A Case Study on Submucous Myoma
AUB prob 2 ® to Submucous Myoma I. Data from Textbook Cause Submucous myoma has no known cause, it is idiopathic. Although there have been many theories developed. Some say it could be caused by increased Estrogen hormones.
Some say that it is hereditary and has a tendency to run in the family. Signs and Symptoms Submucous myoma is generally symptomless. But some of its most common features were experienced by client ILN and they are: * Swollen breasts * Loss of sex drive * Profuse bleeding or heavy menstrual bleeding Hypermenorrhea * Dysmenorrhea * Metrorrhagia * Masses palpated in the abdomen * Pain * Constipation and increased urination * Increased abdominal girth or abnormally enlarged abdomen * Anemia like signs and symptoms (paleness, decrease respiratory rate, dizziness) Treatment * Antibiotic treatment * Hormone treatment * Myomectomy * Current trend presents Radio Frequency Energy which shrinks myomas and reduces symptoms in new minimally invasive procedure * TAHBSO (Total Abdominal Hysterectomy Bilateral Salphingo-oophorectomy)Diagnosis Submucous Myomas may be diagnosed through many ways. They are palpated during pelvic examinations. An ultrasound is also done which could be the Transvaginal Ultrasoung and Vaginal Probe Ultrasound.
Hysteroscopy may also be done wherein the uterus is being viewed. Anatomy and Physiology of Affected Areas The uterus consists of many structures like the ovaries, broad ligament, mesovarium, ovarium ligament and the like.Here are the detailed functions of each. ovary – One of the paired female reproductive organs which produce ova and female sex hormones, estrogens and progesterone; it is located laterally in the pelvic cavity, near the opening to the oviduct, and attached to the posterior surface of the broad ligament; it is regulated by FSH and LH from the anterior pituitary in a complex cycle which begins at puberty and ends at menopause.See endoscopic views below: broad ligament – A broad fold of the peritoneum which extends from the side of the uterus to the wall of the pelvis, it helps hold the uterus, oviducts, and ovaries in place in the pelvic cavity. mesovarium – The fold of peritoneum, a subsection of the broad ligament, connecting the over to the wall of the pelvic cavity.
ovarian ligament – A cord or strap of dense fibrous connective tissue which is found between the folds of the broad ligament, passing from the side of the uterus to the lower end of the ovary; it helps hold the uterus and ovaries in place in the pelvic cavity. uspensory ligament – A band of the peritoneum containing dense fibrous connective tissue which extends upward from the upper pole of the ovary; it contains the ovarian vessels and nerve supply; it helps hold the ovary in place in the pelvic cavity. hilus (ovary) – The opening on medial side of the ovary which leads into the renal sinus and through which the ovarian blood vessels and nerves enter/leave the ovary germinal epithelium – A thin layer of simple cuboidal epithelium covering the ovary, a portion of visceral peritoneum, through which eggs are released at ovulation. troma (ovary) – The coarse connective tissue framework of the ovary which contains irregular fibrous connective tissue (stroma) and the blood vessels and nerve supply, it is found in both the cortex and medulla of the ovary; the term may be used to generally describe the internal connective tissue structural framework of any organ. cortex (ovary) – The outer layer of the ovary which contains the various ovarian follicles interspersed by irregular fibrous connective tissue (stroma) and small blood vessels; the outer surface is covered by the germinal epithelium. medulla ovary) – The inner layer of the ovary which contains dense irregular fibrous connective tissue (stroma) and the larger blood vessels and nerve supply of the ovary.
The most affected area is the intrauterine wall which is the Endometrium. Submucous myoma affects partially in the cavity and partially in the wall of the uterus. This is why it is called “Submucous Myoma”. It is a tumor lying under or involving the tissues under a mucous membrane. II. Physical Examination Assessment A.
General Information Client ILN was admitted at CSMC on July 12, 2011 at room 327 3 Main.She is a 42 year old female, who is single, a Filipino and a Christian. She is a graduated BS ECE in UST and is now an employee. Her chief complaint was that she was having very heavy menstrual bleeding. She was preoperatively and postoperatively diagnosed to have AUB prob 2® to submucous myoma and her admitting vital signs of 36. 5®C temperature, a blood pressure of 120/80 mmHg, a pulse rate of 80 bpm and respiratory rate of 18 bpm.
She weighed 32 kg and is 153 cm tall. She arrived at the hospital by car and arrived on the unit by walking. Client ILN has no allergies for food but tested (+) with tegaderm.She also took Primolut as prescribed by her physician prior to admission. B.
Nursing History Patient ILN described at present that her health is well aside from the pain she is feeling. She verbalized that her pain is rated 5/10 on a pain rate scale where 10 is the most painful. She said that her plan to manage her health is by eating more fish and vegetables and complying with medications given by her physician. Client ILN stated that five years prior to admission, she developed heavy menstrual bleeding with menses occurring every twenty to thirty days lasting for ten days consuming one napkin to three baby diapers per day.They are fully soaked with occasional blood clots for her usual menses every twenty-eight to thirty-two days lasting for seven days consuming three baby diapers fully soaked. This was associated with hypogastric pain, cramps that are not radiating and rated it as 4/10 in a scale of 1 to 10, 10 being the most painful.
There was no pelvic heaviness. There were changes in the bladder and bowel habits, the patient stated she’s having a hard time moving her bowels and has less frequency in urinating. There is an increase in the abdominal girth masses when palpated and so she consulted with a private OBG.She said that her Transvaginal Ultrasound revealed multiple myoma uteri of unrecalled size and location and left ongoing site was given Primolut 2 tabs OD for 3 months. Patient was advised observation and monitoring and was then lost to follow up checkups because of spontaneous resolution of symptoms. Seven months prior to admission, recurrence of heavy menstrual bleeding as previously described was noted.
No associated hypogastric pain, pelvic heaviness and changes in bowel and bladder habits. There is an increase in the abdominal girth and masses were palpated. Client ILN consulted with a private OBG.TRS revealed multiple myoma uteri of unrecalled size and location with left ongoing site started Primolut 3 tabs OD for 3 months and tranexamic acid TID PRN. Patient was advised observation and monitoring every 3 months.
Two months prior to admission, patient still has heavy menstrual bleeding as described before. Her past illnesses were the common colds, cough and fever. She said she was hospitalized at Makati Medical Center on the year 1996 because of heavy menstrual bleeding as well. There she was diagnosed to have had Endometriotic Cyst and was given medications.Client ILN also stated that her mother had hypertension and took maintenance drugs which relieved her mother. She expects to heal well and be kept rested while being admitted at Cardinal Santos Memorial Center and that she knew the treatments done to her would stop the bleeding.
She knew that her uterus was going to be removed. Her reaction to the medications given to her prior to her admission did not stop her bleeding, but the treatment done on her lessened the bleeding. Clien ILN stated that for breakfast, she usually eats one cup of rice, one fish and one cup of Milo.For lunch she would eat one cup of rice and one fish and drinks one glass of water or orange juice. For snacks she would eat one slice of bread with butter and one plate of pancit.
As for supper, she only eats one bowl of cereal with milk and drinks one glass of water or orange juice. She prefers to drink orange juice among other juices but stated that she is not picky with food. She estimated that she drinks water four to five glasses in a day and prefers to drink orange juice. She has no restrictions in food and has no problems with her ability to eat. She takes Calcium (+) and Vit.
B as supplements once a day every day.She estimated that in a day, she voids seven to eight times a day and it is color light yellow. She also stated that when there is heavy menstrual bleeding, her urine is color orange. She has no complaints when urinating, she said that there is no pain. Client ILN also stated that she moves her bowel four times a week usually in the morning or in the afternoon. She said that sometimes she is constipated so she drinks Dulcolax but uses no assertive devices.
Client ILN has no exercise because she doesn’t have time. But she likes to walk a lot, she would walk to nearby places instead of using a car.She listens to the radio and reads the Bible for leisure. She used to have n limitations in physical abilities but now that she is newly operated on, she couldn’t go to work yet and can’t walk so much or get tired because she would feel pain on her operation site. Sometimes when she laughs or breathes deeply, she would feel pain as well.
Client ILN also stated that she used to feel dizziness before her treatment. At 10:00 pm, client ILN sleeps and wakes up at 6:00 am. This is her usual sleep pattern and she gets eight hours of sleep. She sleeps with two pillows and prays before sleeping.She would also apply beauty products on her face before sleeping.
She has no problems regarding sleep. Client ILN has no problems in hearing, smelling, touching and seeing. She is able to read and write, and it is evident with her degree in Electrical Engineering from the University of Sto. Thomas. Client ILN is most concerned about her health and wants to be well immediately so she could go home and go back to work.
Because of her treatment, she is still healing her operation site which is still painful so her activities are limited and so she could not go to work yet.Client ILN can speak English, Filipino and Bicolano, she speaks well English with correct grammar, her sentences are complete and make sense. The significant person with client ILN was her niece and she said that she had no problems regarding her family. Client ILN lives alone as well and has never had coitus and expects to have no change in her sexual relations because of her illness. She has no problems in making decisions, she is well capable to understand and choose the decisions she makes. She said that she had had some stress in the past year but didn’t want to share them because she said they were confidential.
She said that to manage this stress she just went on with her life. She slept, ate and listened to music a lot. Client ILN expects that the nurses of Cardinal Santos Memorial Center and student nurses to provide the best care possible and make her heal better and faster while keeping her comfortable and rested. Client ILN stated that her source of strength and meaning is God and that He is very much important to her and her life. She reads the Bible a lot as her religious practice.
She would read it every day if she had time. Developmental Stage: Frued’s Five stages of Development| Stage| Age| Characteristics| Implications|Oral| Birth to 1 ? year old| Mouth is the center of pleasure| Feeding produces pleasure and sense of comfort and safety. Feeding should be pleasurable and provided when required| Anal| 1 ? to 3 years old| Anus and bladder are the sources of pleasure| Controlling and expelling feces provide pleasure and a sense of control. Toilet training should be a pleasurable experience| Phallic| 4 to 6 years old| Genitals are the center of pleasure| The child identifies with the parent of the opposite sex and later takes on a love relationship outside the family. Encourage identity| Latency| 6 years old to puberty| Energy is directed to hysical and intellectual activities| Encourage child with physical and intellectual pursuits. Encourage sports and other activities with same sex peers| Genital| Puberty and after| Energy is directed toward full sexual maturity and function and development of skills needed to cope with the environment| Encourage separation from parents, achievement of independence and decision making| Client ILN has not yet fully reached the Genital Stage yet for she has not yet used her sexual function to its extent because she has never had coitus but could make decisions on her own and had achieved independence.
She has passed all the other stages but has not yet completed this stage. C. Physical AssessmentDate Performed: July 18, 2011 The patient has good hygiene and good grooming. It is evident by her clean hands, face, and pleasant breath. She has white complexion but pale looking. She is oriented of time, place and person.
She can make eye contact and answers questions well and with sense. The patient is awake, alert and responsive. She had a blood pressure of 110/70 mmHg, a temperature of 36. 3®C, a pulse rate of 75 bpm and a respiratory rate of 19 bpm.Her cranium is symmetric with no signs of depression, lesions, masses and tenderness. There were signs of some flakes but no parasites.
Her temporal arteries were present upon palpation but they are not visible, they are not tender but they are elastic. The face is symmetric, with white complexion and there were no involuntary movements. There were 2 moles on the mid portion of her nose. One which is the higher one is approximately 3mm and the one below it is 2mm. There were no signs of tenderness, swelling, masses, depressions and edema.
The skin is soft and warm to the touch. No flakes were present on her eyebrows.The patient can identify sharp and soft when touched on her face. She is able to move jaw when speaking and when eating. There is no problem with the tongue’s ability to taste and the patient has good speech.
Eyes close involuntary when stimuli is presented and closes voluntarily as well. She can perform all facial expressions when instructed. The face also has good muscle strength with a score of 4/5 when there is active movement against gravity and some resistance. The patient could perceive odor on each nostril and could identify it. No obstructions are present.
The eyes are symmetric, circular and protruding.The sclera are white and the conjunctivas are pink. They eye lashes are curled and the skin surrounding the eyes are white in complexion, warm and soft to the touch without any presence of involuntary movements, masses, edema, tenderness, lesions, depressions and swelling. The eyes are conjugate and parallel. Eyelids also had good muscle strength.
The patient has normal vision and can read in a 20/20 distance. Her eyes don’t deviate, they can follow direction of gaze and they are conjugate and parallel. Could follow extraocular movements in the six cardinal directions of gaze and convergence is present.The pupils are 3mm in size. They constrict when subjected to light and dilates in the absence of light. There was no chance to observe the internal structure of the eye because there was no ophthalmoscope present.
The external ears are symmetric with no signs of deformities, lesions, lumps and tenderness. There is no redness and no involuntary movements. Secretions, foreign bodies and obstructions were not present. The patient could hear correctly on both ears even of the other ear is occluded. The ear canal and tympanic membrane were not observed because no ophthalmoscope was present.
The patient’s neck is white in complexion, warm and soft to the touch. There are no signs of deformities, edema, swelling tenderness and involuntary movements. Lymph nodes were not palpable. There are no deviations in the thyroid gland and the spaces between the trachea and sternomastoid are symmetrical. The thyroid gland moves upward as the patient swallowed and it is symmetric. The patient is able to taste on the 1/3 posterior area of the tongue and is able to swallow.
Gag reflex is present and there is sensations from the ear drum and ear canal. The carotid arteries are present when palpated and they are elastic.They are not visible and not tender. There are no deformities on the upper extremities. The skin is white in complexion, warm and soft to the touch.
The skin has poor skin turgor of 4-5 seconds and the nails have a good capillary refill or 2-3 seconds as well. There are no lesions, masses, tenderness, swelling and depression present. The nails are convex and the nail beds are pink in color. There are normal movement of the joints. The shoulders, the arms and the neck have good muscle strength and they all have a score of 4/5 for muscle strength where in there is activity against gravity and some activity.There is activity to some activity only because the patient still experiences pain from the operation site.
The brachial and radial arteries are present when palpated and are elastic. They are not tender and not visible. There is also good tendon reflex of (+)3. There are no presence of lumps, masses, edema, swelling, tenderness and depression on the breasts and axillae. There are also no lesions, secretions and flakiness of the nipples.
The skin is white in complexion, warm and soft to the touch. The patient has good tactile fremitus and chest excursion. The patient uses axillary muscles when breathing as it rises up and down.There are no lifts present in the precordium and there were no murmors, parasternal impulses and thrills present. The back is symmetric and has no signs of deformities.
There are no signs of edema, masses, swelling, tenderness, depression and lesions. The skin is white in complexion, is warm and soft to the touch. Palpation and percussion was not done over the kidneys because the patient was experiencing pain on the operation site at the abdomen and it may cause bleeding. The posterior thorax is symmetric, has the curvature of the spine which is cervical, thoracic and lumbar. There are no lateral deviations.
There is good chest excursion and tactile fremitus. The jugular vein is not distended. The skin of the four abdominal quadrants is white in complexion, warm and soft to the touch. There is an operation site at the midline of the abdomen which was covered in dressing and the patient refused to show it. percussion and palpation over liver, spleen and kidneys were not done because the patient was experiencing pain because of the operation site and it may cause bleeding.
There are no signs of deformities, swelling, tenderness, depression, edema and lesion on the lower extremities. The skin is white in complexion, warm and soft to the touch.Has poor skin turgor of 4-5 seconds and toenails have good capillary refill of 2-3 seconds as well. There are normal movement of joints and legs have good muscular strength of 4/5 where there is activity against gravity and some resistance. The popliteal, posterior tibial and pedal arteries are present upon palpation and they are elastic. They are not tender and are not visible.
The patient refused to show genitals but stated that there are no rashes, lesions and secretions present except the lessened bleeding. The patient also stated that there is a mild haemorrhoid present externally.The patient failed to state further details. Summary of abnormal findings: The patient is pale-looking; she has external haemorrhoids, has slow skin turgor of 4-5 seconds and has pain of 5/10 at operation site at the abdomen. The patient also verbalized that she has orange colored urine when there is heavy bleeding D. Review of Records i.
Medical Plan of Care 1. TAHBSO 2. Pethidine HCL (Demerol) 25mg IV q4® for 24 hours 3. Pantoprozole (Patoloc) 40 mg IV OD while on NPO 4. Nalbuphin (Nubain) 25 mg IV q4® for Pruritus 5. Co-amoxiclav (Amoclav) 625 mg tab BID .
Biscandyl (Dulcolax) if still no BM 7. Paracetamol + Tramadol (Algesia) 1 tab once on general liquids ii. Diagnostic Test: 8. Blood Typing 9. ECG 10. CBC 11.
Hematology Laboratory Tests Lab Test ; Date| Test| Result| Blood Typing July 12, 2011| Blood Type| “O”| | RH| (+)| Lab Test ; Date| Test| Result| July 12, 2011| ECG| Normal| Lab Test ; Date| Test| Result| Normal level| Significance| Nursing Responsibility| CBC July 12, 2011| WBC| 8. 0 x 10^9/L| 4. 8-10. 8 x 10^9/L| =| Normal| | RBC| 3. 0 x 10^12/L| 4. 7-6.
1 x 10^12/L| Low| Note any bleeding and stop immediately| | Hgb| 9. g/L| 13-17 g/L| Low| Provide oxygen if needed| | Hct| 0. 30| | | | | MCV| 90 fl| 82-88 fl| High| In accordance with disease process| | Mean Corpuscular Hgb| 29 pg| 27-31 pg| =| Normal| | MCHC| 32 ml | | | | | Red Cell Distribution width| 0. 177 ml| 0. 115-0.
150 ml| High| In accordance with disease process| | Platelet count| 0. 319 X 10^12/L| 0. 140-0. 440 X 10^12/L| =| Normal| Differential H count:| Segmenters| 0. 58| 0. 50-0.
70| =| Normal| | Lymphocytes| 0. 32| 0. 20-0. 44| =| Normal| | Monocytes| 0. 07| 0.
02-0. 09| =| Normal| | Eosinophils| 0. 03| 0. 00-0. 04| =| Normal|Lab Test ; Date| Test| Result| Normal level| Significance| Nursing Responsibility| CBC July 14, 2011| WBC| 8. 1 x 10^9/L| 4.
8-10. 8 x 10^9/L| =| Normal| | RBC| 3. 2 x 10^12/L| 4. 7-6. 1 x 10^12/L| Low| Note any bleeding and stop immediately| | Hgb| 9. 0 g/L| 13-17 g/L| Low| Give oxygen if needed| | Hct| 0.
29| | | | | MCV| 92 fl| 82-88 fl| High| In accordance with disease process| | Mean Corpuscular Hgb| 29 pg| 27-31 pg| =| Normal| | MCHC| 31 ml | | | | | Red Cell Distribution width| 0. 174 ml| 0. 115-0. 150 ml| High| In accordance with disease process| | Platelet count| 0. 227 X 10^12/L| 0. 140-0.
40 X 10^12/L| =| Normal| Differential H count:| Segmenters| 0. 77| 0. 50-0. 70| High| In accordance with disease process| | Lymphocytes| 0. 12| 0.
20-0. 44| Low| In accordance with disease process| | Monocytes| 0. 10| 0. 02-0. 09| High| In accordance with disease process| | Eosinophils| 0. 01| 0.
00-0. 04| =| Normal| Lab Test ; Date| Test| Result| Normal level| Significance| Nursing Responsibility| Hematology July 14, 2011| Hgb| 8. 8**| 12-14| Low| Give oxygen if needed| | Hct| 27. 0**| 37-47| Low| In accordance with disease process| | WBC| 5500| 5000-10000| =| Normal| | Basophil| 0| 0-6| =| Normal| Eosinophil| 5**| 0-4| High| In accordance with disease process| | Stabs| 0| 0-5| =| Normal| | Segmenters| 62| 55-65| =| Normal| | Lymphocytes| 27| 25-35| =| Normal| | Monocytes| 6| 0-6| =| Normal| | Platelets| Adequate| | =| Normal| E. Data from Textbook Definition of Diagnosis: Uterine myoma is the most common tumors of female genitalia tract.
Myoma commonly called fibroid is the benign tumor of the smooth muscle in the wall of the uterus. They start of very small, actually from one cell and generally grow over the years before they cause any problem. Most myomas are benign, malignant myomas are very rare.The cause of fibroids is still unknown, although it is known that fibroids have a tendency to run in the family. It may grow as a single nodule or in clusters and may range from 1mm to more than 20cm in diameter.
Myomas are the most frequently diagnosed tumor of the female pelvis, and the most common reason for hysterectomy. Their name depends on their location, submucous myomas are located at the submucous cavity of the uterine wall and the endometric wall. F. Uterine cavity stretches in size The vascular supply in the uterus is interfered Anemia-like s/sx: paleness, low rbc, decreased RR Proliferation of Cells in the submucousOverstimulation Overgrowth of Endometrial Lining Myoma or development of uterine fibroid Excessively thickened Endometrium Predisposing Factors: * Age * Race * Heredity * Early Menarch * Nulliparity Precipitating Factors: * Vegetable diet * Anxiety/Stress Vegetable diet Stress Etiology unknown (Idiopathic) Contains over 5000 sterols that have progestogenic effects Adrenal gland exhaustion Increased Estrogen Production Decreased Progesterone levels * Swollen breasts * Loss of sex drive * Dysmenorrhea Pain Masses palpated in the abdomen Excessive sloughing of the uterine wall during menses Excessive bleeding, heavy menstrual bleedingDoesn’t desquamate easily at the end of cycle Prolonged menstrual bleeding, dysmenorrhea Pain, increase pelvic pressure, increased abdominal girth & size Pathophysiology The vascular supply in the uterus is interfered Deterioration of surrounding tissues Fibroids replace smooth muscle cells Degenration of the interior part of fibroids Fibroid grows in size Pressure on adjacent organs such as the bladder and rectosigmoid Hypermenorrhea, abnormal bleeding, dysmenorrhea Masses palpated Constipation and increased urination Legends: Disease Process Sign and Symptoms of Client ILN G. Drug StudyName| Dose, Frequency, Classification| Action| Indication| Contraindication| Side Effects| Nursing Responsibility| Meperidine (Demerol/Pethidine HCL) | 25mg IV q4® for 24 hoursOpioid Analgesic| Depresses pain impulse transmission at the spinal cord level by ineracting with opioid receptors; produces CNS depression| Moderate to severe pain, preoperatively| Hypersensitivity| Drowsiness, dizziness, constipation, cramps, pruritus| Assess renal function before initiating therapy, poor renal function can lead to accumulation of toxic metabolite and seizures| Pantoprozole (Patoloc) | 40 mg IV OD while on NPOProton Pump Inhibitor| Suppresses gastric secretion by inhibiting hydrogen/potassium ATPase enzyme system in gastric parietal cell; characterized as gastric pump inhibitor since it blocks final step of acid production| Long term hypersecretory conditions| Hypersensitivity| Headache, abdominal pain| Advice patient to avoid hazardous activities as dizziness may occur and to avoid alcohol as it may cause GI irritation | Nalbuphin (Nubain) | 25 mg IV q4® for PruritusOpioid Analgesic| Inhibits ascending pain pathways in limbic system, thalamus, midbrain, hypothalamus by binding to opiate receptor sites, thus altering pain perception and response| Moderate to sever pain, balanced anesthesia| Hypersensitivity| Dizziness, cramps, increased urinary output, pruritus| Monitor CNS changes: dizziness, drowsiness, monitor allergic reactions and give only with resuscitative equipment available. Give slowly to prevent rigidity.
Co-amoxiclav (Amoclav)| 625 mg tab BIDantiinfective| Interferes with cell wall replication of susceptible organisms by binding to the bacterial cell wall; the cell wall, rendered osmotically unstable, swells and bursts from osmotic pressure| Infections of the skin| Hypersensitivity| Abdominal pain| Monitor for bleeding, identify urine output, if decreasing notify physician| Bisacodyl (Dulcolax) | 15 mg in pm or am if still no BMLaxative, stimulant| Acts directly on intestines by increasing motor activity; thought to irritate colonic intramural plexus; increases water in the colon| Short term treatment for constipation| Hypersensitivity, abdominal pain| Cramps| Discontinue drug if cramping, rectal bleeding, nausea and omiting are assessed; give alone with water for better absorption| Acetaminophen(Paracetamol )| 1 tab PRN once on general liquidsNon opioid analgesic| May block pain impulses peripherally that occur in response to inhibition of prostaglandin synthesis; does not possess antiinflammatory properties; antipyretic action results from inhibition of prostaglandins in the CNS| Mild to moderate pain or fever| Hypersensitivity| Drowsiness, abdominal pain| Monitor renal function, check I&O, assess for fever and pain| Tramadol (Algesia)| 1 tab PRN once on general liquidsCentral analgesic| Binds to receptors and inhibits reuptake of norepinephrine, serotonin; does not cause histamine release or affect heart rate| Management of moderate to severe pain| Hypersensitivity| Dizziness, constipation, pruritus| Monitor I&O, decreasing urinary output may indicate urinary retention| Mefenamic Acid| 500 mg 1 tab as needed for pain (PRN)Antiinflammatory, analgesic, antipyretic| Inhibits prostaglandin synthesis| Relief of moderate pain| Hypersensitivity| Headache, dizziness, tiredness, GI pain, renal impairment| Assess for risks for CV events, GI bleeding and monitor accordingly. Give drug with food.If rash, diarrhea, or digestive problems occur, discontinue drug| Ferrous Sulfate (Fero-Grad)| 1 tab TID x 1 monthHematinic| Replaces iron stores needed for RBC development; energy and oxygen transport, utilization, fumarate contains 33% elemental iron; gluconate, 12 %, sulphate, 20%; iron, 30%; ferrous sulphate exsiccated| Iron deficiency anemia| Hypersensitivity| Constipation, epigastric pain| Monitor blood studies for toxicity, bowel elimination and nutrition. Identify cause of iron loss or anemia. Give between meals for best absorption and give at least 1 hour before bedtime because corrosion may occur in the stomach| I.
Nursing Care Plan Date identification| Problem List| Prioritization| | Nursing Diagnosis| 1: Pain related to disease process| 2: Risk for delayed surgical recovery related to bleeding tendency| 3: Activity intolerance related to pain, surgical procedure| Assessment| Nursing Diagnosis| Goal| Objectives| Interventions|Rationale| Evaluation| Subjective:The patient verbalized that she has pain on the operation site and rated it as 5/10, 10 being the most painfulObjective:>there is guarding on paint site>there is a restriction in activity as guarding motion is done| Acute Pain related to disease process, surgical procedure| After 4 hours of nursing interventions, the patient’s pain will be lessened| After 4 hours of nursing interventions, the patient will:;describe non pharmacological methods to help control pain;perform activities with reported acceptable level of pain;describe how unrelieved pain will be managed| ;Prevent any pain possible during procedures;Refer to physician for opioid analgesics;Teach patient non pharmacological methods to help control pain such as distraction, imagery, relxation and application of heat and cold;Plan care activities around periods of greatest comfort possible| ;All pain must be avoided;May help in pain relief;Restore’s client’s self control and helps relieve pain and it is economic;Pain diminishes client’s activity| After 4 hours of nursing interventions:> the patient’s pain is rated 3/10;the patient is able to describe the different non pharmacological methods to help control pain and uses them;the patient performs activities with acceptable level of pain;the patient could describe how unrelieved pain could be managed by opioid prescribed medications and nonpharmacological methods|Assessment| Nursing Diagnosis| Goal| Objectives| Interventions| Rationale| Evaluation| Subjective:Patient stated that there is still vaginal bleeding, pain of 5/10, nausea and loss of appetiteObjective:Wound is still fresh inside the dressing| Risk for delayed surgical recovery related to bleeding tendency| After 8 hours of nursing interventions the patient will show evidence of healing: no redness, draining or immobility| After 8 hours of nursing interventions the patient will:;State that appetite is regained;State the no nausea is present;Demonstrate activity to move about;State that pain is controlled and relieved| ;Play music of client’s choice>Consider using healing touch and other mind body spirit interventions such as stress control and imagery>Use careful aseptic echnique when caring for wounds>Promote mobility and deep breathing exercises>Teach systematic muscle relaxation for pain relief| >This has positive effects in reduction of physiological parameters and anxiety>A powerful way to promote relaxation and enhance healing process>If infection is prevented, there is faster healing>Reduces pain and increases walking function >Relieved ain prevents complications and does not delay recovery| After 8 hours of nursing interventions the patient:>showed evidence of healing as she could now and move about and there are no redness and drainage>stated that her appetite is gradually regained>stated that no nausea is present anymore>could go to the bathroom by herself>stated that her pain is now 3/10| Assessment| Nursing Diagnosis| Goal| Objectives| Interventions| Rationale| Evaluation| Subjective:The patient stated that there is pain on her operation site which she rate as 5/10, 10 being the most painful.She says that it is hard to walk, breathe deeply, cough and laugh because it causes painObjective:>There is guarding of pain site>Patient remains at bed rest>Patient is careful on her activities| Activity intolerance related to pain, surgical procedure| After 4 hours of nursing interventions, the patient will demonstrate increased activity tolerance| After 4 hours of nursing interventions, the patient will:>Maintain normal skin color and skin is warm and dry with activity>Express an understanding of the need to balance rest and activity| >Position on high back rest>Gradually increase activity allowing client to assist in positioning, transferring and self care activities>Perform ROM>Observe and document skin integrity several times a day>Assess for constipation>provide emotional support and encouragement to the client to gradually increase activity| >minimizes cardiac deconditioning>Increases activity tolerance and self esteem>Prevents muscle shortening>activity intolerance may lead to pressure ulcers>Impaired mobility is associated with risk for constipation>Increases willingness to increase activity| After 4 hours of nursing interventions, the patient:>Has demonstrated activity tolerance by being able to go to the bathroom>has maintained a normal skin color and is dry and warm with activity>expresses an understanding of the need to balance rest and activity by doing muscle activities while on bed rest| II. Discharge Plan Date of Discharge: July 18, 2011 12. Medications a. Co-amoxiclav 625 mg 1 tab BID x 5 more days b. Mefenamic acid 500 mg 1 tab as needed for pain c.
Ferrous Sulfate 1 tab TID x 1 month d. Follow up on Friday July 22, 2011 13. Diet: * Diet as tolerated with high protein and high iron diet 14. Activities Restricted: * Strenuous exercises * Long walks May go back to work if operation site is healed and dry 15. Special Health Teachings Objective: After 2 hours of health teaching, the patient and her family will be able to understand the special health teachings and their importance.
Thus they will follow suggested teachings and comply. Methods: Discussion, demonstration and the use of leaflets Topics: * Teach how to change dressings and clean wound * Remind the patient to take a complete bed rest for three months * Discuss how the patient is not in the position to move around much for a period of one month * Discuss that she is not allowed to climb stairs for three months and not to lift heavy load * Teach significant other how to hange bed linens with patient in bed rest * Teach significant other how to do bed bath and bed shampoo to be done to the patient when in bed rest * Teach significant others how to provide urine bed pan to patient in bed rest * Teach significant other and client how to move patient in bed for every 2 hours to prevent bed sores * Emphasize the importance of complying to medications prescribed by the physician * Emphasize the importance for showing up for follow up checkups with the physician Evaluation: After 2 hours of health teachings, the patient and her significant other understood the importance of following the treatment regimen advised by the doctor and the importance of the health teachings done.
