Lourdes College

College of Nursing
Capistrano Street, Cagayan de Oro City

In Partial Fulfillment
Of the Course
NCM 102 – RLE
Maternal and Child Health Nursing

SUBMITTED TO:

Mrs. Ma. Lourdes C.Tayag, RN

Clinical Instructor

SUBMITTED BY:

Jonale Marikit A. Barcelona

TABLE OF CONTENTS
I. INTRODUCTION

II. PATIENT’S PROFILE/ASSESSMENT

• DEMOGRAPHIC DATA
• REASONS FOR HOSPITALIZATION
• HEALTH PERCEPTION/HEALTH MANAGEMENT
• PHYSICAL ASSESSMENT
A. GENERAL APPEARANCE
B. FUNCTIONAL HEALTH ASSESSMENT
• DEVELOPMENTAL TASK

III. MEDICAL MANAGEMENT

IV. DIAGNOSTIC EXAM

V. DRUG STUDY

VI. DIAGNOSIS OF CARE

• ANATOMY AND PHYSIOLOGY
• PATHOPHYSIOLOGY

VII. ACTUAL NURSING MANAGEMENT

VIII. DISCHARGE PLAN/PROGNOSIS

IX. EVALUATION/IMPLICATION

X. BIBLIOGRAPHY

XI. APPENDIX

I.INTRODUCTION:
 Pelvic organ prolapse occurs when a pelvic organ-such as your
bladder-drops from its normal spot in your lower belly and pushes against
the walls of your vagina. This can happen when the muscles that hold your
pelvic organs in place get weak or stretched from childbirth or surgery.

Many women will have some kind of pelvic organ prolapse. It can be
uncomfortable or painful. But it isn't usually a big health problem. It doesn't
always get worse. And in some women, it can get better with time.

Pelvic organ prolapse is most often linked to strain during childbirth.

Normally your pelvic organs are kept in place by the muscles and tissues in
your lower belly. During childbirth these muscles can get weak or stretched.
If they don't recover, they can't support your pelvic organs.

You may also get pelvic organ prolapse if you have surgery to remove
your uterus. Removing the uterus can sometimes leave other organs in the
pelvis with less support.

Pelvic organ prolapse can be made worse by anything that puts pressure on
your belly, such as: being very overweight (obesity), long-lasting cough,
frequent constipation and Pelvic organ tumors.

This case study is about a patient having pelvic organ prolapsed.

II.PATIENT PROFILE/ ASSESSMENT

A.DEMOGRAPHIC DATA

My patient’s name is Sittie Ganim. She’s a Muslim. She is 41

years old and married housekeeper. She lived In Gata Poona Banabao ,
Lanao del Sur. She was admitted last January 19, 2010 and was diagnosed
Pelvic Organ Prolapse.

B. REASONS FOR HOSPITALIZATION

One week prior to admission patient has an episode of

abnormal bleeding. An ultrasound finding was normal sized uterus with slight
endometrial thickening 10.54cm, Nabothian cyst cervix. Vaginal mass after
lifting object. This was prompted and consulted and for admission on January
19 2010. Patient is scheduled for surgery.
The name of the surgery was Anterior and Posterior Colporraphy.
She also undergone ultrasound prior to admission.

C. HEALTH PERCEPTION/HEALTH MANAGEMENT

This is her first hospitalization. No hospital admission, medical or

surgical treatment received previously. Patient was worried about her illness
and perceived it as a threat on her activity of daily living. She has a family
health history of Diabetes on paternal side. Patient doesn’t smoke and she
has no allergy on food and medication as stated.

D. PHYSICAL ASSESSMENT

GENERAL APPEARANCE

Observed weak and thin body build and poor posture, height is
appropriate to age. Hygiene was not well maintained but hair was fair and
fixed. Patient is cooperative and able to answer some queries. She is a little
bit drowsy and needs rest.
FUNCTIONAL HEALTH ASSESSMENT

VITAL SIGNS

The patient’s vital signs upon admission last January 19,

2010 were: Temperature was 36.3 C, Pulse Rate was 80 bpm, Respiration

was 21 cpm and Blood Pressure was 110/90 mmHg.

The patient’s latest vital signs are: Temperature is 36.8

C, Pulse Rate is 67 bpm, Respiration was 19 cpm and Blood Pressure is

110/70 mmHg.

NUTRITION/METABOLIC PATTERN

The patient’s usual diet type is rich in carbohydrate and

vegetables.
Since she is a Muslim so she doesn’t eat pork. She isn’t taking any Vitamins
and food supplements. She has no food preferences. She eats three times a
day. Her usual breakfast is bread and coffee. Her usual lunch and dinner is
vegetable and rice. She usually ate rice and any viand except pork during
lunch and dinner. She hasn’t experienced loss of appetite, nausea and
vomiting and heartburn during eating. She has no allergy to foods. She has
no problems when it comes to swallowing. She has dentures on both upper
and lower gum. Her usual weight is 40 kg. She doesn’t get hot and cold that
easily.
 The patient is tall. Her skin turgor is elastic or good. She has
pale skin and it is moist to touch. She has no edema and no thyroid
enlargement. The condition of his teeth is normal. Her tongue is normal and
slightly rough and pink in color. Her oral mucous membranes are moist. She
has presence of IV, a 1L of D5LR at her left arm. She has no presence of tube
feeding.
ELIMINATION

The patient’s usual bowel pattern is twice a week. She isn’t

taking any laxatives for her to be able to defecate. She said her stool is well-
formed. She has no constipation and diarrhea. She has no history of pain and
bleeding every time she defecates. She has no hemorrhoids. Her usual
voiding pattern is 2-3 times per day. She said her urine is pale yellow and
hazy. She has no pain, burning and difficulty in voiding. She has no history of
kidney and bladder disease. She isn’t taking any diuretics for her to be able
to void.

The patient’s abdomen is soft to touch and is palpable. Can

hear bowel sounds in her upper and lower quadrant in her left and right.

The activity of her abdomen is normal. She has no hemorrhoids and stool
guaiac. There’s no any nasogastric tube for lavage, no presence of foley bag
catheter, no condom catheter and no diaper.

RESPIRATION

The patient’s breathing is normal. She has no cough. She

has no history of illnesses and any other diseases when it involves her lungs.
She is not a cigarette smoker.
 The patient’s respiratory rate is 19 and it is normal and
regular. She isn’t using any accessory muscles and nasal flaring in order for
her to breathe normally. Her breath sounds is clear. There are no sounds of
ronchi, crackles and wheeze on her lungs. The patient is not cyanotic
andthere is no clubbing of fingers. The patient has no cough so there’s no
reason for her breath to be altered.
CIRCULATION

The patient has no history of hypertension, heart trouble,

rheumatic fever, ankle/leg edema, phlebitis, slow healing, claudication,
dysflexia, palpitations and syncope. The patient experience numbness on her
legs if she sat for a period of time. The patient has no cough. The patient
didn’t experience chest pain

The patient’s BP is 110/70 mmHg. Her pulse pressure is 30

mmHg. Her radial and apical pulse rate is 67 bpm and the pulse strength is
4. Her pedal pulse in her right and left is regular and the pulse strength is 4.
There are no vascular bruit, murmur and jugular vein distention. Her breath
sounds is normal. The color of her extremities is pale. Her capillary refill is
pink. There are no Homan’s Sign, varicosities, nail abnormalities andedema.
Her hair distribution is normal. She is pale in appearance. Her mucous
membrane is pinkish. Her lips are pinkish brown. Her nail beds are pink. Her
conjunctiva is pink. Her sclera is white. She has presence of IV, a 1L of plain
NSS regulating at 30 gtts/min infused on her right metacarpal vein arm.
There were no redness, swelling and edema on the IV site.

ACTIVITY/SAFETY/MOBILITY STATUS
 The patient is a housekeeper. Her usual activities are to
take good care of her children and do the household chores. Her hobby is
watching TV. There is limitation imposed by her condition and she is not
allowed to lift heavy objects. She usually does what she had to do. She slept
for about 9 hours. And her naps are for about 1 hour. She had no insomnia so
she can really sleep well. She had no feelings of boredom and dissatisfaction.
She can walk, eat, bath, dress and toileting on her own. She usually took a
bath at 6 in the morning. The patient has no allergies to anything. She hadn’t
been exposed to any infections. She was completely immunized. There was
no previous alteration of immune system and history of sexually transmitted
disease. There were no fractures, arthritis, back problems, changes in moles,
delayed healing, cognitive limitations, impaired vision and hearing,
prosthesis and ambulatory devices.
The patient’s cardiovascular, respiratory, mental status,
neuromuscular assessment, muscle mass tone, posture, range of motion and
strength are all normal. She had no any deformities. She’s pale in
appearance. She is not that well groomed in the way she dresses. She had
no personal habits and body odor. The condition of her scalp is normal.
She had scars. She had no rashes, lacerations, ulcerations, ecchymoses,
blisters, burns and drainage. There were no cultures, immune system testing
and tuberculosis testing done to her.

COGNITION AND PERSPECTIVE/SENSORY REFLEXES

NEUROSENSORY

The patient doesn’t feel of fainting and dizziness. Her

head aches but not very extreme. She can feel numbness on her legs
especially when she sat for about a period of time. She had no brain
injuryand seizures. Her vision is clear. She had no glaucoma and cataract.
Herhearing is clear.

The patient is oriented about what time it is, where she

is at, who she is and her situation. She is alert and cooperative. She had no
glasses, contacts and hearing aids. Her pupil’s shape is circle. Her facial
droop, swallowing, hand grasp and release, posturing and deep tendon reflex
a re all normal.

PAIN/DISCOMFORT

The patient can feel slight pain on her abdomen. The

frequency and duration is just depends on the situation. The quality is mild.
There were no precipitating/ aggravating factor and associated symptoms.

There is no facial grimacing. She’s not guarding the

affected area of pain. Her posture, behavior and emotional response are all
normal. Her blood pressure upon admission was 110/90 mmHg and her latest
blood pressure is 110/80 mmHg. Her pulse rate upon admission was 92 bpm
and her latest pulse rate is 78 bpm.

SEXUALITY/REPRODUCTIVE

The patient is sexually active. She and her husband

didn’t like to use condom or any birth control method. She doesn’t have any
sexual concerns and difficulties. Her age of menarche is 15. The length of
cycle is 28 days. Her menstruation lasted for three days. She uses 2 pads of
napkin per day. She’s not yet on the menopausal stage. There were no
vaginal lubrication and vaginal discharges. She is scheduled for Vaginal
Hysterectomy.
 The patient is comfortable about the thing I asked to her.
Her breast is normal. There were no genital warts/lesions and discharges.

SELF – CONCEPT/COPING

Patient stress factor is handling heavy works. She also

had no financial concerns. Her relationship with her family is okay. She can
feel connectedness with herself. She has no feeling of helplessness,
hopelessness and powerlessness. The patient is calm. Her movement is
normal.

SELF – CONCEPT/COPING/SOCIAL INTERACTION

The patient is married for 23 years. She have nine

siblings the eldest is 21 years old and the youngest is one tear and 5
months.. She had no perception about relationships. They were no extended
family. She had no feeling of mistrust, rejection, unhappiness and loneliness
towards her family. She had no problems related to her condition. She talked
in clear voice. There was no unusual speech impairment. No using of any
communication aids. There was no laryngectomy present
VALUES & BELIEFS

The patient’s religion is Islam and they are practicing

Ramadan. They are not allowed to eat pork.

E. DEVELOPMENTAL TASK

Care: Generativity vs. Stagnation (Middle Adulthood, 35 to

65 years)

• Psychosocial Crisis: Generativity vs. Stagnation

• Main Question: "Will I produce something of real value?"
• Virtue: Care
• Related Elements in Society: parenting, educating, or other productive social
involvement
Generativity is the concern of establishing and guiding the next generation.
Socially-valued work and disciplines are expressions of generativity. Simply
having or wanting children does not in and of itself achieve generativity.

During middle age the primary developmental task is one of contributing to

society and helping to guide future generations. When a person makes a
contribution during this period, perhaps by raising a family or working toward
the betterment of society, a sense of generativity- a sense of productivity
and accomplishment- results. In contrast, a person who is self-centered and
unable or unwilling to help society move forward develops a feeling of
stagnation- a dissatisfaction with the relative lack of productivity.

Central tasks of Middle Adulthood

• Express love through more than sexual contacts.

• Maintain healthy life patterns.
• Develop a sense of unity with mate.
• Help growing and grown children to be responsible adults.
• Relinquish central role in lives of grown children.
• Accept children's mates and friends.
• Create a comfortable home.
• Be proud of accomplishments of self and mate/spouse.
• Reverse roles with aging parents.
• Achieve mature, civic and social responsibility.
• Adjust to physical changes of middle age.
• Use leisure time creatively.
• Love for others

III.MEDICAL MANAGEMENT
DATE DOCTOR’S ORDER
&TIME
1/19/10

4:30 

12 MN
1/12/10

7:00 AM 
1/13/10

7:00 AM 
1/14/10

7:00 AM 

IV.DIAGNOSTIC EXAM

ULTRASOUND

Uterus was anteverted and measures 7.56cmx4.27cmx5.24cm (LxAPxW) wit

hompgenous myometrial echopattern and slightly thickened(0.84cm).

• Both ovaries are not visualized

• There is no fluid in the posterior Cul de Sac
• Normal sized uterus with slight endometrial thickening(0.84cm)
• Nabothian cyst cervix
HEMATOLOGY REPORT

Test Result Unit Reference

WBC 7,700 10^3/uL

RBC 4.0 10^6/uL 4.2 – 5.14
Hg 11.7 g/dL 12.0 – 18.0
Hematocrit 35 % 37.0 – 47.0
MCV 88 fL 82.0 – 98.0
MCH 29.2 pg 27.0 – 31.0
MCHC 31.3 g/dL 31.5 – 35.0
RDW – CV % 12.0 – 17.0

Differential Count

Lymphocyte (%) 28 % 17.4 –48.2

Neutrophil (%) 66 % 43.4 -76.2
Monocyte (%) 01 % 4.5 -10.5
Eosinophils (%) 05 % 1.0 -3.0
Platelet Count 428 10^3/uL 150 –400

URINALYSIS REPORT

Physical Properties Chemical Properties Microscopic

Macroscopic • Protein- negative • RBC/ hpf- 0-1

• Color-yellow
• Appearance-clear
• Reaction-6.5
• Specific gravity-
1000
• Glucose-negative • WBC/hpf- 0-2
• Ketones-negative • Epith cell-
• Blood-negative moderate
• Leukocytes- • M.threads-
negative abundant
• Nutrite-negative • Crystals- negative
• Bilirubin-negative • Bacteria- rare

VI.DIAGNOSIS OF CARE
ANATOMY AND PHYSIOLOGY

THE VAGINA

• A fibromuscular canal, 7-9 cm long, extending from the

uterus to the vulva.
• Four-walled structure with a vault superiorly into which
projects the cervix.
• The vaginal vault is divided into four fornices by the cervix.
• Relations:
Anteriorly: base of the bladder and urethra
Laterally: the levator ani, visceral pelvic fascia and ureters
Posteriorly (inferior to superior): the anal canal, rectum and
rectouterine pouch.
• Highly elastic structure, capable of distension during
delivery of the fetus.
• Support to the upper part of the vagina is provided by the
cardinal (transverse cervical) and uterosacral ligaments

SUPPORT OF PELVIC FLOOR

• Peritoneum: not contributory
• Pelvic fascia
• Pelvic floor fascia (fascia over pelvic floor muscles)
- Endopelvic fascia: main support
- Lateral cervical (transverse cervical, cardinal or Mackenrodt) ligament:
lateral aspect of cervix and upper vagina to pelvic side walls
- Uterosacral ligament: back of uterus to front of sacrum
- Pubocervical ligament (fascia): anterior aspect of cervix to back of body of
pubis
- Posterior Pubourethral Ligament: post. inf. Of symphysis pubis to ant. of
middle ⅓ of urethra & bladder
• Pelvic Floor muscles
- Levator ani muscle (pelvic diaphragm):
Pubococcygeus, Iliococcygeus, Puborectalis
- Coccygeal muscle
- Urogenital diaphragm: superficial and deeptransverse perineal muscles

Urogenital diaphragm

The urogenital diaphragm (perineal membrane) is a triangular sheet of dense

fibrous tissue spanning the anterior half of the pelvic outlet, which is pierced
by the vagina and urethra. It arises from the inferior ischiopubic rami and
attaches medially to the urethra, vagina and perineal body, thus supporting
the pelvic floor.

Perineal body

The perineal body lies between the vagina and the rectum and provides a
point of insertion for the muscles of the pelvic floor. It is attached to the
inferior pubic rami and ischial tuberosities through the urogenital diaphragm
and superficial transverse perineal muscles. Laterally it is attached to the
fibers of the pelvic diaphragm while posteriorly it inserts into the external
anal sphincter and coccyx.

Pelvic fascia

The endopelvic fascia is a meshwork of collagen and elastin which represents

the fused adventitial layers of the visceral structures and pelvic wall
musculature. Condensations of the pelvic fascia are termed ligaments and
these play an important part in the supportive role of the pelvic floor. The
natural 'variation' that exists in the inherent mechanical properties of these
and other supportive tissues in the pelvis has been emphasized in recent
studies.[7]

Pathophysiology

Although they may present with significant morbidity, pelvic organ

prolapse and stress urinary incontinence are mainly afflicitions that affect
quality of life. To appropiately treat these entities, comprehension of the
various theories of pathophysiology is paramount. Utilizing a Medline search,
this article reviews recent data concerning intrinsic (i.e., genetics,
postmenopausal status) and extrinsic factors (i.e., previous hysterectomy,
childbirth) leading to organ prolapse or stress incontinence
 Pelvic organ prolapse is a common and distressing condition. It occurs
when there is a weakness in the supporting structures of the pelvic floor
allowing the pelvic viscera to descend. While usually not life-threatening,
prolapse is often associated with deterioration in quality of life and may
contribute to bladder, bowel and sexual dysfunction. Extended life
expectancy and an expanding elderly population mean that prolapse is an
increasingly prevalent condition.

Symptoms associated with prolapse are often difficult to correlate with the
anatomical site or severity of the 'bulge' and are often nonspecific. Women
with prolapse typically complain of the sensation of a 'lump' or vaginal
'heaviness', recurrent irritative bladder symptoms, voiding difficulty,
incontinence or defecatory difficulty. Other symptoms such as low back or
pelvic pain may or may not be related to prolapse. Surgery for pelvic organ
prolapse accounts for approximately 20% of elective major gynecological
surgery and these increases to 59% in elderly women. The lifetime risk of
requiring surgery for prolapse is 11%, a third of these procedures are
operations for recurrent prolapse.

The incidence of urogenital prolapse increases with age. Approximately half

of all women over the age of 50 years complain of symptomatic prolapse.
One-third of all hysterectomies in postmenopausal women and 81% of
vaginal hysterectomies (representing about 16% of all hysterectomies) are
performed for prolapse. The yearly incidence of hysterectomy for prolapse
peaks in the 65-69-year age group at around 30 per 10,000.

Pelvic organ prolapse is more common following childbirth although it is

frequently asymptomatic. Studies have estimated that 50% of parous women
have some degree of urogenital prolapse and of these, 10-20% are
symptomatic.[5] Only 2% of nulliparous women are reported to have
prolapse and this is usually uterine rather than vaginal.
VIII.DISCHARGE PLAN/PROGNOSIS

Many women who have pelvic organ prolapse do not have symptoms and do not require
treatment. If your symptoms are bothersome, you may want to consider treatment. Treatment
decisions should take into account which organs are affected, how bad symptoms are, and
whether other medical conditions are present. Other important factors are your age and sexual
activity.

Many women are able to reduce pain and pressure from a pelvic organ prolapse with nonsurgical
treatment, which may include making lifestyle changes, doing exercises, and/or using a
removable device called a pessary that is placed into the vagina to support areas of prolapse.

If your pelvic organ prolapse is causing pain or problems with bowel and bladder functions or is
interfering with your sexual activity, you may want to consider surgery. Surgical procedures
used to correct different types of pelvic organ prolapse include repair of the supporting tissue of
the prolapsed organ or vagina wall. Another option is the removal of the uterus (hysterectomy)
when it is the prolapsed organ or if it is causing the prolapse of other organs (such as the vagina).

Sometimes surgery cannot repair all the prolapsed organs. And sometimes pelvic organ prolapse
comes back after surgery.

Initial treatment

Pelvic organ prolapse can be a long-lasting condition, but it does not have to be a cause of
symptoms that disrupt your life. Many women with pelvic organ prolapse are able to relieve their
symptoms without treatment by adjusting their activities and lifestyle habits. These changes
might include:

• Doing pelvic floor (Kegel) exercises every day to tighten and strengthen
pelvic muscles.
• Eating high-fiber foods to prevent constipation. Get at least 20g of fiber a
day.
 • Cutting down on caffeine (found in coffee, tea, and soft drinks), which acts as
a diuretic, causing you to urinate more often. Drink about 8 to 10 glasses of
water a day.
• Reaching and staying at a healthy weight.
• Avoiding activities, such as heavy lifting, that stress your pelvic muscles.

If your symptoms are not relieved by these lifestyle changes, you may want to consider treatment
for pelvic organ prolapse. Treatment will be different depending on which organs are involved,
how bad your symptoms are, and what other medical conditions are present. Treatment may
include using a vaginal pessary, a removable device that is placed into the vagina to support
areas of prolapse.

Ongoing treatment

Pelvic organ prolapse can be a long-lasting condition, but it often responds to adjustments in
activities and lifestyle habits. If you have tried self-care, such as eating high-fiber foods, staying
at a healthy weight, and doing pelvic floor (Kegel) exercises, but your symptoms are increasingly
bothersome, you may want to consider nonsurgical treatment. Treatment will be different
depending on which organs are involved, how bad your symptoms are, and what other medical
conditions are present. Treatment may include using a vaginal pessary, a removable device that
is placed into the vagina to support areas of pelvic organ prolapse.

Treatment if the condition gets worse

f you have pain and discomfort from pelvic organ prolapse that does not respond to nonsurgical
treatment and lifestyle changes, you may want to consider surgery. The choice of surgery
depends upon which organs are involved, how bad your symptoms are, and what other medical
conditions are present. Also, your surgeon may have experience with and preference for a certain
procedure. Types of surgery for pelvic organ prolapse include:

• Repair of the bladder (cystocele) or urethra (urethrocele).

• Removal of the uterus (hysterectomy).
• Repair of the rectum (rectocele) or small bowel (enterocele).
• Repair of the vaginal wall (vaginal vault suspension).
 • Closure of the vagina (vaginal obliteration).

Often the doctor performs more than one of these surgeries at the same time. These surgeries are
designed to treat specific symptoms, so other symptoms may remain after surgery.

If you are considering having children, you may want to delay pelvic organ surgery. If
you have surgery and then deliver a child vaginally, the strain on your pelvic organs may cause
them to prolapse again.

Sometimes surgery cannot repair all the prolapsed organs. And sometimes pelvic organ prolapse
comes back after surgery. If you have surgery to repair pelvic organ prolapse, whatever caused
the pelvic organ prolapse the first time may cause it to happen again. Certain exercises and
changes in lifestyle and diet can sometimes prevent this.

Pelvic organ prolapse may be a progressive condition, gradually getting worse and causing more
severe symptoms. But in many cases it does not progress and may improve over time.2

IX. EVALUATION/IMPLICATION
Damage to the muscular and fascial supports of the
pelvic floor as a result of pregnancy and childbirth contributes to the
development of prolapse. In the Oxford Family Planning Association
prolapse epidemiology study parity was the strongest risk factor for
the development of prolapse with an adjusted relative risk of 10.9.
While the risk increased with increasing parity, the rate of increase
slowed after two deliveries. Samuelsson et al . also found statistically
significant associations of increasing parity and maximum birth weight
with the development of prolapse

Denervation of the pelvic floor musculature has been

shown to occur following childbirth.Gradual denervation has been
demonstrated in nulliparous women with increasing age; however, the
 effects were greatest in those women who had documented stress
incontinence or prolapse Thus it would appear that partial denervation
of the pelvic floor is part of the normal aging process, which may be
accelerated by pregnancy and childbirth.

X. BIBLIOGRAPHY

http://www.meb.uni-bonn.de/dtc/primsurg/docbook/html/x6977.html
http://en.wikipedia.org/wiki/Erikson
%27s_stages_of_psychosocial_development
www.google.com
www.yahoo.com