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General Objectives:

This case study aims to gather significant information that contributes to giving
nursing care to a patient diagnosed with endometrial hyperplasia. This also intends to
help the patient achieve the maximum level of health within his capability.

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




Endometrial hyperplasia is a condition of excessive proliferation of the cells of

the endometrium, or inner lining of the uterus.

Most cases of endometrial hyperplasia result from high levels of estrogens,

combined with insufficient levels of the progesterone-like hormones which ordinarily
counteract estrogen's proliferative effects on this tissue. This may occur in a number of
settings, including polycystic ovary syndrome, estrogen producing tumours (e.g.
granulosa cell tumour) and certain formulations of estrogen replacement therapy.
Endometrial hyperplasia is a significant risk factor for the development of endometrial
cancer so careful monitoring and treatment of women with this disorder is essential.

Like other hyperplastic disorders, endometrial hyperplasia initially represents a

physiological response of endometrial tissue to the growth-promoting actions of estrogen.
However, the gland-forming cells of a hyperplastic endometrium may also undergo
changes over time which predispose them to cancerous transformation. Several
histopathology subtypes of endometrial hyperplasia are recognisable to the pathologist,
with different therapeutic and prognostic implications.

• Endometrial hyperplasia (simple or complex) - Irregularity and cystic expansion

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

• Atypical endometrial hyperplasia (simple or complex) - Simple or complex

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

 Heavy menstruation
 Extended menstruation
 Menorrhagia
 Irregular menstruation

Medical Management:

Progestin therapy

Because endometrial hyperplasia is estrogendependent, progestins are often used

to induce regression. Progestin appears to decrease glandular cellularity in these lesions
by triggering apoptosis. In addition, medroxyprogesterone acetate (MPA) significantly
inhibits angiogenesis in the myometrium immediately underlying complex endometrial

Gonadotropin-releasing hormone analogues

Gonadotropin-releasing hormone (GnRH) analogues suppress the
hypothalamicpituitary-ovarian axis, thereby inhibiting estrogen production and,
potentially, causing the regression of endometrial hyperplasia. GnRH analogues also
appear to have a direct antiproliferative effect on endometrial cells.
Laser therapy
Vilos and Ettler reported another case in which a patient with complex a typical
hyperplasia underwent laser intrauterine thermal therapy. After 13 months of
surveillance with transvaginal sonography, there was no evidence of disease.
Surgical Management:
Thermal balloon ablation
The patient initially presented with a complaint of menorrhagia and had a
preoperative endometrial biopsy that showed no evidence of hyperplasia. When she
subsequently underwent a thermal balloon ablation procedure, a curettage specimen
indicated complex hyperplasia with atypia. The patient underwent a hysterectomy 8
months later, at which time no pathologic evidence of persistent hyperplasia or
carcinoma was found.
It is best treated surgically with hysterectomy. However, if a patient desires
future pregnancy, a trial of hormonal treatment may be given.
Nursing Interventions:

• Assess patient’s bleeding

• Prepare patient for D/C
• Stop bleeding
• Monitor vital signs
• Promote weight reduction
• Promote regular aerobic exercise
• Increase fluid intake
• Administer medications as ordered
Patient J.D. is a 35 year old woman, married, residing at Basak, Rizal, Maasin
City. She was born on March 17, 1975. She is a Filipino citizen and a Mormon. She is a
housewife . She was admitted on February 13, 2010 at 10 am for vaginal bleeding.


According to patient, it was 7 days before admission that patient J.D. experienced
bleeding. Two days prior to admission, patient had a headache, fever and chills. On the
night of February 12, 2010, she experienced heavy bleeding that’s why they brought him
at SOYMPH through a van. She was diagnosed with endometrial hyperplasia by Dr.
Beneliana Dajao. She was hooked with D5NM 1L@40gtts/min.


According to patient J.D., she had her first menstruation when she was 13 years
old. According to her mother, she was brought to the hospital since she was still 1month
old every month due to asthma. She was also brought to the hospital last 2 years due to
allergy. She had measles, mumps and chickenpox when she was young. Patient’s mother
added that the patient was fully immunized.


According to patient J.D., her paternal side has a history of hypertension and lung
disease and her maternal side has a history of heart disease.


Paternal Side Maternal Side


- male - lung cancer - hypertension

- female -bone disease - gout

- heart disease - hyperglycemia - convulsion

- nervous breakdown - asthma -deceased

- endometrial hyperplasia


Patient J.D. describes her usual health status as fair. She says she is satisfied with
her usual health status. She doesn’t smoke cigarette and doesn’t use any street drugs. She
doesn’t drink any alcohol. She rates his living condition at home as fair. She does not
exercise on a regular basis. She suggested that she must exercise to lose weight. She does
not do breast self-examination. She views health as the absence of illness.


Patient gains 5 kg weight in the last 6 months. She describes her appetite as good.
Her food intolerance is “inun-unan nga isda”. Her average day’s food intake is 3 meals
and 2 snacks. His average day’s fluid intake is 5 glasses. He likes to eat barbecue and
“humba” and to drink softdrinks and juices. She says she doesn’t have problem with
chewing and swallowing. She took vitamins in the previous months.

Patient says she usually defecates every morning . Her stool is usually soft,
yellow and has no bleeding. She had a history of constipation and diarrhea. She doesn’t
have any history of incontinence. She usually void 3 times a day. Her urine is usually

Patient rates her self-care in feeding as 0, bathing /hygiene as 0,
dressing/grooming as 0, toileting as 0 and ambulation as 0 with 0 as completely
independent. She has no oxygen use at home. She uses only 1 pillow to sleep. Her works
are washing clothes and sweeping the floor. Her way of exercise is walking but not
regularly. Her hobbies are listening to music and watching television.


Patient’s sleeping hours range from 5 hours per night. She sleeps at 12mn and
wakes up at 5 am. She has also a nap during 1 pm. She does not have any difficulty going
to sleep. She uses 2 pillows to sleep. Her relaxation technique is watching TV.

Patient J.D. doesn’t have any difficulty in decision-making. She can define what
his current problem is that she is having heavy vaginal bleeding. She thinks all will be
alright after her stay in the hospital.

Patient’s J.D. live with her family. She has no children. She is the only daughter
of the family. She likes to watch TV. She likes being stagnant.


Patient J.D. has an irregular menstrual cycle which is only once a year. She has
also a history of vaginal bleeding. She thinks she has a difficulty of bearing a child.


Patient J.D. experienced a severe skin allergy at the lower parts in both of his legs
2008. She had a moment of fear then when a certain somebody in the Barangay health
station said that her legs would be amputated. She rates his usual handling of stress as
average. Her primary way of dealing with stress or problems is consulting her mother.


Patient says she is satisfied with the way her life has been developing because she
is a commerce graduate . She is a Mormon. She says her church prohibits drinking coffee
because they believe it can damage the cells of the body.


General Appearance:

Patient J.D. is fat. She is infused with D5NM 1L@40gtts/min at her right arm.
Her weight is 80 kgs and her height is 5’.

Skull and face

• skull are symmetrical round, hard and smooth without lesion
• face are symmetric, no abnormal movement noted
• thick, evenly distributed
• long, curly hair
• free from infestation of lice
• smooth and firm
• moderately bulging eyes
• short eyelashes
• eyeballs are symmetrically aligned in sockets without protruding or sinking
• eyes and eyelids are free from inflammation and masses
• transparent conjunctiva and lens
• white sclera
• iris is typically round, flat and evenly colored
• pupils equally round, reactive to light accommodation
• equal in size bilaterally
• consistent with facial color
• symmetrical with upper attachment
• free from lesions and pain
• ear wax discharge is present
• able to hear words
Nose and Sinuses
• frontal and maxillary sinuses are non tender
• color is the same as the rest of the face
• no inflammation of sinuses upon palpation
• nasal structure is smooth and symmetric
• no mucous discharge
• lips are smooth, moist and pink. without lesions or swelling
• gums are pink and moist
• teeth is yellowish from the upper portion
• tongue pink, moist, a moderate size with papillae (little protuberances) present
• no foul-smelling breath
• able to open mouth wide
• fair dry little pale skin
• no lesions
• smooth
• scars are present because of recent rashes in her feet
• temperature is 37.5 °C
• dirty nails in the toes
• nail bed is pink
• nail base is firm
• 160-degree angle between the nail base and the skin
• able to move without complaint of pain
• symmetric without bulging masses
• muscles are symmetrical with head
• lymph nodes are not palpable, without enlargement or tenderness
Thorax and Lungs
• posterior and anterior thorax is free from lesions
• respiration is 22 cpm
• symmetric chest
• slope of the ribs is symmetrical
• spine is straight
• scapula are symmetric
• pitch is low breath sound
• no adventitious sound
Cardiovascular system
• heart rate is 62 bpm
• S1 and S2 are audible
• absence of visible pulsations
• pulses are equal in rate and rhythm
• protuberant abdomen
• 47 inches waistline circumference
• non tender and soft
• bowel sounds are loud
• no lesions
• no pain upon palpation
External Genitalia, Anus and Rectum
• spot bleeding

Musculoskeletal system
• posture erect
• shoulders, arm and elbows are symmetrical, no redness, swelling or deformity
• hands and fingers are symmetric, non tender, without nodules
• knees are in alignment with each other
• feet are in alignment with lower legs
• lower leg in alignment with upper leg
• toes and feet are in alignment with the lower leg
• conscious
• good eye contact, smiles, and frowns appropriately
• speech moderate tone, clear
• able to hear
• able to swallow
• follows directions accurately
• recalls recent events without difficulty
• her eyes are in coordinated motion in all directions
• can identify correct flavor

Laboratory Exam Normal Results Patient’s Results Indication

Hematology * Leukocyte # cone : 4.5 - 11.0 x 109 / L * Leukocyte # cone : 15.1x109/L Increased
* Hemoglobin Mass cone : 139 - 163 g / L * Hemoglobin Mass cone : 78g/L Normal
the science dealing with the * Different Counts * Different Counts
formation, composition, functions and → Segmenters : 0.31 - 0.76% → Segmenters : 0.74% Normal
diseases of the morphology of the blood → Lymphocytes : 0.14 - 0.44% → Lymphocytes : 0.26% Normal
forming organs → Eosinophils : 0 - 0.04% → Eosinophils : 0.25 Normal
* Erythrocyte vol. fraction : 0.40 – 0.50 * Erythrocyte vol. fraction : 0.48 Normal
Laboratory Exam Normal Results Patient’s Results Indication
Urinalysis *Color: amber to yellow *Color: yellow *normal
*Character: clear *Character: turbid *
is a group of manual and/or *Reaction(ph): *Reaction(ph): *normal
automated qualitative and semi- adults &children(4.6-8.0) adults: 8.0
quantitative test perform on a urine newborn(5.0-7.0)
sample. *Specific gravity: 1.010-1.025 *Specific gravity: 1.008 *decreased
*Albumin: negative *Albumin: negative *normal
*Sugar: negative *Sugar: negative *normal

Laboratory Exam Normal Results Patient’s Results Indication

Blood chemistry Total cholesterol :up to 6.17 mmol Total cholesterol : 2.94 Decreased : low fat diet, malabsorption, anemia,
/L liver disorders, carbohydrate sensitivity.
-a group of tests that measures Creatinine : 88-176.88 mmol/L 88.4 Increased : kidney damage
different chemicals in the blood. It is 10-20mg s%
also termed the Chem 7, Chem 8, or Fasting blood glucose: 75-115 mg 86 Increased : diabetes, liver disease, obesity,
Chemistry Panel. These tests usually s / d/ 4.2-6.4 mmol pancreatitis, stress
are done on the fluid (plasma) part of Triglycerides :up to 1.71 mmol /L 0.46 Increased : too much carbohydrate intake and
blood. The tests can give doctors Uric acid : hyperlipidism
information about many organs in the M=3.4-7 mg s /dL 6.52 Normal
blood, although they are most specific
for the kidneys. F=2.4 - 5.7 mgs/dL
Drug Date Classification Mechanism of Action Indication Side Effects Nursing Implications
Generic 02-13- Broad-spectrum Interfere with the bacterial cell wall Treatment of Diarrhea, rash, vomiting, Assess:
name: 10 antiinfective synthesis during active multiplication susceptible oral candidiasis, severe -I&O ratio; report
Ampicillin 250mg causing cell wall death and resultant bacterial abdominal pain, hematuria, oliguria, since
Brand q6h bactericidal activity against susceptible infections. encephalophathy, penicillin in high doses is
name: IVTT bacteria. seizures, lymphathic nephrotoxic.
Ampicin leukemia. -Culture sensitivity before
drug theraphy; drug may be
taken as soon as culture is
- Bowel pattern before,
during treatment.
-Skin eruptions after
administration of penicillin
to 1 wk after discontinuing
-Respiratory status: rate,
character, wheezing,
tightness in chest.
-Anaphylaxis: rash, itching,
dyspnea facial swelling;
stop drug, notify prescriber,
have emergency equipment
Drug Date Classification Mechanism of Indication Side Effects Nursing
ordered Action Implications
Generic 02-13- Bactericidal Bactericidal Treatment of Dizziness, fatigue, headache, rash, nausea, vomiting, Give on an empty
name: 10 Antibiotic antibiotic with susceptible bacterial pseudo membranous colitis, transient neutropenia stomach to increase
Cephalexin 500mg mechanism infections, including anemia transient elevation, liver enzymes. total absorption;
cap, q8 similar to that those caused by give around the
Brand PO of penicillins; group A beta clock rather than 4
name: inhibits Hemolytic times a day to
Cefamex mucopeptide streptococcus, promote less
synthesis in the staphylococcus, variation in peak
bacterial cell klebsiela pneumonia and through serum
wall. E.coli proteus level.
mirabilis and
Drug Date Classification Mechanism Indication Side Effects Nursing Implications
ordered of Action
Generic 01-11- Analgesic Produce for the relief of fever, minor Paracetamol, when taken within • Assess for fever.
name: 10 and analgesia by aches and pains the recommended dose and • Store drug at temp. not
paracetamol 500mg Antipyretic blocking pain duration of treatment, has low exceeding 30°C
1 tab impulses by Contraindications: Anemia, incidence of side effects. • Assess for hepatotoxicity
Brand q4h , inhibiting cardiac and pulmonary disease. • Assess for allergic
name: PO prostaglandin Hepatic or severe renal disease Skin rashes and minor stomach reaction
Biogesic synthesis in and intestinal disturbances have • Evaluate therapeutic
the CNS or of been reported. response: reduced fever
that sensitize
receptors to
The drug may
relief fever
central action
in the
Drug Date Classification Mechanism of Indication Side Effects Nursing Implications
ordered Action
Generic 02-13- Laxatives, Stimulates Treatment of constipation, CNS: -Administer tablets 2 hours prior,
name: 10 Stimulant peristalsis by colonic e evacuation prior to Muscle weakness or 4 hours after antacids,
bisacodyl 2 tab, directly irritating procedures of examination. GI: increased PH may dissolve the
P.O the smooth Nausea, vomiting, anorexia enteric coating leading to GI
Brand muscles of the cramps, diarrhea, rectal distress;do not crush enteric
name: intestine, possibly burning(suppositories) coated during product .
Dulcolax the colonic META: ASSESS:
intramuscular Protien- losing enterophathy, -Blood, urine electrolytes if drug
flexus, alters alkosis, hypokalemia, tetany, is used as often by patient.
water and electrolyte, fluid imbalances. -I&O ratio to identify fluid loss.
electrolyte -Cause of constipation; identify
secretions whether fluids, bulk, or exercise
producing missing from lifestyle
intestinal fluid -Cramping, rectal bleeding,
accumulation and nausea, vomiting; if these
laxation. symptoms occur, drug should be
Drug Date Classification Mechanism of Action Indication Side Effects Nursing Implications
Generic 02-13-10 Anti- Inhibits short term relief of Skin rash, dizziness, Take with food, milk or with
name: 500mg cap, inflammatory prostaglandin mild to moderate abdominal cramps, antacids; extended release
mefenamic TID Nonsteroidal synthesis by pain including heartburn, indigestion capsules must be swallowed
acid decreasing the primary nausea, itching, ringing in intact.
Brand activity of the dismenorrhea. ears, fluid retention,
name: enzyme, cyclo- -Increased effect of headache.
Ponstan oxygenase, which toxicity with oral
results in decreases anticoagulants,
formation of mnethotrexate.
Drug Date Classification Mechanism of Action Indication Side Effects Nursing Implications
Generic 02-13-10



The uterus (Latin word for womb) is a major female hormone-responsive

reproductive sex organ of most mammals, including humans. It is within the uterus that
the fetus develops during gestation.

The uterus is located inside the pelvis immediately dorsal (and usually somewhat
rostral) to the urinary bladder and ventral to the rectum. The human uterus is pear-shaped
and about 3 in. (7.6 cm) long. A females uterus can be divided anatomically into four
segments: The fundus, corpus, cervix and the internal os.


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

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


The layers, from innermost to outermost, are as follows:

The lining of the uterine cavity is called the "endometrium". It consists of the
functional endometrium and the basal endometrium from which the former arises.
Damage to the basal endometrium results in adhesion formation and/or fibrosis
(Asherman's syndrome). In most mammals, including humans, the endometrium
builds a lining periodically which is shed or reabsorbed if no pregnancy occurs.
Shedding of the functional endometrial lining in humans is responsible for
menstrual bleeding (known colloquially as a woman's "period") throughout the
fertile years of a female and for some time beyond. In other mammals there may
be cycles set as widely apart as six months or as frequently as a few days.
The uterus mostly consists of smooth muscle, known as "myometrium." The
innermost layer of myometrium is known as the junctional zone, which becomes
thickened in adenomyosis.
The loose surrounding tissue is called the "perimetrium."
The uterus is surrounded by "peritoneum."

The uterus provides structural integrity and support to the bladder, bowel, pelvic
bones and organs. The uterus helps separate and keep the bladder in its natural position
above the pubic bone and the bowel in its natural configuration behind the uterus. The
uterus is continuous with the cervix, which is continuous with the vagina, much in the
way that the head is continuous with the neck, which is continuous with the shoulders. It
is attached to bundles of nerves, and networks of arteries and veins, and broad bands of
ligaments such as round ligaments, cardinal ligaments, broad ligaments, and uterosacral
ligaments .

The uterus is essential in sexual response by directing blood flow to the pelvis and
to the external genitalia, including the ovaries, vagina, labia, and clitoris. The uterus is
needed for uterine orgasm to occur.

The reproductive function of the uterus is to accept a fertilized ovum which

passes through the utero-tubal junction from the fallopian tube. It then becomes
implanted into the endometrium, and derives nourishment from blood vessels which
develop exclusively for this purpose. The fertilized ovum becomes an embryo, develops
into a fetus and gestates until childbirth. Due to anatomical barriers such as the pelvis, the
uterus is pushed partially into the abdomen due to its expansion during pregnancy. Even
during pregnancy the mass of a human uterus amounts to only about a kilogram (2.2

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


continuous estrogen stimulation

unopposed by progesterone
S- “sakit akong Activity
DIAGNOSIS GOAL: 1. Evaluate patient actual act and perceived limitations/degree deficit in After 5hrs of nursing
dapi- dapi”aho
S- “ sakit intolerance
Impaired RT the
GOAL:patient will 1.light of usual
Evaluate status.
or continuously monitor degree of joint inflammation or pain. intervention,
After 5 hourspatient
of is
dapi-dapi” as injury
physicalof the left still
The be further R: Provides comparative baseline and provides
R: Level of activity or exercise depends information
on progression about
and resolution of still free
nursing from injury.
O- Swollenby
verbalized joints buttocks.
mobility free from
patient injury
will needed education.
inflammatory process. interventions,
patient left related to pain after
maintain orof
5 hrs. the patient was
buttock Scientific Basis: nursing
increase 2.2. Maintain
chair and
rest more
whenabout and degree
indicated. of assistance
Schedule activities able to maintain
O- -Inability
Swollen to “Activity
Scientific basis: intervention.
strength and necessary.
providing frequent rest periods and uninterrupted night time sleep. or increase
get to the toilet
joints intolerance
“Impaired function of R: Systemic
R: Determines
acute and needs.
attacks and important throughout all strength and
by himself
-Bruised left reflects
physicalthe affected or phases of disease to reduce fatigue and improve strength. function of
buttock impact
mobility…of the compensatory 3. Monitor vital signs every 2 hours affected or
-Inability to illness
Relatedon the body parts 3.R:Encourage
Provides information or patient’s
adequate fluid intake. status. compensatory
get to the toilet client’s
Factors… ability After 5 hours of R: To assist with excretion of uric acid and decrease likelihood of stone Body part.
by himself to performed
Pain/ nursing 4. Provide positive atmosphere
discomfort” of interventions. R: Helps to minimize frustrations.
daily living” 4. Assist with active or passive range of motion.
Nurses’ Pocket 5. Assist
R: withor
Maintains patient’s
joint function, muscle strength, and general
guide by of R:Stamina.
Prevents further injury.
nursing by
Doenges, p.458
Delaune and 5.6. Encourage
Provide information about theupright
patient to maintain effect of
andlifestyle on activity
erect posture when sitting,
lander, P.813 intolerance.
Standing or walking.
R: Maximizes
R: Educates patient.
joint function, maintains mobility.

theparticipation in recreation
patient to avoid alcohol.
. R: That
R: Enhances sense of well
can precipitate being.
acute attack.

7.8. Review
that devices
are rich in purines like sardines, anchovies, shell
R: Fish
patient’s mobility.
organ meats.
R: To avoid foods that precipitate Acute attacks.

8. Provide safety needs.

R: Help prevent accidental injuries or falls.
S- “Di ta Risk for GOAL: 1.Assess skin routinely After 5hrs of nursing
kalihok-lihok impaired skin R: Monitors skin vulnerability. interventions, the patient
kay sakit atong integrity R/T After 5hrs. of is cooperative with the
dapi-dapi” as impaired nursing 2. Note presence of conditions that may impair skin integrity nursing care rendered.
verbalized by the circulation interventions, the R: Prevent further skin alterations.
patient. patient will
demonstrate 3. Handle client gently
Scientific basis: behaviors to R:prevent skin tears
O- Difficulty to “..At risk for prevent skin
walk. skin being breakdown. 4. Encourage patient to move.
-Patient is adversely R:Promotes good circulation
always sitting altered…
Risk factors 5. Avoid exposure to sunlight
Internal R: Prevents skin inflammation
circulation”. 6. Increase oral intake
R: Keeps the skin moist
Nurses’ Pocket
guide by 7.Provide adequate clothing
Doenges,p.624 R: Prevents hyperthermia

8. Apply herbal oil to patient’s body

R: Keeps the skin oily


S- “Nakapaus-os Risk for GOAL: 1. Monitor BP and pulse After 5hrs of nursing
gyud ngadto sa decreased After 5hrs. of R:Assess patient’s blood flow intervention, the
100/80 kining cardiac output nursing patient’s BP is 130/70
herbal medicine” R/T orthostatic intervention’s, 2. Encourage client to stop taking unapproved herbal medicines as and pulse is 64.
as verbalized by hypotension the patient’s ordered by the doctor
S- “Nahagba Risk for injury Goal: 1. Note clients decision-making ability After 5hrs of
man diay R/T impaired after 5 hours R:Assess patient’s ability to protect self nursing
kuno ko” as physical mobility. of nursing interventions,
verbalize by interventions, the 2. Assess mood of aggression patient
the patient patient will R: Monitor patient’s misbehavior understands the
verbalized value of
Scientific basis: understanding of 3.Assess client’s muscle strength, gross and carefulness.
O- difficulty “Clients who are factors that fine motor coordination
of walking at risk for injury contribute to R: Identify risk for falls
-swollen may have other possibility of injury.
joints problems… 4. Maintain bed lowest position.
-injured Impaired R:Ensure safety
scapula physical
mobility...” 5. place assistive devices
R: Prevents further injury
Fundamentals of
nursing by 6. Monitor environment
Deluane and R: Identifies contributing factors to injury
7.. Administer medications as ordered
R: Aids in clients progress

8. Teach patients S.O.S the importance of

railings heading to comfort rooms of their
R:Aids in patient’s mobility


1. Medications
Name of drug Dosage and Route Curative Effects Side Effects
2. Exercise / Activity

Type of Activity Allowed / to be



Procedure or Steps:

Use of Equipment (if



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


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

( ) clinic appointments schedule ( ) use of alternative medicines

( ) follow up laboratory examinations ( ) relapse prevention measures

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

( ) others __________________
5. a.. Observed signs and symptoms that need reporting:



b. Interventions / Home Remedies that may be done immediately prior to seeking


6. Diet (prescribed by the doctor / dietician).

a. Prescribed Diet:

b. Restrictions:

7. Spiritual and Psychological Needs

( ) Spiritual Counseling ( ) Confession ( ) Supportive
( ) Grief Work ( ) Family Therapy ( ) Join Organizations/ Church
( ) Anger Management ( ) Reconciliation of Conflicted Relationships

A. Discharge Details

a. Date and Time of Discharge:


b. Accompanied by:

c. Mode of Transportation:

d. General Condition upon Discharge:



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