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Uterine

Myoma
Presented by:
Abu, Camile
Granada, Glyde Pebbles
Landicho, Katrina
Linatoc, Jeanne Lyn
Luza, Ailen
Maralit, Ma. Krishna
Sim, Khay
Ulan, Darlene
Umali, Marianne Lyn
Avena, Gaudencio
Dimaculangan, Argenald Joseph
Hernandez, Michael Franklin
INTRODUCTION
Uterine myoma is the most common tumors of
the female genitalia tract. Myoma commonly called
fibroid. It is the benign tumor of the smooth muscle in
the wall of the uterus. Hysterectomy has been a
common therapy in patients who have completed
reproduction. Total hysterectomy plus unilateral
salphingo oophorectomy TAHBSO- this procedure
removes the utereus, cervix, one ovary and one
fallopian tube, while one ovary and one fallopian tube
are left in places.
Fibroids can be present and be apparent. However
they are clinically apparent in up to 25 % of the
women. Although, myoma is generally considered to
be slowly growing tumor in 20-40% of women at the
age of 35 and more have uterine fibroids of
significant sizes with severe clinical symptoms.
Moreover, myoma can be relapse in 7-28% of patient
after surgical treatment and in certain case it may
even turn to malignant tumor, this could causes
significant morbidity including prolonged or heavy
menstrual bleeding, pelvic pleasure and pain and in
rare cases reproductive dysfunction. Myoma affects
one of every four women ¾ of woman with this
condition,however, experience no symptoms.
Uterine myoma is developing on the background of hyper
estrogen, progesterone, deficits in hyper gonodotrophine.
The majority of the researches say that the growth of
myoma depends on concentration of cystosolic receptors to
the sex hormones and their interactions, with the endrogen
or extrogen hormones. In accordance to clinical
observations, it can be admitted that both growth and
regressions of myoma are estrogen-dependent, is the tumor
size gets increased during pregnancy and is regressed after
menopause. The only that needs to clear is to find out
whether it is decreased in receptors numbers of estrogen,
progesterone and androgen- hormones quantities which
lead to regression in myoma size ( regarding androgen there
is an hypothesis that myoma is sensitive to androgen ) for
growth that formed tumors, the need to be further supported
by negative factors.
Abortions, long term used of inadequate contraceptive
pills, chronic sub-acute and acute inflammation of uterus
or its appendices, stress, ultraviolet radiation, cystic
formation of ovary etc. for example, the woman who had
ten abortions by the age of thirty have double to
developed uterine myoma at fourty years old. In fact,
uterine myoma = account for 20% of 650,000
hysterectomies performed annually in the U.S interest in
the uterine preservation and organ preserving surgery
through techniques minimally invasive surgery has
increased the first reports of laparoscopic myomectomy.
SPECIFIC OBJECTIVES

To be able to:

> know the disease ,its clinical manifestations, risk factors,


pathophysiology and diagnostic procedures for the disease.
> Identify different medical and surgical management of a
patient diagnosed with uterine myoma.
> Enhance our skills in caring a patient with uterine myoma.
> Familiarized us with the medications used to managed the
disease.
> Recognized appropriate nursing care and management.
> Help the patient realized her role in maintaining and
improving health.
GENERAL OBJECTIVES

> Our group aims to be formulate a


comprehensive case analysis that would
provide essential knowledge and skills in
delivering quality health care to patient’s
diagnosis with uterine myoma.
PATIENT’S PROFILE

PATIENT’S NAME: Lady L.


AGE: 48 years old
GENDER: Female
PERMANENT ADDRESS: Inosluban, Lipa City
BIRTHDATE: August 26, 1960
BIRTHPLACE: Lipa City, Batangas
CIVIL STATUS: Married
CITIZENSHIP: Filipino
RELIGION: Roman Catholic
ADMISSION DATE: August 22, 2008
ADMISSION DIAGNOSIS: Uterine Myoma
ATTENDING PHYSICIAN: Dra. Lovely Cacho
Dra. Alice Lojo
HISTORY OF PRESENT ILLNESSS

Present condition started about 6 years prior to


admission. When patient noted heavy vaginal bleeding and
body weakness every menstrual period that last almost a
week. Due to that instance, she went to the hospital for
check-up and she found out that she has a myoma. Her
attending physician said that she need to undergo surgery
but they didn’t have enough money that time, they would
need to save for the hospitalization and operation that will
undergo. Until August 22, 2008, when her relative noted
her to be pale, having dizziness and body weakness
bought her to the hospital. After a series of examination,
she was scheduled and prepared her to surgery.
PAST MEDICAL HISTORY

She has never been hospitalized except when


she had two breech presentations with her two
sons. Other than that, she usually experiences
cough, cold, fever and buys over the counter drugs
to treat the said illnesses. Prior to that, sometimes
she consults the said quack doctors or faith
healers if she thinks that it’s just that a simple
illness.
SOCIO – CULTURAL

She is a friendly person. She is closed with her four


sons and loves them so much. She admitted that few
years ago, she used to smoke when she is defecating
and after eating. She said that she loves to eat
vegetables and she exercises regularly. She cooks in a
canteen in Lipa bus stop which sustains their basic
needs.
PHYSICAL ASSESSMENT
ACTUAL NORMAL INTERPRETA
VITAL SIGNS VALUES TION

RR- 24 12-20 beats/min. Normal

PR- 80 60-100 Normal


beats/min.
BP- 120/70 90/60- 130/90 Normal
mmHg
Height = 5’1 cm Weight = 57 Kg.

Body Parts Technique Normal Actual Significance


used findings findings
Head Inspection NormocephaNormocephaNormal
Palpation lic lic Normal
No No
abdominal abdominal
mass mass
Hair and Inspection Evenly Even Normal
scalp distributed, distribution
Thick hair, of hair , no
no infection infection
and and
infestation infestation
Eyes Inspection Symmetric Sunken Not Normal.
to the face, eyeball Due to
both eyes dehydration
coordinated
with parallel
alignment.

External Inspection Hair evenly Evenly Normal


eye distributed, distributed
Structure Skin intact with skin
Eyebrows intact
Eyelashes Inspection Equally Equally Normal
distributed, distributed,
Curled Curled
slightly slightly
outward outward
Eyelids Inspection Skin intact, Skin intact, Normal
No no
discharge, discharge,
No no
discolorationdiscoloration
, , lids are
Lids close symmetrical.
symmetricall
y
Lacrimal Inspection No edema No edema Normal
gland or tearing. and tearing
Pupils Inspection Black in Black in Normal
(color , color, equal color, equal
shape and in size in size 4mm
symmetry normally 3- in diameter
of size) 7 mm in
diameter,
round
smooth
border , iris
flat and
round.
Ears Inspection Symmetrica Positioned Normal
lly aligned symmetrically
to the face, to the face,
firm and No notable ear
not tender discharge,
with no clean and dry,.
discharged
noted.

Nose Inspection Symmetric Symmetric Normal


and and straight ,
straight, no no nasal
discharges discharges
or flaring noted, no
flaring noted
Mouth Inspection Uniform Uniform dark Not Normal
Lips pink in color dry due to
color, soft chemical
and moist content of
and smooth cigarette
such as
nicotine.

Tongue Inspection Tongue at Dry and free ofNormal


midline lesion
without
lesion
Teeth Inspection Complete, Incomplete, Not normal.
white, shiny missing teeth, ill Aging is a
tooth enamel, fitting dentures factor
free of debris affecting loss
of teeth and
also
insufficient
calcium and
fluoride.

Neck Inspection Coordinated , Coordinated Normal


Palpation smooth movement with Normal
movement no discomfort
with no No masses,
discomfort tenderness
No masses,
tenderness
Upper Inspection Pinkish in Pallor Not normal.
Extremities color It is a
Skin manifestatio
n of in
adequate
circulating
blood or
hemoglobin.

Palpation Slightly Poor skin turgor Not normal


moist due to
dehydration
Palpation Normother Not warm, not Normal
mia cold to touch,
T=36
Arms Inspection Normally Normally firm, Normal
Palpation firm, no no contracture, Normal
contracture, no swelling,
no swelling, equal size on
equal size both sides of
on both body
sides of Pulse rate: 80
body
Pulse Rate:
60-100
Nails Inspection Smooth, highly Pink, smooth Normal
Palpation vascular and texture, convex Normal
intact curvature
epidermis Capillary refill: 2
Capillary Refill seconds
of 1-2 seconds

Chest and Inspection Symmetric Symmetric chest Normal


Lungs chest expansion, quiet,
expansion, rhythmic and
quiet, rhythmic effortless
and effortless respiration
respiration
Palpation No No retraction, Normal
retraction, no tenderness,
no no masses
tenderness,
no masses
Auscultatio Quiet, BronchovesiculNormal
n rhythmic ar and
vesicular
breath sounds
Heart Auscultatio Normal Cardiac rate of Normal
n heart rate 80
60-100bpm
Abdominal Inspection Unblemishe Lesions noted Not normal
d skin, on the surgical because of
uniform in site post
color procedure
done

Auscultation Average Audible bowel Normal


normal sound of 8 per
bowel minute
sounds 5-25
per minute
Lower Inspection No lesion, No edema, no Normal
extremities Palpation can move deformities Normal
Skin freely and can move
Capillary freely
refill: 1-2 Capillary
seconds refill: 2
seconds
IV. ANATOMY AND PHYSIOLOGY
ANATOMY OF FEMALE REPRODUCTIVE ORGAN
STRUCTURE LOCATION & FUNCTION
DESCRIPTION

Cervix The lower narrower portion During childbirth,


of the uterus. contractions of the
uterus will dilate the
cervix up to 10 cm in
diameter to allow the
child to pass through.
During orgasm, the
cervix convulses and
the external is dilates
Fallopian tubesExtending upper Egg transportation from
part of the uterus ovary to uterus (fertilization
on either side. usually takes place here).

Ovaries Pelvic region on Provides an environment for


(female either side of the maturation of oocyte.
gonads) uterus. Synthesizes and secretes sex
hormones (estrogen and
progesterone).
Vagina Canal about 10-8 cm Receives penis during mating.
long going from the Pathway through a woman’s body
cervix to the outside of for the baby to take during
the body. childbirth. Provides the route for
the menstrual blood (menses) from
the uterus, to leave the body. May
hold forms of birth control, such
as an IUD, diaphragm, neva ring,
or female condom

Uterus Located in the center of House and nourishes the fetus.


Endometrium the pelvic cavity Contains glands that secrete fluids
Myometrium The innermost layer of that bathe the uterine lining.
Perimetrium uterine wall. Contract to help expel the baby.
Smooth muscle in the Covers the uterus
uterine wall.
Outer layer of the
uterus
Uterus Located in the House and nourishes the
Endometrium center of the pelvic fetus.
Myometrium cavity Contains glands that
Perimetrium The innermost layer secrete fluids that bathe
of uterine wall. the uterine lining.
Smooth muscle in Contract to help expel
the uterine wall. the baby.
Outer layer of the Covers the uterus
uterus
ESTROGEN
It is the most important hormone during puberty
in female and is responsible for secondary sexual
characteristics (e.g. breast enlargement, menstruation,
pelvic enlargement, long bones). Generally secreted by
the ovary specifically secreted by the Grafian follicle.
Estrogen production

Hypothalamus

GnRH

Anterior Pituitary Gland

FSH

Graafian Follicle

Estrogen
V. PATHOPHYSIOLOGY

Pregnancy Early Menarche


(11 years old)

Increase the lifetime exposure


Increase Estrogen production
to estrogen

Stimulates the growth of fibroid

Grows in the anterior wall of the uterus


Pelvic pain

Deform uterine cavity

Menorrhagia

Myoma
VI. COURSE IN THE WARD
Day 1
A 48 years old female was admitted at exactly 2:16:07 p.m last
August 22, 2008, accompanied by her son, with a chief complaint
of body weakness. She was admitted under the service of Dra.
Lovely Cacho and Dra. Alice Lojo and following orders are
given. Diet as tolerated, temperature, pulse rate and respiratory
rate must be recorded every shift, for chest x-ray posterior-
anterior, for electrocardiogram x 12 leads, for complete blood
count blood typing and for chem. 7. It was done at the same day.
The physician ordered a 5% Dextrose in Lactated Ringers 1 liter
plus 1 ampule of EC to be regulated at 20 gtts/min. The physician
ordered four units of whole blood that are properly typed and
cross matched to be run for 4-6 hours. The physician also ordered
“Lady L” that may have full diet at 4:40 p.m. The first unit of
whole blood with a serial number B-08-4660 started at 10:00
p.m.. Diphenhydramine 1 ampule intravenous 30 min. prior to
blood transfusion.
Day 2
The above unit of blood finished at August 23, 2008, 2:20 a.m. There
is no reaction during and after the blood transfusion. At the same
time, the second unit of whole blood with a serial number B-08-4681
was hooked and consumed at 7:20 a.m. The third unit of blood with a
serial number B-08-4666 was started at same time. The blood
transfusion site was transferred from left to right at 11:20 a.m. At
12:30 p.m., the third unit of whole blood with a serial number B-08-
4668 was consumed and followed up of fourth unit of whole blood
and consumed at 4:30 p.m. Intravenous fluid number one consumed
and followed the number two 5% Dextrose in Lactated Ringers 1 liter
plus one ampule of EC regulated at the same rate. By 11:10 p.m.
“Lady L” is under nothing per orem. “Lady L” informed about Total
Hysterectomy Bilateral Salphingo Oophorectomy with signed consent
of her husband and her son at the same day. Anesthesiologist on deck
was informed. Cefuroxime 750 mg, intravenous started every 8 hours
after negative skin testing. At 11:40 p.m. Valium tablet 5 mg one
tablet was given as pre-operative drugs.
Day 3
August 24, 2008, at exactly 7:00 a.m. “Lady L” was brought to
the operating room. At 4:50 p.m. post-op orders were given.
Monitor vital signs every 15 minutes until fully stable. Nothing
per orem temporarily. The patient was instructed to lie flat on bed
and low back rest for pneumonia precaution. Oxygen inhalation
administered at 3 liters per minute. Suction secretion when
necessary. Intake and output were recorded hourly. 5% Dextrose
Lactated Ringers 1 liter post-op to run at 15gtts/min then to
follow 5% Dextrose Lactated Ringers 1 liter at same rate. Last
dose of Cefuroxime to consumed, Metronidazole 500 mg slow
intravenous push every 6 hours. Tramadol 500 mg after negative
skin testing every 6 hour. Intravenous fluid regulated at 30
gtts/min when blood transfusion finished. Repeat hemoglobin
and hematocrit.
At 5:20 p.m. the operation ended and at 6:40 p.m. patient was
bought to the intensive care unit and hooked to ventilator and
Furosemide 40 mg IV was given. At around 8:45 p.m
Omeprazole 40 mg IV was given. Serum, sodium, potassium,
chloride, prothrombin time, partial prothrombin time done and
result in “Lady L” was nebulized if Combivent 1 neb and
maintained every 8 hours potassium 30 millequivalent
incorporate to her intravenous fluid and decrease it to 8 hours.
Another one unit of packed red blood cell, Calcium gluconate
one ampule was given thru slow intravenous push.
Day 4
August 25, 2008, 5a.m. patient was brought to room 206 and then
nebulization started and extubated at the time and secretion
suctioned. Oxygen maintained at 4 liters per minutes via nasal
canula. Diphenhydramine one ampule was given at 3:30 p.m, 30
minutes prior to blood transfusion. Blood type “B” with a serial #
of BO8-445 run at 4-6 hours. At 6:05 p.m “Lady L” was
confirmed that she is positive in flatulence and may sips of water
and hot soup. Measuring drained output was recorded shiftly.
Day 5
1 a.m. of August 26, 2008, to follow intravenous fluid 5%
Dextrose Lactated Ringers 1 liter regulated at same rate and
encouraged patient to turn side to side. Serum, creatinine, and
complete blood count done. At 9:37 a.m. the physician advised to
continue medications. At 10:00 p.m. patients temperature is
38.2˚C and paracetamol 200 mg one ampule was given thru
intravenous. At 11:03 a.m. nebulization was stopped. The
physician suggests changing Cefuroxime to Tazocin 4.5 grams
intravenous every 8 hours. Above intravenous fluid consumed
and followed up of 5% Dextrose in Lactated Ringers 1 liter
regulated at same rate. At 3:15 p.m. incentive spirometer every 8
hours and two minutes oxygen inhalation was discontinued.
Patient was encouraged to ambulate. At 8:30 p.m. intravenous to
follow of 5% Dextrose Lactated Ringers 1 liter regulated at same
rate. Foley catheter was removed at 9:15 p.m. At 10:45 p.m
“Lady L” was gargled a one tablespoon of Orahex solution plus
30 cc water every 6 hours.
Day 6
Nursing care done. Vital signs are monitored and recorded.
Intravenous fluid regulated at 15 gtts/min “Lady L” has no
further complaint. The patient is ambulatory. Tazocin 4.5 grams
intravenous every 8 hours was given. Attending Physician did not
visit’s the patient and no new orders were made that day.
Day 7
August 28, 2008, patient may have clear liquid then soft diet at 4
p.m., above intravenous fluid consumed and followed up of 5%
Dextrose Lactated Ringers 1 liter regulated at the same rate. For
possible discharge on the next day.

Day 8
August 29, 2008, removal of jackson-pratt drain was done and
intravenous fluid was terminated. There is no o objection for
discharge. Home medications instructed and patient may go
home and start oral medication. At 8 p.m. patient was discharged
accompanied by her son via the wheelchair.
VII. LABORATORY
AUGUST 22, 2008
ULTRASOUND
Transvaginal Ultrasound

Transabdominal pelureus shows an enlarged uterus measure


about 12.6x7.5x9.1 cm (LxWxAP). There is a large hypo echoic
mass in the posterior lower segment of the uterus, measuring
approximately 10.0x10.0x9.0 cm.
There is a cystic structure with internal echoes and septations in
the night adnexae, measuring about 60x4.5x4.3 cm.
There is no fluid in the posterior culde-sac.

Impression:
Enlarged uterus with large sub serous myoma wit
intramural component, posterior lower segment consider ovarian
cyst at the right. Normal left ovary.
AUGUST 22, 2008
CLINICAL CHEMISTRY

Laboratory Test Normal Value Result Significance/Inter


pretation
FBS 3.89-5.84 mmol/L 4.24 mmol/L Normal

BUN 2.5-8.33 mmol/L 2.80 mmol/L Normal


Creatinine 45-235 u/L 89.0 u/L Normal
Bld. Uric Acid 143-345 mmol/L 179.0 mmol/L Normal
Triglyceride 0.11-2.37 mmol/L 0.58 mmol/L Normal

HDL 0.25-2.65 mmol/L 1.50 mmol/L Normal

LDL 1.10-3.81 mmol/L 2.52 mmol/L Normal


AUGUST 22,
2008
HEMATOLOGY
Diagnostic/Laborat Normal Value Result Significance/Interpret
ory Test ation
Hemoglobin M 13.0-18.0 6.93 g/dL Anemia, recent
g/dL hemorrhage
F 12.0-16.0 g/dL

Hematocrit M 40-54% 21 % Anemia


F 37-47%
WBC 5,000-10,000 5,000 Normal

Platelet Count 150,000-450,000 337,000 cu/mm Normal


cu/mm
Segmenters 0.51-0.57 0.70

Lymphocytes 0.21-0.35 0.20

Monocytes 0.02-0.35 0.10 Normal


AUGUST 23, 2008
HEMATOLOGY
Diagnostic/Laborat Normal Value Result Significance/Interpret
ory Test ation
Hemoglobin M 13.0-18.0 10.8 g/dL Anemia, recent
g/dL hemorrhage
F 12.0-16.0 g/dL

Hematocrit M 40-54% 36.70 % Anemia


F 37-47%
WBC 5,000-10,000 6,500 Normal
Platelet Count 150,000-450,000 247,000 cu/mm Normal
cu/mm

Segmenters 0.51-0.57 0.83 Infection


Lymphocytes 0.21-0.35 0.11 Infection
Monocytes 0.02-0.35 0.06 Normal
AUGUST 24, 2008

HEMATOLOGY
Diagnostic/Laborator Normal Value Result Significance/Interpretati
y Test on
Hemoglobin M 13.0-18.0 g/dL 12.5 g/dL Normal
F 12.0-16.0 g/dL

Hematocrit M 40-54% 37.5 % Normal


F 37-47%
WBC 5,000-10,000 20,600 Infection

Platelet Count 150,000-450,000 225,000 cu/mm Normal


cu/mm
Segmenters 0.51-0.57 0.93 Infection

Lymphocytes 0.21-0.35 0.03 Infection

Monocytes 0.02-0.35 0.04 Infection

Eosinophill 0.01-0.04 Infection


AUGUST 24, 2008
CLINICAL CHEMISTRY

Laboratory Normal Value Result Significance/I


Test nterpretation

Sodium 135-145 142.3 mmol/L Normal


mmol/L
Potassium 4-4.5 mmol/L 3.133 mmol/L Hypokalemia
Chloride 99.9-110 106.7 mmol/L Normal
mmol/L
Pro- time 12-15 seconds 13 seconds Normal
AUGUST 24, 2008
CHEST X-RAY AP

> There are no active parenchemal infiltrates.


> The heart is not enlarged.
> Aorta is tortous.
> The rest of the findings are unremarkable.
> ET at level of T4.

Impression:
> Tortous Aorta
`
AUGUST 24, 2008
ABDOMEN AP

> Hx: S/P TAHBSO


> Free air is noted at the pelvic cavity.
> There are feces filled undilated bowel loops obscuring the renal and psoas shadows.
> The flank stripes are intact
> No abnormal calcification noted.

Impression:
>Pneumoperitoneum, likely post surgical.
AUGUST 25, 2008
HEMATOLOGY
Diagnostic/Labo Normal Result Significance/Interp
ratory Test Value retation

Hemoglobin M 13.0-18.0 10.5 g/dL Anemia, recent


g/dL hemorrhage
F 12.0-16.0
g/dL

Hematocrit M 40-54% 32.70 % Anemia


F 37-47%
WBC 5,000- 16,600 Infection
10,000
Platelet Count 150,000- 206,000 Normal
450,000 cu/mm
cu/mm

Segmenters 0.51-0.57 0.96 Infection

Lymphocytes 0.21-0.35 0.02 Infection

Monocytes 0.02-0.35 0.01 Infection

Eosinophill 0.01-0.04 0.01 Normal


AUGUST 26, 2008

HEMATOLOGY

Diagnostic/Lab Normal Result Significance/Inter


oratory Test Value pretation

Hemoglobin M 13.0-18.0 11.4 g/dL Anemia, recent


g/dL hemorrhage
F 12.0-16.0
g/dL
Hematocrit M 40-54% 35.10 % Anemia
F 37-47%

WBC 5,000- 15,200 infection.


10,000
Platelet Count 150,000- 196,000 Normal
450,000 cu/mm
cu/mm

Segmenters 0.51-0.57 0.90 Infection

Lymphocytes 0.21-0.35 0.08 Infection

Monocytes 0.02-0.35 0.02 Normal


AUGUST 26, 2008
CLINICAL CHEMISTRY

Laboratory Normal Result Significance/Interp


Test Value retation

Potassium 4-4.5 3.56 mmol/L Hypokalemia


mmol/L

Creatinine 45-235 u/L 102.0 u/L Normal


IX. DRUG STUDY
NAME CLASSIFI- ACTION INDICATION& ADVERSE NURSING
CATION DOSAGE REACTION CONSIDE-
RATION
Generic Antiprotozoals or Direct -acting >Amebic liver >CNS: headache, > Monitor liver
Name:Metronida Antimicrobia trichomonacide abcess>To seizure, fever, function test
zoleBrand and amebicide prevent post vertigo, ataxia, result carefully in
Name:Flagyl that works inside operative dizziness>CV: elderly patient.>
and outside the infection in flattened T wave, Observe pt. for
intestines. It’s contaminated or edema, edema especially
thought to enter potentially flushing>EENT: if receiving
the cells of contaminated rhinitis, sinusitis, corticosteroid>Re
microorganisms colorectal surgery pharyngitis>GI: cord number and
that contain Dosage:500mg nausea, character of
nitroreductase, IV abdominal stools when drug
forming unstable cramping or pain, is used to treat.
compounds that stomatitis,
bind to DNA and vomiting,
inhibit synthesis, diarrhea>GU:
causing cell vaginitis,
death. darkened urine,
polyuria,
NAME CLASSIFI- ACTION INDICATION& ADVERSE NURSING
CATION DOSAGE REACTION CONSIDE-
RATION
Generic Cephalosporins Inhibits cell wall Serious lower > CV: > Before giving
name:Cefuroxime synthesizes respiratory tract thrombophlebitis, drugs, ask patient
Brand Name: promoting infection, UTI, phlebitis > GI: if he allergic to
Zinacef osmotic skin structure diarrhea, nausea, penicillin or
instability infection, bone or vomiting, cephalosporins>
joint infection, anorexia> Skin: Obtain specimen
gonorrheaDosage maculo papular, for culture and
:750mg IV erythematous sensitivity test
rashes before giving first
dose
NAME CLASSIFI- ACTION INDICATION& ADVERSE NURSING
CATION DOSAGE REACTION CONSIDE-
RATION
Generic Opioid Analgesic > Bind to opioid > Moderate to > CNS: dizziness, > Monitor CV,
Name:TramadolB receptors and moderately headache, and respiratory
rand inhibit reuptake severe vertigo, anxiety, status withhold
Name:Ultram of norepinephrine painDosage:50m confusion> CV: dose and notify
or serotonin g IV vasodilation > prescriber if
EENT: visual respiration
disturbances> GI: decrease or rate is
constipation, below 12bpm>
nausea , Monitor bowel
vomiting, and bladder
abdominal pain> function > For
GU: menopausal better analgesic
symptoms urine effect give drug
retention before onset of
intense pain.
NAME CLASSIFI- ACTION INDICATION& ADVERSE NURSING
CATION DOSAGE REACTION CONSIDE-
RATION
Generic Anti Ulcer Drug > Inhibits activity > Symptomatic > CNS: asthenia, > Drug increases
Name:Omeprazol of acid pump and GERD without dizziness, its bioavailability
eBrand bind to hydrogen esophageal headache> GI: with repeated
Name:Losec potassium lesion> short abdominal pain, doses. Drug is
adenosine, term treatment of constipation, unstable in
triphosphatase at active benign nausea, vomiting gastric acid; less
secretory surfaces gastric drug is loss to
of gastric parietal ulcerDosage:40m hydrolysis
cells to block g IV because drug
formation of increases gastric
gastric acid pH.>Dosage
adjustment may
be necessary in
Asians and
patients wit
hepatic
impairment.
NAME CLASSIFI- ACTION INDICATION& ADVERSE NURSING
CATION DOSAGE REACTION CONSIDE-
RATION
Generic Bronchodilators >Relaxes >To prevent or >CNS: tremor, >Drug may
Name:Salbutamol bronchial, uterine treat nervousness, decrease
Brand and vascular bronchospasm in headache >CV: sensitivity of
Name:Combivent smooth muscle patients with tachycardia , spirometry used
by stimulating reversible palpitations, for diagnosis of
beta2 receptors. obstructive hypertension>E asthma.>Use of a
airway ENT: dry and AeroChamber
diseaseDosage:1 irritated may improve
nebule nose>GI: drug delivery to
nausea, lungs.>Tell
vomiting,anorex patient to remove
ia canister and wash
inhaler with
warm, soapy
water at least
once a week.
NAME CLASSIFI- ACTION INDICATION& ADVERSE NURSING
CATION DOSAGE REACTION CONSIDE-
RATION
Generic Antibiotics >Inhibits cell- >Moderate to >CNS: headache, >Before giving
Name:Piperacilli wall synthesis severe infections insomnia, fever drug, ask patient
n SodiumBrand during bacterial from piperacillin- >CV: about allergic
Name:Tazocin multiplication. resistantDosage:4hypertension, reactions to
.5g IV tachycardia, chest penicillins>Obtai
pain>EENT: n specimen for
rhinitis >GI: culture and
diarrhea, nausea, sensitivity test
vomiting before giving first
dose.>Monitor
patient’s sodium
intake.
X. NURSUNG CARE PLAN
ASSESSMENT DIAGNOSIS PLANNING NURSING INTERVENTIONS EVALUATION

SUBJECTIVE: Pain related to After 4 hours of INTERVENTIONS RATIONALE After 4 hours of


“Masakit ang tahi tissue trauma and nursing nursing
ko” as verbalized incisional intervention intervention the
by the patient. discomfort as patient’s pain Change the position Pain is sometimes patient reported
OBJECTIVE: manifested by evidenced by of the patient due to the position of pain was
Restlessness grimace and pain pain scale =7 be Provide comfort the patient lessened to pain
Irritability scale =7. reduced to 3. measures  To reduce the scale =3.
With cold Assist patient in discomfort
clammy skin breathing techniques To assist in muscle
Excessive Provide quiet and generalized
perspiration environment relaxation
Facial grimace Relay on the patient For patient
Increased report of pain comfortabili-ty and
respiration RR=26 Encourage lessen the discomfort.
bpm divertional activities To reduce anxiety
Pain scale = 7: Monitor vital sign felt by the patient
pain scaling of 1- Administer analgesic To divert the
10 where 1 is the as ordered by the AP attention from pain to
least painful and activities
10 is the most Usually altered in
painful pain.
Impaired thought To maintain
acceptable level of
pain.
ASSESSMENT DIAGNOSIS PLANNING NURSING INTERVENTIONS EVALUATION
OBJECTIVE: Fluid volume After 8 hours INTERVENTION RATIONALE After 8 hours of
Poor skin turgor deficit related to of nursing S nursing
Dry lips the risk of post- intervention the intervention, the
Weak in operative patient will  Change dressings To protect patient was

appearance hemorrhage. maintain fluid frequently the skin and maintained fluid as
Pale looking at a functional  Provide frequent monitor losses manifested by
v/s of: level. oral care  To prevent good skin turgor
BP = 100/80  Measure input and injury from
PR = 64 output dryness
RR = 26 Monitor v/s Helps
T = 37.8 Administer IV maintaining
fluids as indicated fluid in the
Give medications body
as ordered by the To monitor
attending physician fluids in the
body
To assess the
patient and it
serve as base
line data
To reduce
blood loss
ASSESSMENT DIAGNOSIS PLANNING NURSING INTERVENTIONS EVALUATION

SUBJECTIVE: Impaired After 8 hours INTERVEN- RATIONA- After 8 hours of


“Hindi ako mobility relatedof nursing TIONS LE nursing
makagalaw ng to decreased intervention the intervention, the
Provide To reduce
ayos” as muscle strength patient will be patient was able to
verbalized by the as manifested able move activities with the fatigue move safely and
patient. by limited safety and adequate rest Promotes
independently.
OBJECTIVE: ROM. independently. period. well being and
Impaired ability Encouraged maximize
to turn side to adequate intake energy
side. of fluids production
Cannot eat Advise to move To
without support hands and legs exercise/mobili
Slowed slowly zation of body
 Encourage parts and
movement
Irritable participation in develop muscle
Limited ROM self care strength
Enhances
self concept
and sense of
independence
XI. DISCHARGE PLANNING

Medication
Ciprofloxacin 500 mg 1tablet 3x a day for 1 week
Metronidazole 500 mg 1 tablet 3x a day for 1
week
Tramadol (Dolcet) 1 tablet 3x a day for pain

Environment
Instruct patient’s relative to provide the patient an
environment conducive for her easy recovery. Her
place/room in their house must be the most accessible
area. Her environment should be free from
contamination and infection.
Treatment
The patient should follow the physician’s prescription and
should take his home medication on the right time and right dose.

Health Teaching
Instruct the patient the importance of proper taking of medication
on time.
Instruct the patient and her family the proper wound care to avoid
contamination and infection at surgical site.
Instruct the patient to eat nutritious foods.
Encourage ambulation for early recovery.
Good sanitation is advised.
Out Patient Department
The patient should return on the scheduled date of her
follow up check-up on September 5, 2008 in Metro Lipa Medical
Center from 4:30 pm to 6:30 pm and should continuously take
her home medication as prescribed by her physician. The patient
should visit her physician whenever she feels any discomfort.

Diet
Diet as Tolerated. In order to attain proper diet, the
patient should be guided to the prescribed foods as advised by her
physician. Her meals should include Vitamin C-rich foods for
wound healing.
Spiritual
Patient should enhance her spiritual relationship with
God. Have faith and trust in God’s divine power, and believed
that the lord will help in her early recovery. Keep on praying,
because praying is the number one key to live a healthy life and
to be close to God.
XII. PROGNOSIS
The mortality rate in uterine myoma is low provided early
diagnosis and management are made and no complication will
occur. According to the attending physician the case of Lady L
greatly improved after the management, therefore, the prognosis
is good.
XII. EVALUATION
Date 22 23 24 25 26 27 28 29

D5LR 1L √ √ √ √ √ √ √

BT FWB√ √

TPR
temp 36.7 36.2 36 37.3 36.8 36.2 37.6 36.2

BP 120/70 120/80 120/70 130/80 130/80 110/70 140/90 120/70

RR 24 20 21 24 22 20 28 22
PR 80 90 72 91 68 75 80 68
MEDS 22 23 24 25 26 27 28 29
Omeprazol √
e
Salbutamo √ √ √ √ √
l
(combiven
t)
Piperacilli √ √ √ √ √ √
n
(Tazocin)

Tramadol √ √
(ultram)

Diphenhyd √ √ √ √
ramine
HCl
(Benadryl)

Metronida √ √ √ √ √ √
zole
(Flagyl)
Metronidazole √ √ √ √ √ √
(Flagyl)

Cefuroxime √
(Zinacef)

Paracetamol √

CXR AP √

Abdomen AP √
UTZ √

Clinical √ √ √
Chemistry

Cross Matching √

Hematology √ √ √ √ √

DIET 22 23 24 25 26 27 28 29

DAT √ √

Soft diet √

NPO √ √ √ √