, Antidote, Diagnostic agent (ophthalmic preparations), Belladonna alkaloid Actions: Competitively blocks the effects of acetylcholine at muscarinic cholinergic receptors that mediate the effects of parasympathetic postganglionic impulses, depressing salivary and bronchial secretions, dilating the bronchi, inhibiting vagal influences on the heart, relaxing the GI and GU tracts, inhibiting gastric acid secretion (high doses), relaxing the pupil of the eye (mydriatic effect), and preventing accommodation for near vision (cycloplegic effect); also blocks the effects of acetylcholine in the CNS. Indications • Antisialagogue for pre-anesthetic medication to prevent or reduce respiratory tract secretions • Restoration of cardiac rate and arterial pressure during anesthesia when vagal stimulation produced by intra-abdominal traction causes a decrease in pulse rate, lessening the degree of AV block when increased vagal tone is a factor (eg, some cases due to digitalis) • Relief of bradycardia and syncope due to hyperactive carotid sinus reflex • Relief of pylorospasm, hypertonicity of the small intestine, and hypermotility of the colon • Relaxation of the spasm of biliary and ureteral colic and bronchospasm • Relaxation of uterine hypertonicity • Management of peptic ulcer Contraindications: Hypersensitivity to anticholinergic drugs. Contraindicated with glaucoma, adhesions between iris and lens, stenosing peptic ulcer, pyloroduodenal obstruction, paralytic ileus, intestinal atony, severe ulcerative colitis, toxic megacolon, symptomatic prostatic hypertrophy, bladder neck obstruction, bronchial asthma, COPD, cardiac arrhythmias, tachycardia, myocardial ischemia, impaired metabolic, liver, or kidney function, myasthenia gravis. Use cautiously hypertension, hyperthyroidism and lactation. Side Effects: Blurred vision, mydriasis, cycloplegia, photophobia, increased intraocular pressure, headache, flushing, nervousness, weakness, dizziness, insomnia, mental confusion or excitement (after even small doses in the elderly), nasal congestion, Palpitations, bradycardia (low doses), tachycardia (higher doses), Dry mouth, altered taste perception, nausea, vomiting, dysphagia, heartburn, constipation, bloated feeling, paralytic ileus, gastroesophageal reflux, Urinary hesitancy and retention; impotence, Decreased sweating and predisposition to heat prostration, suppression of lactation Nursing considerations: • Encourage oral fluids • Provide therapeutic environment and room temperature control to prevent hyperpyrexia • Encourage patient to take drug as prescribed. • Inform patient about the drug and the side effects that may occur • Advise patient to report to health care provider if rash; flushing; eye pain; difficulty breathing; tremors, loss of coordination; irregular heartbeat, palpitations; headache; abdominal distention; hallucinations; severe or persistent dry mouth; difficulty swallowing; difficulty in urination; constipation; sensitivity to light occurs 3.) Ranitidine Hydrochloride (Zantac) Class: H2- antagonist Actions: Competitively inhibits the action of histamine at the histamine2 (H2) receptors of the parietal cells of the stomach, inhibiting basal gastric acid secretion and gastric acid secretion that is stimulated by food, insulin, histamine, cholinergic agonists, gastrin, and pentagastrin. Indications: • Short-term treatment of active duodenal ulcer • Maintenance therapy for duodenal ulcer at reduced dosage • Short-term treatment of active, benign gastric ulcer

• Short-term treatment of gastroesophageal reflux disease • Treatment of heartburn, acid indigestion, sour stomach Contraindications: Hypersensitivity to Zantac. Use cautiously to patients with impaired renal or hepatic functions. Lactation Side Effects: Headache, malaise, dizziness, somnolence, insomnia, vertigo, Tachycardia, bradycardia, Rash, alopecia, Constipation, diarrhea, nausea, vomiting, abdominal pain, hepatitis, increased ALT levels, Gynecomastia, impotence or decreased libido, Leukopenia, granulocytopenia, thrombocytopenia, pancytopenia, Pain at IM site, local burning or itching at IV site, Arthralgias Nursing Considerations: • Advise patient to take drug with meals to prevent GI upset • Explain to the patient about the drug she is receiving and its side effects • Encourage patient to take drug as prescribed by the doctor. • Advise patient to report if sore throat, fever, unusual bruising or bleeding, tarry stools, confusion, hallucinations, dizziness, severe headache, muscle or joint pain occurs. 4.) Metronidazole Class: Antibiotic, Antibacterial, Amebicide, Antiprotozoal Action: Bactericidal: inhibits DNA synthesis in specific (obligate) anaerobes, causing cell death; antiprotozoal-trichomonacidal, amebicidal: biochemical mechanism of action is not known. Indications: • Acute infection with susceptible anaerobic bacteria • Preoperative, intraoperative, postoperative prophylaxis for patients undergoing colorectal surgery • Topical application in the treatment of inflammatory papules, pustules, and erythema of rosacea • Unlabeled uses: prophylaxis for patients undergoing gynecologic, abdominal surgery; hepatic encephalopathy Contraindications: Hypersensitivity to metronidazole; pregnancy. Use cautiously with CNS diseases, hepatic disease, candidiasis (moniliasis), blood dyscrasias, lactation. Side Effects: Headache, dizziness, ataxia, vertigo, incoordination, insomnia, seizures, peripheral neuropathy, fatigue, Unpleasant metallic taste, anorexia, nausea, vomiting, diarrhea, GI upset, cramps, dysuria, incontinence, darkening of the urine, thrombophlebitis (IV); redness, burning, dryness, and skin irritation (topical), severe, disulfiram-like interaction with alcohol, Nursing considerations: • Advise patient to take drug with food to avoid GI upset • Inform the patient about the drug she is receiving and its side effects. • Advise patient not to drink alcohol (beverages or preparations containing alcohol, cough syrups); severe reactions may occur. • Explain to the patient that their urine may appear dark; this is expected. • Advise patient to report severe GI upset, dizziness, unusual fatigue or weakness, fever, chills 5.) Nalbuphine HCl Class: Narcotic Agonist- antagonist analgesia Action: Acts as agonist at specific opioid receptors in the CNS to produce analgesia, sedation but also acts to cause hallucinations and is an antagonist at mu receptors Indication: Relief of moderate to severe pain. Preoperative analgesia, as a supplement to surgical anesthesia. Contraindication: Hypersensitivity to Nalbuphine, Sulfites; lactation Side Effects: Sedation, Clamminess, Sweating, Headache, Nervousness, Restlessness, Depression, Confusion, Faintness, Hostility, Unusual Dreams, Hallucinations, Euphoria, Nausea, Vomiting, Cramps, Dry mouth, Respiratory depression, Dyspnea, Hypertension, Hypotension, Bradycardia, Tachycardia Nursing Considerations:

• • • • • •

Monitor patient's vital signs Advise patient to follow doctor's prescription Give oral drug with food to decrease GI upset and enhance absorption Inform patient on the side effects that may occur Discontinue if hypersensitivity occurs Provide narcotic antagonist or facilities for controlled respiration in case of respiratory depression

6.) Kalium Durule Class: Electrolyte (potassium supplement) Action: • Maintains acid- base balance, isotonicity, and electrophysiologic balance of the cell • Activator in many enzymatic reactions; essential to transmission of nerve impulses; contraction of cardiac, skeletal, and smooth muscle; gastric secretion; renal function; tissue synthesis and carbohydrate metabolism Indication: PO,IV: Treatment or prevention of potassium depletion IV: treatment of certain arrhythmias due to cardiac glycoside toxicity Contraindication: Hyperkalemia, severe tissue trauma, severe renal impairment Side Effects: restlessness, confusion, weakness, arrhythmias,nausea, vomiting, diarrhea, abdominal pain, GI ulceration Nursing Considerations: • Asses patient for signs and symptoms of hypokalemia such as weakness, fatigue, arrhythmias, polyuria, polydypsia • Monitor pulse, blood pressure and ECG periodically throughout intravenous therapy • Treatment includes discontinuation of potassium, administration of sodium bicarbonate to correct acidosis, dextrose, and insulin to facilitate passage of potassium into cells, calcium salts to reduce ECG effects • Infuse slowly, at a rate up to 20 mEq/hr • Explain to patient the purpose of the medication and the need to take as directed, especially when concurrent cardiac glycosides or diuretics taken • Advise patient regarding sources of dietary potassium 7.) Traxenamic Acid Class: Hemostatic agent (plasminogen inactivator), Anti fibrinolytic agent Action: Inhibits activation of plasminogen, thereby preventing the conversion of plasminogen to plasmin Indication: Prevention of hemorrhage following surgery in hemophiliacs Contraindication: Hypersensitivity to drug, active intravascular clotting Side Effects: dizziness, visual abnormalities, hypotension, thrombosis, thromboembolism, nausea, vomiting Nursing Considerations: • Observe site of surgery for excessive bleeding • Patients taking tranexamic acid for more than several days should have ophthalmological examinations to detect visual abnormalities prior to and at regular intervals during and after therapy • Check signs for thromboembolism such as tenderness, reddish and warm spots • Check V/S regularly to monitor any unusualities • Instruct patient to complete drug therapy as indicated

8.) Bupivacaine Hydrochloride (Sensorcaine) 5-10 cc q 4H (epidural analgesia) Classification: local anesthesia

Action: inhibits initiation and conduction of sensory nerve impulses by altering the influx of sodium ions and efflux of potassium ions in neurons Indication: may be combined with epidural opioids or clonidine in the management of severe acute or chronic pain Contraindications: children under 12 years of age, for spinal or topical anesthesia or paracervical block, and in patients with known history of hypersensitivity reactions to local anesthetics of the amide type Adverse Reactions: headache, seizures, irritability, arrhythmias, cardiovascular collapse, bradycardia Nursing Interventions: Assess for sensory and motor deficit - Monitor BP regularly - Check solutions for particles - Discard partially used vials - Should not be used for IV regional anesthesia - Use solutions with epinephrine cautiously in patients with CV disorders and in body areas with limited blood supply - Protect solutions containing epinephrine from light - Use cautiously in debilitated, elderly and in patients with severe hepatic diseased or drug allergies 9.) Cefazolin Classification: First generation cephalosporin Action: Binds to bacterial cell wall membrane causing cell death Indication: • Maybe used as perioperative prophylactic anit-infective • Treatment of : Skin and skin structure infections, pneumonia, urinary tract infections, bone and joint infection and septicemia Contraindications: • Hypersensitivity to cephalosporins • Severe hypersensitivity to penicillins Adverse Reactions: seizures, nausea and vomiting, nephrotoxicity, rashes, phlebitis at IV site, pain at IM site, superinfections Nursing Considerations: • Asses patients for infection (Vital signs; incision or wound, urine,sputum,stool;WBC) at beginning and throughout course of therapy • Obtain culture and sensitivity • Assess for hypersensitivity through skin test • Assess for superinfection (Fever, Diarrhea, Foul discharges, Oral thrush, Black Furry tongue) 10.) Tetracaine Class: Local Anesthetic, CNS agent Action: Interfere with transmission of nerve impulses by interacting with membranous sheath that covers nerve fibers by physical and biochemical mechanisms, stop propagation of nerve impulses, eventually blocking conduction Indication: Topical anesthesia on accessible mucous membranes such as oropharynx, used primarily for spina;l anesthesia Contraindication: Hypersensitivity to tetracaine or any component of formulation; ophthalmic secondary to bacterial infection; liver disease, CNS disease, meningitis if used for epidural or spinal anesthesia, myasthenia gravis Adverse Reactions: cardiac arrest, hypotension, chills, convulsions, dizziness, drowsiness, nervousness, unconsciousness, nausea, vomiting, tremors, respiratory arrest Nursing Consideration: • Monitor vital signs especially BP because it may causes hypotension • Monitor skin condition

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Clean administration site well before administering Don’t use if rash occurs Explain procedure prior to administration

DISCHARGE PLAN Health Teachings: - advised to have adequate rest and sleep - instructed to do deep breathing exercise when she feels pain and anxious. - encouraged patient to ambulate - instructed not to do strenuous activities - encouraged eating the proper diet as advised by the doctor. - advised to keep incision site clean and dry - advised to have diversional activities - instructed to take the medications at the right route, route dose and right time. - encouraged verbalizing when in pain Anticipatory guidance:

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encouraged taking note of any signs of infection at the incision site advised to have wound dressing every day and as necessary instructed to have a regular check up with the physician advised to take medications as prescribed instructed not to stop medication if not prescribe by the doctor instructed to check on incision site once in a while

Spirituality, security and safety: - encouraged praying every day - encouraged hearing mass every Sunday - advised to continue with the prayer group - advised to keep all sharp object away from the incision site - advised to have confession at least once in every 3 months - instructed to put pillows at the side of the bed when lying Medications: - advised to take medications at the right route, dose and time - advised to take medications as prescribed - instructed not to stop medication if not prescribed by the doctor Incision care: - advised to do hand washing before and after wound care - instructed to take note of any signs of infection such as warmth, redness and swelling - encouraged to have wound dressing every day or as needed.

Nutrition: - encouraged oral fluids - advised to follow the proper diet recommended - instructed to avoid eating foods high in fats and cholesterol Environment: - instructed to provide a clean environment - advised to have things accessible for the client - instructed to have a clean and quiet home conducive for resting - advised to listen to light music for relaxation - advised to have a safe home and free from any health hazards

SUMMARY OF SIGNIFICANT FINDINGS GORDON’S FUNCTIONAL HEALTH PATTERNS • Previous hospitalization was on 1973 in Cebu City Medical Center (CCMC) for the excision of cyst on her right breast. • “ang kawal-on ug sakit”. She is currently concerned with her condition is excited but anxious about the surgery that she states “Nahadlok man ko dong, pero normal raman siguro na dong, pero ganahan nako ma-operahan para maayo nako”. • “Nalipay kaau ko na nahuman na ang operation ug na tangtang ang mayoma”. • After her breast excision surgery, she has no correct knowledge in performing breast self-examination and only palpates her breast once in a while. • Patient doesn’t weigh herself so weight 3 months ago is unknown. But, she states that there was no significant change in her weight. She currently weighs 115 lbs. or 52.27 kg and is 5 feet 2 inches tall. Her ideal body weight is 51.74 kg., and her BMI is 21.21 and is categorized of having a normal weight. • She was ordered not to take any food and any liquid (NPO) 11 hours before surgery. And after the surgery and passing flatus, the patient only took crackers and water as the doctor ordered general liquid diet and crackers with no carbonated drinks. • There was no change in her bowel movement during hospitalization. • She didn’t feel any pain in doing her everyday activities back then. Patient was observed to grimace, and presented guarding behavior through splinting of the wound. The patient was not able to perform her daily activities such as housekeeping or laundry since admission.

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During hospitalization, patient claims that “Sige ko mata mata dong kay sige ug sulod ang mga nurse sa room”. She verbalized that before hospitalization, she feels refreshed after sleeping but now she feels that she didn’t regain her energy as she verbalized “La-ay man gihapon akong lawas”. After surgery, the patient always stays in bed and wakes up when she needs to eat and when the nurse enters the room to get the vital signs. The patient views herself as a kind and loving person. She also thinks positively. Her sister describes her as a caring person and very responsible. She states that she is very happy with her life today. After the surgery, the patient was asked about the essence of her womanhood and replied “Okay raman dong, tiguwang naman pud ko.” “Gi-tumor man sad sa matres akong duha ka mga iya-an.” When asked whether the operation will affect her womanhood, she replied “ ok ra man dong, tigulang naman sad ko, wala nakoy plano manganak”. When asked about her stressors and problems, patient states that “ pasalamat ko sa ginoo dong kay kani ra jud ako sakit ang pinaka dako na problema karon, maau ra man ang akong pamilya bisan kulang usahay ang kita sa ako bana”.

PHYSICAL EXAMINATION PRE-OPERATIVE • presence of IV line on left arm • uterus palpated with the enlargement noted to be dominantly at the right side. • scar is present at the bottom part of the right areola. INTRA-OPERATIVE • Presence of IV line noted at the left arm. • Uterus palpated with the enlargement noted to be dominantly at the right side. POST-OPERATIVE • Presence of IV line on left arm. • A presence of a binder covering a bandage estimated to be 12 inches long, in turn this bandage covers a horizontal incision estimated to be 7 inches long located below the umbilicus. • Romberg’s test and tandem walk not done as it might endanger the patient.