VELEZ COLLEGE
F. Ramos St., Cebu City
College of Nursing

A CASE ANALYSIS REPORT ON PATIENT N.M.C., 47 YEARS OLD, FEMALE, DIAGNOSED WITH UTERINE LEIOMYOMA
(s/p TOTAL ABDOMINAL HYSTERECTOMY and BILATERAL SALPINGO OOPHORECTOMY),
BILATERAL OVARIAN NEWGROWTHS, METABOLIC SYNDROME, AND HYPERTENSION

Submitted By:
Villavelez, Carmina Anne Z.
BSN III-C

Submitted to:
Mrs. Miraluna Echavez, RN, MN

March 2013

UTERINE LEIOMYOMA/ UTERINE FIBROIDS
Uterine fibroids are noncancerous growths of the uterus that often appear during your childbearing years. Also called fibromyomas, leiomyomas or myomas, uterine fibroids aren't associated with an increased risk of uterine cancer and almost never develop into cancer.
As many as 3 out of 4 women have uterine fibroids sometime during their lives, but most are unaware of them because they often cause no symptoms. Your doctor may discover fibroids incidentally during a pelvic exam or prenatal ultrasound.
In general, uterine fibroids seldom require treatment. Medical therapy and surgical procedures can shrink or remove fibroids if you have discomfort or troublesome symptoms. Rarely, fibroids can require emergency treatment if they cause sudden, sharp pelvic pain or profuse menstrual bleeding.
Symptoms
In women who have symptoms, the most common symptoms of uterine fibroids include: * Heavy menstrual bleeding * Prolonged menstrual periods — seven days or more of menstrual bleeding * Pelvic pressure or pain * Frequent urination * Difficulty emptying your bladder * Constipation * Backache or leg pains
Rarely, a fibroid can cause acute pain when it outgrows its blood supply. Deprived of nutrients, the fibroid begins to die. Byproducts from a degenerating fibroid can seep into surrounding tissue, causing pain and fever. A fibroid that hangs by a stalk inside or outside the uterus (pedunculated fibroid) can trigger pain by twisting on its stalk and cutting off its blood supply.
Fibroid location influences your signs and symptoms: * Submucosal fibroids. Fibroids that grow into the inner cavity of the uterus (submucosal fibroids) are thought to be primarily responsible for prolonged, heavy menstrual bleeding and are a problem for women attempting pregnancy. * Subserosal fibroids. Fibroids that project to the outside of the uterus (subserosal fibroids) can sometimes press on your bladder, causing you to experience urinary symptoms. If fibroids bulge from the back of your uterus, they occasionally can press either on your rectum, causing constipation, or on your spinal nerves, causing backache.
When to see a doctor
See your doctor if you have: * Pelvic pain that doesn't go away * Overly heavy or painful periods * Spotting or bleeding between periods * Pain with intercourse * Difficulty emptying your bladder * Difficulty moving your bowels
Seek prompt medical care if you have severe vaginal bleeding or sharp pelvic pain that comes on suddenly.
Causes
Uterine fibroids develop from the smooth muscular tissue of the uterus (myometrium). A single cell reproduces repeatedly, eventually creating a pale, firm, rubbery mass distinct from neighboring tissue. The growth patterns of uterine fibroids vary — some fibroids may continue to grow slowly; other fibroids may remain the same size or even shrink on their own over time.
Fibroids range in size from seedlings, undetectable by the human eye, to bulky masses that can distort and enlarge the uterus. They can be single or multiple, in extreme cases expanding the uterus so much that it reaches the rib cage.
Doctors don't know the cause of uterine fibroids, but research and clinical experience point to these factors: * Genetic alterations. Many fibroids contain alterations in genes that are different from those in normal uterine muscle cells. * Hormones. Estrogen and progesterone, two hormones that stimulate development of the uterine lining during each menstrual cycle in preparation for pregnancy, appear to promote the growth of fibroids. Fibroids contain more estrogen and progesterone receptors than do normal uterine muscle cells. * Other chemicals. Substances that help the body maintain tissues, such as insulin-like growth factor, may affect fibroid growth.
Risk factors
There are few known risk factors for uterine fibroids, other than being a woman of reproductive age. Other factors that can have an impact on fibroid development include: * Heredity. If your mother or sister had fibroids, you're at increased risk of also developing them. * Race. Black women are more likely to have fibroids than are women of other racial groups. In addition, black women have fibroids at younger ages, and they're also likely to have more or larger fibroids. * Pregnancy and childbirth. Pregnancy and childbirth seem to have a protective effect and may decrease your risk of developing uterine fibroids.
Areas of research
Research examining other potential factors in the development of fibroids continues in these areas: * Obesity. Some studies have suggested that obese women are at higher risk of fibroids, but other studies have not shown a link. * Oral contraceptives. So far, strong data exist showing that women who take oral contraceptives have a lower risk of fibroids. This is generally true for all women, except those who start oral contraceptives between ages 13 and 16. Some evidence also shows that progestin-only contraceptives may decrease risk.
Complications
* discomfort * anemia from heavy blood loss. * fibroid tumors can grow out of your uterus on a stalk-like projection. If the fibroid twists on this stalk, you may develop a sudden, sharp, severe pain in your lower abdomen. * distort or block your fallopian tubes * interfere with the passage of sperm from your cervix to your fallopian tubes * Submucosal fibroids may prevent implantation and growth of an embryo, and in these cases, doctors often recommend removing these fibroids before attempting pregnancy.
Tests and diagnosis
Uterine fibroids are frequently found incidentally during a routine pelvic exam. Your doctor may feel irregularities in the shape of your uterus, suggesting the presence of fibroids.
Ultrasound
If confirmation is needed, your doctor may obtain an ultrasound — a painless exam that uses sound waves to obtain a picture of your uterus — to confirm the diagnosis and to map and measure fibroids. A doctor or technician moves the ultrasound device (transducer) over your abdomen (transabdominal) or places it inside your vagina (transvaginal) to obtain images of your uterus.
Transvaginal ultrasound provides more detail because the probe is closer to the uterus. Transabdominal ultrasound visualizes a larger anatomic area. Sometimes, fibroids are discovered during an ultrasound conducted for a different purpose, such as during a prenatal ultrasound.
Other imaging tests
If traditional ultrasound doesn't provide enough information, your doctor may order other imaging studies, such as: * Hysterosonography. Also called sonohysterography, this ultrasound variation uses sterile saline to expand the uterine cavity, making it easier to obtain interior images of the uterus. This test may be useful if you have heavy menstrual bleeding despite normal results from traditional ultrasound. * Hysterosalpingography. This technique uses a dye to highlight the uterine cavity and fallopian tubes on X-ray images. Your doctor may recommend it if infertility is a concern. In addition to revealing fibroids, it can help your doctor determine if your fallopian tubes are open. * Hysteroscopy. Your doctor inserts a small, lighted telescope called a hysteroscope through your cervix into your uterus. Your doctor injects (instills) saline into your uterus expanding the uterine cavity and allowing your doctor to examine the walls of your uterus and the openings of your fallopian tubes. A hysteroscopy can be performed in your doctor's office.
Imaging techniques that may occasionally be necessary include computerized tomography (CT) and magnetic resonance imaging (MRI).
Other tests
If you're experiencing abnormal vaginal bleeding, your doctor may want to conduct other tests to investigate potential causes. He or she may order a complete blood count (CBC) to determine if you have iron deficiency anemia because of chronic blood loss. Your doctor may also order blood tests to rule out bleeding disorders and to determine the levels of reproductive hormones produced by your ovaries.
Treatments and drugs
There's no single best approach to uterine fibroid treatment. Many treatment options exist.
Watchful waiting
Many women with uterine fibroids experience no signs or symptoms. If that's the case for you, watchful waiting (expectant management) could be the best option. Fibroids aren't cancerous. They rarely interfere with pregnancy. They usually grow slowly — or not at all — and tend to shrink after menopause when levels of reproductive hormones drop.
Medications
Medications for uterine fibroids target hormones that regulate your menstrual cycle, treating symptoms such as heavy menstrual bleeding and pelvic pressure. They don't eliminate fibroids, but may shrink them. Medications include: * Gonadotropin-releasing hormone (GnRH) agonists. Medications called GnRH agonists (Lupron, Synarel, others) treat fibroids by causing your natural estrogen and progesterone levels to decrease, putting you into a temporary postmenopausal state. As a result, menstruation stops, fibroids shrink and anemia often improves. Your doctor may prescribe a GnRH agonist to shrink the size of your fibroids before a planned surgery. Many women have significant hot flashes while using GnRH agonists. * Progestin-releasing intrauterine device (IUD). A progestin-releasing IUD can relieve heavy bleeding and pain caused by fibroids. A progestin-releasing IUD provides symptom relief only and doesn't shrink fibroids or make them disappear. * Androgens. Danazol, a synthetic drug similar to testosterone, may effectively stop menstruation, correct anemia and even shrink fibroid tumors and reduce uterine size. However, this drug is rarely used to treat fibroids. Unpleasant side effects, such as weight gain, dysphoria (feeling depressed, anxious or uneasy), acne, headaches, unwanted hair growth and a deeper voice, make many women reluctant to take this drug. * Other medications. Oral contraceptives or progestins can help control menstrual bleeding, but they don't reduce fibroid size. Nonsteroidal anti-inflammatory drugs (NSAIDs), which are not hormonal medications, may be effective in relieving pain related to fibroids, but they don't reduce bleeding caused by fibroids.
Hysterectomy
This operation — the removal of the uterus — remains the only proven permanent solution for uterine fibroids. But hysterectomy is major surgery. It ends your ability to bear children, and if you also elect to have your ovaries removed, it brings on menopause and the question of whether you'll take hormone replacement therapy. Most women with uterine fibroids can choose to keep their ovaries.
Myomectomy
In this surgical procedure, your surgeon removes the fibroids, leaving the uterus in place. With myomectomy, there's a risk of fibroid recurrence.
Myomectomy options include: * Abdominal myomectomy. If you have multiple fibroids, very large fibroids or very deep fibroids, your doctor may use an open abdominal surgical procedure to remove the fibroids. * Laparoscopic or robotic myomectomy. If the fibroids are small and few in number, you and your doctor may opt for a laparoscopic procedure, which uses slender instruments inserted through small incisions in your abdomen to remove the fibroids from your uterus. Your doctor views your abdominal area on a remote monitor via a small camera attached to one of the instruments. Use of a surgical robot now allows for removal of more fibroids or larger fibroids. * Hysteroscopic myomectomy. This procedure may be an option if the fibroids are contained inside the uterus (submucosal). A long, slender instrument (hysteroscope) is passed through your vagina and cervix and into your uterus. Your doctor can see and remove the fibroids through the scope. This procedure is best performed by a doctor experienced in this technique.
Focused ultrasound surgery
MRI-guided focused ultrasound surgery (FUS) is a noninvasive treatment option for uterine fibroids that preserves your uterus.
This procedure is performed while you're inside of a specially crafted MRI scanner that allows doctors to visualize your anatomy, and then locate and destroy (ablate) fibroids inside your uterus without making an incision. Focused high-frequency, high-energy sound waves are used to target and destroy the fibroids. One or two treatment sessions are done in an on- and off-again fashion, sometimes spanning several hours.
Because it's a newer technology, researchers are learning more about the long-term safety and effectiveness of FUS. Research continues, but so far data collected show that FUS for uterine fibroids is safe and very effective.
Other minimally invasive procedures for fibroids
Certain procedures can destroy uterine fibroids without actually removing them through surgery. They include: * Myolysis. In this laparoscopic procedure, an electric current or laser destroys the fibroids and shrinks the blood vessels that feed them. A similar procedure called cryomyolysis freezes the fibroids. The safety, effectiveness and associated risk of fibroid recurrence of myolysis and cryomyolysis have yet to be determined. * Endometrial ablation. This treatment, performed with a specialized instrument inserted into your uterus, uses heat, microwave energy, hot water or electric current to destroy the lining of your uterus, either ending menstruation or reducing your menstrual flow. Endometrial ablation is effective in stopping abnormal bleeding, but doesn't affect fibroids outside the interior lining of the uterus. * Uterine artery embolization. Small particles (embolic agents) injected into the arteries supplying the uterus cut off blood flow to fibroids, causing them to shrink. This technique, performed by an interventional radiologist, is proving effective in shrinking fibroids and relieving the symptoms they can cause. Advantages over surgery include no incision and a shorter recovery time. Complications may occur if the blood supply to your ovaries or other organs is compromised.
Nursing Management * -Provide comfort to the patient. * -Monitor any signs of anemia such as pallor, CRT>3seconds, fatigue * -Provide iron supplementation to prevent anemia due to blood lost * -monitor vital signs for any unusualities. * -Assist patient in any of the diagnostic test, or surgery required

BILATERAL OVARIAN NEWGROWTHS/ OVARIAN CYST
Ovarian cysts are fluid-filled sacs or pockets within or on the surface of an ovary. Women have two ovaries — each about the size and shape of an almond — located on each side of the uterus. Eggs (ova) develop and mature in the ovaries and are released in monthly cycles during your childbearing years.
Many women have ovarian cysts at some time during their lives. Most ovarian cysts present little or no discomfort and are harmless. The majority of ovarian cysts disappear without treatment within a few months.
However, ovarian cysts — especially those that have ruptured — sometimes produce serious symptoms. The best ways to protect your health are to know the symptoms that may signal a more significant problem, and to schedule regular pelvic examinations.
Symptoms
Most cysts don't cause any symptoms and go away on their own. A large ovarian cyst can cause abdominal discomfort. If a large cyst presses on your bladder, you may feel the need to urinate more frequently because bladder capacity is reduced.
The symptoms of ovarian cysts, if present, may include: * Menstrual irregularities * Pelvic pain — a constant or intermittent dull ache that may radiate to your lower back and thighs * Pelvic pain shortly before your period begins or just before it ends * Pelvic pain during intercourse (dyspareunia) * Pain during bowel movements or pressure on your bowels * Nausea, vomiting or breast tenderness similar to that experienced during pregnancy * Fullness or heaviness in your abdomen * Pressure on your rectum or bladder that causes a need to urinate more frequently or difficulty emptying your bladder completely
When to see a doctor
Seek immediate medical attention if you have: * Sudden, severe abdominal or pelvic pain * Pain accompanied by fever or vomiting
These signs and symptoms — or those of shock, such as cold, clammy skin, rapid breathing, and lightheadedness or weakness — indicate an emergency and mean that you need to see a doctor right away.
Causes
Most ovarian cysts start during the normal function of your menstrual cycle. These are known as functional cysts. Other types of cysts are much less common.
Functional cysts
Your ovaries normally grow cyst-like structures called follicles each month. Follicles produce the hormones estrogen and progesterone and release an egg when you ovulate. Sometimes a normal monthly follicle just keeps growing. When that happens, it becomes known as a functional cyst. There are two types of functional cysts: * Follicular cyst. Around the midpoint of your menstrual cycle, an egg bursts out of its follicle and begins its journey down the fallopian tube in search of sperm and fertilization. A follicular cyst begins when something goes wrong and the follicle doesn't rupture or release its egg. Instead it grows and turns into a cyst. * Corpus luteum cyst. When a follicle does release its egg, the ruptured follicle begins producing large quantities of estrogen and progesterone in preparation for conception. This changed follicle is now called the corpus luteum. Sometimes, however, the escape opening of the egg seals off and fluid accumulates inside the follicle, causing the corpus luteum to expand into a cyst.
The fertility drug clomiphene (Clomid, Serophene), which is used to induce ovulation, increases the risk of a corpus luteum cyst developing after ovulation. These cysts don't prevent or threaten a resulting pregnancy.
Functional cysts are usually harmless, rarely cause pain, and often disappear on their own within two or three menstrual cycles.
Other cysts
Some types of cysts are not related to the normal function of your menstrual cycle. These cysts include: * Dermoid cysts. These cysts may contain tissue such as hair, skin or teeth because they form from cells that produce human eggs. They are rarely cancerous. * Cystadenomas. These cysts develop from ovarian tissue and may be filled with a watery liquid or a mucous material. * Endometriomas. These cysts develop as a result of endometriosis, a condition in which uterine endometrial cells grow outside your uterus. Some of that tissue may attach to your ovary and form a growth.
Dermoid cysts and cystadenomas can become large, causing the ovary to move out of its usual position in the pelvis. This increases the chance of painful twisting of your ovary, called ovarian torsion.
Complications
Some women develop less common types of cysts that may not produce symptoms, but that your doctor may find during a pelvic examination. Cystic ovarian masses that develop after menopause may be cancerous (malignant). These factors make regular pelvic examinations important.
Infrequent complications associated with ovarian cysts include: * Ovarian torsion. Cysts that become large may cause the ovary to move out of its usual position in the pelvis. This increases the chance of painful twisting of your ovary, called ovarian torsion. * Rupture. A cyst that ruptures may cause severe pain and lead to internal bleeding.
Tests and diagnosis
A cyst on your ovary may be found during a pelvic exam. If a cyst is suspected, doctors often advise further testing to determine its type and whether you need treatment. Typically, doctors address several questions to determine a diagnosis and to aid in management decisions: * Size. What size is it? * Composition. Is it filled with fluid, solid or mixed? Fluid-filled cysts aren't likely to be cancerous. Those that are solid or mixed — filled with fluid and solid — may require further evaluation to determine if cancer is present.
To identify the type of cyst, your doctor may perform the following procedures: * Pregnancy test. A positive pregnancy test may suggest that your cyst is a corpus luteum cyst, which can develop when the ruptured follicle that released your egg reseals and fills with fluid. * Pelvic ultrasound. In this painless procedure, a wand-like device (transducer) is used to send and receive high-frequency sound waves (ultrasound). The transducer can be moved over your abdomen and inside your vagina, creating an image of your uterus and ovaries on a video screen. This image can then be photographed and analyzed by your doctor to confirm the presence of a cyst, help identify its location and determine whether it's solid, filled with fluid or mixed. * Laparoscopy. Using a laparoscope — a slim, lighted instrument inserted into your abdomen through a small incision — your doctor can see your ovaries and remove the ovarian cyst. * CA 125 blood test. Blood levels of a protein called cancer antigen 125 (CA 125) often are elevated in women with ovarian cancer. If you develop an ovarian cyst that is partially solid and you are at high risk of ovarian cancer, your doctor may test the level of CA 125 in your blood to determine whether your cyst could be cancerous. Elevated CA 125 levels can also occur in noncancerous conditions, such as endometriosis, uterine fibroids and pelvic inflammatory disease.
Treatments and drugs
Treatment depends on your age, the type and size of your cyst, and your symptoms. Your doctor may suggest: * Watchful waiting. In many cases you can wait and be re-examined to see if the cyst goes away on its own within a few months. This is typically an option — regardless of your age — if you have no symptoms and an ultrasound shows you have a small, fluid-filled cyst. Your doctor will likely recommend that you get follow-up pelvic ultrasounds at periodic intervals to see if your cyst has changed in size. * Birth control pills. Your doctor may recommend birth control pills to reduce the chance of new cysts developing in future menstrual cycles. Oral contraceptives offer the added benefit of significantly reducing your risk of ovarian cancer — the risk decreases the longer you take birth control pills. * Surgery. Your doctor may suggest removal of a cyst if it is large, doesn't look like a functional cyst, is growing, or persists through two or three menstrual cycles. Cysts that cause pain or other symptoms may be removed.
Some cysts can be removed without removing the ovary in a procedure known as a cystectomy. In some circumstances, your doctor may suggest removing the affected ovary and leaving the other intact in a procedure known as oophorectomy.
If a cystic mass is cancerous, however, your doctor will likely advise a hysterectomy to remove both ovaries and your uterus. Your doctor is also likely to recommend surgery when a cystic mass develops on the ovaries after menopause.
Nursing Management * -Assess pain scale if pain is experience on the pelvic area. * -Monitor urine output (frequency, amount) * -Monitor if there is difficulty in defecating. * -Ask the patient if there are any irregularities in her menstrual cycle. * -Educate patient of her diagnosis and the reasons why she is experiencing the symptoms presented.

TOTAL ABDOMINAL HYSTERECTOMY AND BILATERAL SALPINGO-OOPHERECTOMY (TAH-BSO)
This is the removal of the uterus including the cervix as well as the tubes and ovaries using an incision in the abdomen. The scar may be horizontal or vertical, depending on the reason the procedure is performed, and the size of the area being treated. TAHBSO allows the whole abdomen and pelvis to be examined, which is an advantage in women with cancer or investigating growths of unclear cause. Clearly a woman cannot bear children herself after the procedure, so it is not performed on women of childbearing age unless there is a serious condition, such as cancer.

The most common hysterectomy by an incision through the abdomen (abdominal hysterectomy. Now most surgeries can utilize laparoscopic assisted or vaginal hysterectomies (performed through the vagina rather than through the abdomen) for quicker and easier recovery. The hospital stay generally tends to be longer with an abdominal hysterectomy than with a vaginal hysterectomy, and hospital charges tend to be higher. The procedures seem to take comparable lengths of time (about 2 hours), unless the uterus is of a very large size, in which a vaginal hysterectomy may take longer.

Women with inherited types of cancer of the ovary or breast will have an oophorectomy as preventive surgery in order to reduce the risk of future cancer of the ovary or breast. The procedure is also referred to as surgical menopause.

* Hysterectomy * refers to removal of the uterus * may be total, as removing the body and cervix of the uterus or partial, also called supra-cervical. * Salpingo * refers specifically to the removal of the fallopian tubes which connect the ovaries to the uterus. * Oophorectomy * refers to the surgical removal of an ovary or ovaries.
Indications of TAH-BSO * Hysterectomy is often performed on cancer patients or to relieve severe pelvic pain from endometriosis or adenomyosis. * Hysterectomy is also used as a last resort for postpartum obstetrical haemorrhage or uterine fibroids that cause heavy or unusual bleeding and discomfort in some women. * Transsexuals undergoing sex reassignment surgery as part of a female-to-male(FTM) transition commonly have hysterectomies and oophorectomies to remove the primary sources of female hormone production. * The National Institute for Health and Clinical Excellence (NICE) recommends that the ovaries should only be removed if there is a significant risk of further problems – for example, if there is a family history of ovarian cancer.

Risks & Side Effects OF TAH-BSO * Hysterectomy has been found to be associated with increased bladder function problems, such as incontinence. * When the ovaries are also removed, estrogen levels will fall. This removes the protective effects of estrogen on the cardiovascular and skeletal system. * A menopausal woman has a three times greater risk of developing cardiovascular disease such as atherosclerosis, peripheral artery disease or of having a heart attack when compared to premenopausal women * Studies have also found that the risk of developing osteoporosis may increase.
Surgical Procedure 1.) The patient is placed in the dorsal lithotomy position, and an adequate pelvic examination is performed with the patient under general anesthesia. This is extremely important because it allows the surgeon to become acquainted with the anatomy of the internal genitalia. The patient is then put in approximately a 15° Trendelenburg position. A Foley catheter is left in the bladder and connected to straight drainage. | 2.) Self-retaining retractors are placed in the abdominal incision, and the bowel is packed off with warm, moist gauze packs. A 0 synthetic absorbable suture is placed in the fundus of the uterus and used for uterine traction. The uterus is deviated to the patient's right. The left round ligament is placed on stretch and incised between clamps. | 3.) The distal stump of the round ligament is ligated with 0 synthetic absorbable suture. The proximal stump is held with a straight Ochsner clamp. At this point the leaves of the broad ligament are opened both anteriorly and posteriorly. This is performed by delicate dissection with the Metzenbaum scissors. | 4.) While retracting the uterus cephalad, the surgeon opens the anterior lead of the broad ligament to the vesicouterine fold. Steps 2-4 are carried out on the opposite side. | 5.) The vesicoperitoneal fold is elevated, and the fine filmy attachments of the bladder to the pubovesical cervical fascia are visible. The bladder can be dissected off the lower uterine segment of the uterus and cervix by either blunt or sharp dissection. If there has been extensive lower segment disease, previous cesarean sections, or pelvic irradiation, blunt dissection of the bladder off the cervix is dangerous, and a sharp dissection technique should be performed. | 6.) If the ovaries are to be preserved, the uterus is retracted toward the pubic symphysis and deviated to one side with the infundibulopelvic ligament, tube, and ovary on tension. A finger should be inserted through the peritoneum of the posterior leaf of the broad ligament under the suspensory ligament of the ovary and Fallopian tube. The tube and suspensory ligament are doubly clamped, incised, and tied with 0 synthetic absorbable suture. The distal stump of this structure is best doubly tied, first with a single tie of 0 synthetic absorbable suture and then with a ligature of 0 synthetic absorbable suture. The same procedure is carried out on the opposite side. | 7.) The uterus is then retracted cephalad and deviated to one side of the pelvis with the lower broad ligament on stretch. The filmy tissue surrounding the uterine vessels is skeletonized by elevating the round ligament and dissecting the tissue away from the uterine vessels. Three curved Ochsner clamps are placed at the junction of the lower uterine segment on the uterine vessels. This is best performed by placing the tips of the curved Ochsner clamps onto the uterus and allowing them to slide off the body of the uterus, thus ensuring complete clamping of the uterine vessels. An incision is made between the upper Ochsner clamp and the two lower Ochsner clamps. This is suture-ligated with two 0 synthetic absorbable sutures, placing the first suture at the tip of the lower Ochsner clamp and tying the suture behind the base of the clamp. The middle Ochsner clamp is left in place and is similarly suture-ligated by a second ligature placed at the tip of the Ochsner clamp and tied behind the base of the clamp. No attempt is made to place a suture in the middle of the pedicle, since it contains blood vessels and a pedicle hematoma can be created. The same procedure is carried out on the opposite side.A delicate, transverse, curved incision is made in the pubovesical cervical fascia overlying the lower uterine segment. The separation of the pubovesical cervical fascia from the underlying cervical stroma is facilitated by placing traction on the uterus in the cephalad position. | 8.) The uterus is held in traction in the cephalad position, and the handle of the knife is used to dissect the pubovesical cervical fascia inferiorly. This step mobilizes the ureter laterally and caudally. | 9.) Two straight Ochsner clamps are applied to the cardinal ligament for a distance of approximately 2 cm. The cardinal ligament is incised between the two clamps, and the distal stump is ligated with 0 synthetic absorbable suture. The suture is tied at the base of the clamp; no attempt is made to place this suture within the body of the pedicle because vessels can be torn and hematomas created. The same procedure is carried out on the opposite cardinal ligament. | 10.) The posterior leaf of the broad ligament is incised down to the uterosacral ligaments and across the posterior lower uterine segment between the rectum and cervix. | 11.) The uterosacral ligaments on both sides are clamped between straight Ochsner clamps, incised, and ligated with 0 synthetic absorbable suture. | 12.) The uterus is placed on traction cephalad, and the lower uterine segment and upper vagina are palpated between the thumb and first finger of the surgeon's hand to ensure that the ligaments have been completely incised. The vagina is entered by a stab wound with a scalpel and is cut across with either a scalpel or scissors. The uterus is removed. The edges of the vagina are picked up with straight Ochsner clamps in a north, south, east, and west direction. |

13.) The edges of the vaginal mucosa are sutured with a running locking 0 synthetic absorbable suture starting at the midpoint of the vagina underneath the bladder and carried around to the stumps of the cardinal and uterosacral ligaments, which are sutured into the angle of the vagina.At this point, the pelvis is thoroughly washed with sterile saline solution. Meticulous care is taken to ensure that hemostasis is present throughout the dissected area. | 14.) The pelvis is reperitonealized with running 2-0 synthetic absorbable suture from the anterior to the posterior leaf of the broad ligament. The stumps of the tubo-ovarian round, suspensory ligament of the ovary, and the cardinal and uterosacral ligaments are buried retroperitoneally. | 15.) Drains are rarely needed. If they are indicated, they are placed through the open vaginal cuff and carried along the lateral pelvic wall retroperitoneally. | 16.) If the tube and ovary are to be removed, they are removed at Step 6 in the operation. Instead of placing a finger underneath the tube and suspensory ligament of the ovary, a finger is placed under the infundilbulopelvic ligament on that side. Care is taken to ensure that the ureter is not included. In various forms of pelvic disease (endometriosis, pelvic inflammatory disease, etc.), the ureter can be deviated close to the infundibulopelvic ligament. | 17.) The tube and ovary have been mobilized medially with the uterine specimens. The remainder of the operation is carried out as described in Steps 7-13. | 18.) The peritoneum of the pelvis has been reestablished with the tube and ovary removed. The stump of the infundibulopelvic ligament is buried retroperitoneally.Postoperatively, no vaginal packing is left in the vagina, and no Foley catheter drainage of the bladder is indicated. |

Nursing Responsibilities:

Pre-Operative: * Preoperative assessment and physical examination as well as history * Preoperative teachings * Assess for baseline vital signs * NPO 8hrs or post-midnight * Pre-surgical checklist * Cleansing enema * Skin prepping

Intra-Operative: * Position patient accordingly providing comfort and safety * Ensures quality of care through proper use of instruments, equipments and supplies * Assess patient’s physiological stability * Maintain strict aseptic techniques. * Perform time in, time out, sign out as well as sponge and instrument count. * Monitor vital signs. * Assist in passing and cleaning surgical instruments. * After-care of the room and instruments.

Post-Operative: * Responsible for all the safekeeping of patient’s personal belongings endorse by OR nurse * Responsible for endorsing such items to patient’s relatives or floor nurse * Diligently carries out doctor’s orders as soon as possible * Check and record vital signs every 15minutes at the PACU * Assess patient’s surgical site for any signs of infection * Observes keenly the patient for complications such as shock, respiratory distress and cardiac arrest * Notifies the anaesthesiologist or surgeon immediately for any unusual symptoms * Provides and reinforces health teachings.

METABOLIC SYNDROME
Metabolic syndrome is a cluster of conditions — increased blood pressure, a high blood sugar level, excess body fat around the waist or abnormal cholesterol levels — that occur together, increasing your risk of heart disease, stroke and diabetes.
Having just one of these conditions doesn't mean you have metabolic syndrome. However, any of these conditions increase your risk of serious disease. If more than one of these conditions occur in combination, your risk is even greater.
If you have metabolic syndrome or any of the components of metabolic syndrome, aggressive lifestyle changes can delay or even prevent the development of serious health problems.
Symptoms
Having metabolic syndrome means you have three or more disorders related to your metabolism at the same time, including: * Obesity, with your body fat concentrated around your waist (having an "apple shape"). For a metabolic syndrome diagnosis, obesity is defined by having a waist circumference of 40 inches (102 centimeters or cm) or more for men and 35 inches (89 cm) or more for women, although waist circumference cutoff points can vary by race. * Increased blood pressure, meaning a systolic (top number) blood pressure measurement of 130 millimeters of mercury (mm Hg) or more or a diastolic (bottom number) blood pressure measurement of 85 mm Hg or more. * High blood sugar level, with a fasting blood glucose test result of 100 milligrams/deciliter (mg/dL), or 5.6 millimoles per liter (mmol/L), or more. * High cholesterol, with a level of the blood fat called triglycerides of 150 mg/dL, (1.7 millimoles/liter or mmol/L) or more and a level of high-density lipoprotein (HDL) cholesterol — the "good" cholesterol — of less than 40 mg/dL (1.04 mmol/L) for men or 50 mg/dL (1.3 mmol/L) for women.
Having one component of metabolic syndrome means you're more likely to have others. And the more components you have, the greater are the risks to your health.
When to see a doctor
If you know you have at least one component of metabolic syndrome — such as high blood pressure, high cholesterol or an apple-shaped body — you may have the others and not know it. It's worth checking with your doctor. Ask whether you need testing for other components of the syndrome and what you can do to avoid serious diseases.
Causes
The metabolic syndrome includes several symptoms that have different causes.
Insulin resistance
Metabolic syndrome is linked to your body's metabolism, possibly to a condition called insulin resistance. Insulin is a hormone made by your pancreas that helps control the amount of sugar in your bloodstream.
Normally, your digestive system breaks down the foods you eat into sugar (glucose). Your blood carries the glucose to your body's tissues, where the cells use it as fuel. Glucose enters your cells with the help of insulin. In people with insulin resistance, cells don't respond normally to insulin, and glucose can't enter the cells as easily. As a result, glucose levels in your blood rise despite your body's attempt to control the glucose by churning out more and more insulin. The result is higher than normal levels of insulin in your blood. This can eventually lead to diabetes when your body is unable to make enough insulin to control the blood glucose within the normal range.
Even if your levels aren't high enough to be considered diabetes, an elevated glucose level can still be harmful. In fact, some doctors refer to this condition as "prediabetes." Increased insulin raises your triglyceride level and other blood fat levels. It also interferes with how your kidneys work, leading to higher blood pressure. These combined effects of insulin resistance put you at risk of heart disease, stroke, diabetes and other conditions.
Combination of factors
Insulin resistance probably involves a variety of genetic and environmental factors. Some people may be genetically prone to insulin resistance, inheriting the tendency from their parents. But being overweight and inactive are major contributors.
Risk factors
The following factors increase your chances of having metabolic syndrome: * Age. The risk of metabolic syndrome increases with age, affecting less than 10 percent of people in their 20s and 40 percent of people in their 60s. However, warning signs of metabolic syndrome can appear in childhood. * Race. Hispanics and Asians seem to be at greater risk of metabolic syndrome than other races are. * Obesity. A body mass index (BMI) — a measure of your percentage of body fat based on height and weight — greater than 25 increases your risk of metabolic syndrome. So does abdominal obesity — having an apple shape rather than a pear shape. * History of diabetes. You're more likely to have metabolic syndrome if you have a family history of type 2 diabetes or a history of diabetes during pregnancy (gestational diabetes). * Other diseases. A diagnosis of high blood pressure, cardiovascular disease or polycystic ovary syndrome — a similar type of metabolic problem that affects a woman's hormones and reproductive system — also increases your risk of metabolic syndrome.
Complications
Having metabolic syndrome can increase your risk of developing these conditions: * Diabetes. If you don't make lifestyle changes to control your insulin resistance, your glucose levels will continue to increase. You may develop diabetes as a result of metabolic syndrome. * Cardiovascular disease. High cholesterol and high blood pressure can contribute to the buildup of plaques in your arteries. These plaques can cause your arteries to narrow and harden, which can lead to a heart attack or stroke.
Tests and diagnosis
Although your doctor is not typically looking for metabolic syndrome, the label may apply if you have three or more of the traits associated with this condition.
Several organizations have criteria for diagnosing metabolic syndrome. These guidelines were created by the National Cholesterol Education Program (NCEP) with modifications by the American Heart Association. According to these guidelines, you have metabolic syndrome if you have three or more of these traits: * Large waist circumference, greater than 35 inches (89 cm) for women and 40 inches (102 cm) for men. Certain genetic risk factors, such as having a family history of diabetes or being of Asian descent — which increases your risk of insulin resistance — lower the waist circumference limit. If you have one of these genetic risk factors, waist circumference limits are 31 to 35 inches (79 to 89 cm) for women and 37 to 39 inches (94 to 99 cm) for men. * A triglyceride level higher than 150 mg/dL (1.7 mmol/L), or you're receiving treatment for high triglycerides. * Reduced HDL ("good") cholesterol — less than 40 mg/dL (1.04 mmol/L) in men or less than 50 mg/dL (1.3 mmol/L) in women — or you're receiving treatment for low HDL. * Increased blood pressure, meaning a systolic (top number) blood pressure measurement of 130 millimeters of mercury (mm Hg) or more or a diastolic (bottom number) blood pressure measurement of 85 mm Hg or more. * Elevated fasting blood sugar (blood glucose) of 100 mg/dL (5.6 mmol/L) or higher, or you're receiving treatment for high blood sugar.
Treatments and drugs
Tackling one of the risk factors of metabolic syndrome is tough — taking on all of them might seem overwhelming. But aggressive lifestyle changes and, in some cases, medication can improve all of the metabolic syndrome components. Getting more physical activity, losing weight and quitting smoking help reduce blood pressure and improve cholesterol and blood sugar levels. These changes are key to reducing your risk. * Exercise. Doctors recommend getting 30 to 60 minutes of moderate-intensity exercise, such as brisk walking, every day. * Lose weight. Losing as little as 5 to 10 percent of your body weight can reduce insulin levels and blood pressure and decrease your risk of diabetes. * Eat healthy. The Dietary Approaches to Stop Hypertension (DASH) diet and the Mediterranean Diet, like many healthy-eating plans, limit unhealthy fats and emphasize fruits, vegetables, fish and whole grains. Both of these dietary approaches have been found to offer important health benefits — in addition to weight loss — for people who have components of metabolic syndrome. Ask your doctor for guidance before starting a new eating plan. * Stop smoking. Smoking cigarettes increases insulin resistance and worsens the health consequences of metabolic syndrome. Talk to your doctor if you need help kicking the cigarette habit.
Work with your doctor to monitor your weight and your blood glucose, cholesterol and blood pressure levels to ensure that lifestyle modifications are working. If you're not able to reach your goals with lifestyle changes, your doctor may also prescribe medications to lower blood pressure, control cholesterol or help you lose weight. Taking a daily aspirin — after discussing it with your doctor — may help reduce your risk of heart attack and stroke.
Lifestyle and home remedies
You can do something about your risk of metabolic syndrome and its complications — diabetes, stroke and heart disease. Start by making these lifestyle changes: * Lose weight. Losing as little as 5 to 10 percent of your body weight can reduce insulin levels and blood pressure and decrease your risk of diabetes. * Exercise. Doctors recommend getting 30 to 60 minutes of moderate-intensity exercise, such as brisk walking, every day. * Stop smoking. Smoking cigarettes increases insulin resistance and worsens the health consequences of metabolic syndrome. Talk to your doctor if you need help kicking the cigarette habit. * Eat fiber-rich foods. Make sure you include whole grains, beans, fruits and vegetables in your grocery cart. These items are packed with dietary fiber, which can lower your insulin levels.
Prevention
Whether you have one, two or none of the components of metabolic syndrome, the following lifestyle changes will reduce your risk of heart disease, diabetes and stroke: * Commit to a healthy diet. Eat plenty of fruits and vegetables. Choose lean cuts of white meat or fish over red meat. Avoid processed or deep-fried foods. Eliminate table salt and experiment with other herbs and spices. * Get moving. Get plenty of regular, moderately strenuous physical activity. * Schedule regular checkups. Check your blood pressure, cholesterol and blood sugar levels on a regular basis. Make additional lifestyle modifications if the numbers are going the wrong way.
Nursing Management: * -Check CBC results for any unusualities. * -encourage patient to stop smoking if he or she is a smoker. * -Plan a healthy diet for the patient. * -Do health teachings about lifestyle changes such as diet, exercise. * -Advise patient to have regular checkups to have a data on his/her BP, sugar, cholesterol level.

HYPERTENSION

Hypertension is one of the leading causes of death and disability among adults. Hypertension is a latent disorder in many people as it has a long a symptomatic phase. The problem itself has no clinical signs and symptoms until organ damage has taken place. Hypertension is a most common condition requiring lifelong drug therapy. Hypertension is a major health problem affecting about 20% of adult population in most of the countries. It is also the major risk for cardiovascular mortality, which accounts for 20 to 50% of all deaths and for morbidity which contributes disability. Hypertension is a major cause of heart failure, stroke and kidney failure. * A persistent elevation of the systolic blood pressure at a level of 140 mm Hg or higher and diastolic blood pressure at a level of 90 mmHg or higher * Condition when the pressure inside of your large arteries is too high * Has been called the “silent killer” because it usually doesn’t cause symptoms for many years – until a vital organ is damaged

Types of Hypertension * Primary Hypertension * also known as essential or idiopathic hypertension * etiology is a multifactorial, with no identifiable cause, but several interacting homeostatic forces are generally involved concomitantly * Secondary Hypertension * results from an identifiable cause such as renal disease * White coat Hypertension * hypertension in people who are actually normotensive except when their blood pressure is measured by a health care professional * Isolated systolic hypertension (ISH) * occurs when the systolic blood pressure is 140 mmHg or higher but the diastolic blood pressure remains less than 90 mmHg * Persistent severe hypertension or resistant hypertension * formerly called malignant hypertension * characterized by a diastolic blood pressure above 110 to 120 mmHg

Classifications of Blood Pressure Category | Systolic Blood Pressure | Diastolic Blood Pressure | Normal BP | Below 130 mmHg | Below 85 mmHg | High Normal BP | 130-139 | 85-89 | Stage 1 (mild) hypertension | 140-159 | 90-99 | Stage 2 (moderate) hypertension | 160-179 | 100-109 | Stage 3 (severe) hypertension | 180-209 | 110-119 | Stage 4 (very severe) hypertension | 210 or higher | 120 or higher |

Causes * Genes * Lifestyle and environment- ex. smoking & alcohol intake * Diet * Certain medications * Disorders of the kidneys or endocrine glands.
Signs and Symptoms * High BP * Few complain of headache, nape pains or dizziness, which are usually mild and tolerable. * Thus, hypertension is treated not only to relieve symptoms, but to prevent the development of target organ damage, which occur in those with chronic untreated, elevated blood pressure.

Diagnosis Diagnosis of hypertension is generally on the basis of a persistently high blood pressure. Usually this requires three separate measurements at least one week apart. Exceptionally, if the elevation is extreme, or end-organ damage is present then the diagnosis may be applied and treatment commenced immediately. Static hypotension, measuring lying sitting and standing BP may be useful. The BP should at some time have been measured in each arm, and the higher pressure arm preferred for subsequent measurements. Once the diagnosis of hypertension has been made it is important to attempt to exclude or identify reversible (secondary) causes.Over 90% of adult hypertension has no clear cause and is therefore called essential/primary hypertension. Often, it is part of the metabolic "syndrome X" in patients with insulin resistance: it occurs in combination with diabetes mellitus (type 2), combined hyperlipidemia and central obesity.

Complications * Target organ damage is a general term used for the complications occurring as a result of uncontrolled hypertension. They include the brain, the eyes, the kidneys, and the heart. * Stroke results when arteries in the brain burst (bleeding) or become blocked (thrombosis). Part of the brain dies and the patient becomes paralyzed * Heart Attack occurs when coronary arteries in the heart are blocked. The heart muscle dies, and may stop beating. Patient dies as a consequence. * Heart Failure results when the heart pumps too hard for too long, trying to keep blood flowing through the body. Eventually, the heart weakens. The patient now tires easily and is always out-of-breath * Kidney Failure happens when tiny vessels in the kidneys are blocked. The kidneys malfunction are unable to clean the body of wastes. Patient is slowly poisoned, becomes weak and bloated. Unless “dialyzed”, the patient will die of poisoning from his own body wastes * Blindness or Impaired Vision occurs when tiny blood vessels in the eye rupture or become blocked, damaging the surrounding eye tissues
Effects
* Heart The heart is responsible for pumping blood to your entire body. Uncontrolled high blood pressure can damage your heart in a number of ways, such as: Enlarged left heart-High blood pressure forces your heart to over exert itself. This causes the left ventricle to enlarge (left ventricular hypertrophy). This enlargement limits the ventricle's ability to expand sufficiently and to completely fill with blood. In turn, the ventricle can't pump out as much blood to your body. Angina - the work demanded of the heart muscle exceeds the ability of the coronary arteries to supply the oxygen and fuel needed to perform it causing chest pains and difficulty in breathing Heart failure – over time, the added exertion demanded by high blood pressure can cause your heart muscle to weaken and work less efficiently. Eventually, your overwhelmed heart simply begins to wear out and fail * Blood vessels Arteriosclerosis and atherosclerosis - excessive pressure in the arteries from high blood pressure alters the cells of the arteries' inner lining, thus, launching a cascade of events that make artery walls thick and stiff arteriosclerosis or hardening of the arteries. Circulating fats pass through the altered cells and accumulate to start the process of atherosclerosis. These changes can affect arteries throughout your body, obstructing blood flow to your heart, kidneys, brain and extremities Aneurysm - over time, the constant pressure of blood coursing through a weakened artery can cause a section of its wall to enlarge and form a bulge (aneurysm). This can rupture and cause life-threatening internal bleeding. * Brain Transient ischemic attack (TIA) - a brief, temporary obstruction of blood supply to your brain often caused by atherosclerosis or a blood clot — both of which can arise from high blood pressure. This is often a warning that you're at risk of a full-blown stroke. Stroke - high blood pressure can lead to stroke by damaging and weakening your brain's blood vessels, causing them to narrow, rupture, or leak. High blood pressure can also cause an aneurysm — a bulge in the blood vessel wall that can burst, causing life-threatening bleeding in the brain. Dementia - Dementia is a brain disease resulting in impaired thinking, speaking, reasoning, memory, vision and movement. Vascular dementia can result from extensive narrowing and blockage of the arteries that supply blood to the brain. It can also result from strokes caused by an interruption of blood flow to the brain. In either case, high blood pressure may be the culprit. High blood pressure that occurs even as early as middle age can increase the risk of dementia in later years. * Eyes Retinopathy - high blood pressure can damage the vessels supplying blood to your retina. Damaged enough, the blood vessels can leak or become blocked, resulting in retinopathy. This condition can lead to bleeding in the eye, microaneurysms, swelling of the optic nerve, blurred vision and complete loss of vision * Kidneys Kidney failure - high blood pressure can damage both the large arteries leading to your kidneys and the tiny blood vessels (glomeruli) within the kidneys. Damage to either disrupts the ability of your kidneys to filter waste products from your blood. As a result, dangerous levels of fluid and waste can accumulate.

Risk Factors Nonmodifiable Risk Factors * Family History * In any person with a family history of hypertension, several genes may interact with each other and the environment to cause the blood pressure to elevate over time * Patients with parents who have hypertension are a greater risk for hypertension at a younger age * Age * Hypertension typically appears between the ages of 30 and 50 years * Gender * Overall incidence of hypertension is higher in men than in women until about age 55 yrs. * Between the ages 55 and 74 years, the risk in mean and that in women are almost equal * After age 74 years, women are at greater risk * Ethnicity * Black people have higher prevalence than white people

Modifiable Risk Factors * Stress * increases peripheral vascular resistance and cardiac output and stimulates sympathetic nervous system * Obesity * Nutrients * Substance Abuse * Cigarette smoking, heavy alcohol consumption are risk factors for hypertension

Medical Management * Diuretics, which initially increase urination to reduce salt and water retention and lower blood volume. * Beta-blockers (BB’s), which slow the heart rate and lower the output of the heart. * Angiotensin converting enzyme (ACE) inhibitors, which block production of a specialized hormone called angiotensin II. Angiotensin II causes the arteries to constrict and also stimulates the release of another hormone that causes the kidneys to retain salt. * Angiotensin II receptor blockers (ARBs or A II A’s), which relax blood vessels by blocking the action of angiotensin II. * Calcium channel blockers (CCB’s) of which there are two types: Dihydropyridines (DHPs), and heart rate slowing calcium channel blockers. Both types relax blood vessels by slowing the entry of calcium into cells. The DHPs increase the heart rate a little while the others slow it a little. * Alpha-1 blockers work on the blood vessels to block the effect of constricting hormones such as norepinephrine. These are also commonly used to treat prostate problems. * Alpha-2 agonists, which work in the brain to decrease the action of the nervous system to constrict blood vessels. * Direct vasodilators, which relax the artery walls. * Sympathetic nerve blockers, which prevent those nerves from constricting blood vessels.

* Lifestyle modification Doctors recommend weight loss and regular exercise as the first steps in treating mild to moderate hypertension. These steps are highly effective in reducing blood pressure, although most patients with moderate or severe hypertension end up requiring indefinite drug therapy to bring their blood pressure down to a safe level. Discontinuing smoking does not directly reduce blood pressure, but is very important for people with hypertension because it reduces the risk of many dangerous outcomes of hypertension, such as stroke and heart attack. An increase in daily calcium intake has also been shown to be highly effective in reducing blood pressure. Mild hypertension is usually treated by diet, exercise and improved physical fitness. A diet rich in fruits and vegetables and low fat or fat-free dairy foods and moderate or low in sodium lowers blood pressure in people with hypertension. This diet is known as the DASH diet (Dietary Approaches to Stop Hypertension). Dietary sodium (salt) may worsen hypertension in some people and reducing salt intake decreases blood pressure in a third of people. Regular mild exercise improves blood flow, and helps to lower blood pressure. In addition, fruits, vegetables, and nuts have the added benefit of increasing dietary potassium, which offsets the effect of sodium and acts on the kidney to decrease blood pressure.

URINARY TRACT INFECTION

A urinary tract infection, or UTI, is an (ascending) infection that can happen anywhere along the urinary tract. Urinary tract infections have different names, depending on what part of the urinary tract is infected. * Bladder: an infection in the bladder is also called cystitis or a bladder infection * Kidneys: an infection of one or both kidneys is called pyelonephritis or a kidney infection * Ureters: the tubes that take urine from each kidney to the bladder are only rarely the site of infection * Urethra: an infection of the tube that empties urine from the bladder to the outside is called urethritis

Types * Lower urinary tract infection involves the urethra, the bladder; and, in men, the prostate gland. * Upper urinary tract infection refers to infection of the kidneys.

Causes
Urinary tract infections are caused by germs, usually bacteria that enter the urethra and then the bladder. This can lead to infection, most commonly in the bladder itself, which can spread to the kidneys. Most of the time, your body can get rid of these bacteria. However, certain conditions increase the risk of having UTIs. Women tend to get them more often because their urethra is shorter and closer to the anus than in men. Because of this, women are more likely to get an infection after sexual activity or when using a diaphragm for birth control. Menopause also increases the risk of a UTI.
The following also increase chances of developing a UTI: * Diabetes * Advanced age * Problems emptying your bladder completely (urinary retention) * A tube called a urinary catheter inserted into your urinary tract * Bowel incontinence * Enlarged prostate, narrowed urethra, or anything that blocks the flow of urine * Kidney stones * Staying still (immobile) for a long period of time * Pregnancy * Surgery or other procedure involving the urinary tract
Symptoms
Lower urinary tract infection (urethritis or cystitis): The lining of the urethra and bladder becomes inflamed and irritated. * Dysuria: pain or burning during urination * Frequency: more frequent urination (or waking up at night to urinate, sometimes referred to as nocturia); often with only a small amount of urine * Urgency: the sensation of having to urinate urgently * Hesitancy: the sensation of not being able to urinate easily or completely (or feeling that you have to urinate but only a few drops of urine come out) * Cloudy, foul-smelling, or bloody urine * Lower abdominal (suprapubic) pain * Mild fever (less than 38.33 C), chills, and body malaise
Upper urinary tract infection (pyelonephritis): Symptoms develop rapidly, and may or may not include the symptoms for a lower urinary tract infection. * Fairly high fever (higher than 38.33 C) * Shaking chills * Nausea&Vomiting * Flank (costrovertebral angle) pain: pain in your back or side, usually on only one side at about waist level

Exams and Tests
A urine sample is usually collected to perform the following tests: * Urinalysis is done to look for white blood cells, red blood cells, bacteria, and to test for certain chemicals, such as nitrites in the urine. Most of the time, your doctor or nurse can diagnose an infection using a urinalysis. * Urine culture- clean catch may be done to identify the bacteria in the urine to make sure the correct antibiotic is being used for treatment. * CBC and a blood culture may be done.

Treatment
Pharmacological Management:
MILD BLADDER AND KIDNEY INFECTIONS
Antibiotics taken by mouth are usually recommended because there is a risk that the infection can spread to the kidneys. * For a simple bladder infection, you will take antibiotics for 3 days (women) or 7-14 days (men). For a bladder infection with complications such as pregnancy or diabetes, or a mild kidney infection, you will usually take antibiotics for 7-14 days. * It is important that you finish all the antibiotics, even if you feel better. If you do not finish all your antibiotics, the infection could return and may be harder to treat.Commonly used antibiotics include trimethoprim-sulfamethoxazole, amoxicillin, augmentin, doxycycline, and fluoroquinolones.Your doctor may also recommend drugs to relieve the burning pain and urgent need to urinate. Phenazopyridine hydrochloride (Pyridium) is the most common of this type of drug. You will still need to take antibiotics. * Maintenance medication of the patient: Pregabalin (Lyrica) 50mg/tab 1 tab OD PO qHs. * Everyone with a bladder or kidney infection should drink plenty of fluids.Some people have urinary tract infections that keep coming back or that do not go away with treatment. Such infections are called chronic UTIs. If you have a chronic UTI, you may need antibiotics for many months, or stronger antibiotics may be prescribed.If a structural (anatomical) problem is causing the infection, surgery may be recommended.

Outlook (Prognosis)
A urinary tract infection is uncomfortable, but treatment is usually successful. Symptoms of a bladder infection usually disappear within 24-48 hours after treatment begins. If you have a kidney infection, it may take 1 week or longer for your symptoms to go away.
Possible Complications * Life-threatening blood infection (sepsis)- risk is greater among the young, very old adults, and those whose bodies cannot fight infections (for example, due to HIV or cancer chemotherapy) * Kidney damage or scarring * Kidney infection

Nursing Management
BATHING AND HYGIENE * Do not douche or use feminine hygiene sprays or powders. As a general rule, do not use any product containing perfumes in the genital area. Mild soap is suggested. * Take showers instead of baths. Avoid bath oils. * Keep genital area clean. * Wipe genital area from front to back after using the bathroom. * Avoid tight-fitting clothes * Wear cotton-cloth (absorbent) underwear and change at least once a day. * Offer plenty of fluids, cranberry juice or use cranberry tablets.

ANATOMY AND PHYSIOLOGY FEMALE REPRODUCTIVE SYSTEM
Reproduction
Reproduction can be defined as the process by which an organism continues its species. In the human reproductive process, two kinds of sex cells ( tes), are involved: the male the (sperm), and the female te (egg or ovum). These two tes meet within the female's uterine tubes located one on each side of the upper pubic cavity,and begin to create a new individual. The female needs a male to fertilize her egg; she then carries offspring through pregnancy and childbirth.
A woman's ova (eggs) are completely formed during fetal development.
At about 5 months gestation, the ovaries contain approximately six to seven million oogonia, which then go through meiosis, and are matured into oocytes.
The ovaries of a newborn baby girl contain about two million oocytes. This number declines to 300,000 to 400,000 by the time puberty is reached. On average, 400 oocytes are ovulated during a woman's reproductive lifetime.
When a young woman reaches puberty around age 12 or 13, an ova (one of the matured oocytes) is discharged from alternating ovaries every 28 days. This continues until the woman reaches menopause, usually around the age of 50 years. Occytes are present at birth, and ages as a woman ages. This may be one reason older women are more likely to have a hard time becoming pregnant or more likely to have children with genetic defects.
Female Reproductive System
• Produces eggs (ova) * Secretes sex hormones
• Receives the male spermatazoa during
• Protects and nourishes the fertilized egg until it is fully developed
• Delivers fetus through birth canal
• Provides nourishment to the baby through milk secreted by mammary glands in the breast

Vulva
The external female genitals are collectively referred to as The Vulva. This consists of the labia majora and labia minora (while these names translate as "large" and "small" lips, often the "minora" can be larger, and protrude outside the "majora"), mons pubis, clitoris, opening of the urethra (meatus), vaginal vestibule, vestibular bulbs, vestibular glands.
The term "vagina" is often improperly used as a generic term to refer to the vulva or female genitals, even though - strictly speaking - the vagina is a specific internal structure and the vulva is the exterior genitalia only. Calling the vulva the vagina is akin to calling the mouth the throat.
Mons Veneris
The mons veneris, Latin for "mound of Venus" (Roman Goddess of love) is the soft mound at the front of the vulva (fatty tissue covering the pubic bone). It is also referred to as the mons pubis. The mons veneris is sexually sensitive in some women and protects the pubic bone and vulva from the impact of sexual intercourse. After puberty it is covered with pubic hair, usually in a triangular shape. Heredity can play a role in the amount of pubic hair an individual grows.
Labia Majora
The labia majora are the outer "lips" of the vulva. They are pads of loose connective and adipose tissue, as well as some smooth muscle. The labia majora wrap around the vulva from the mons pubis to the perineum. The labia majora generally hides, partially or entirely, the other parts of the vulva. There is also a longitudinal separation called the pudendal cleft. These labia are usually covered with pubic hair. The color of the outside skin of the labia majora is usually close to the overall color of the individual, although there may be some variation. The inside skin is usually pink to light brown. They contain numerous sweat and oil glands. It has been suggested that the scent from these oils are sexually arousing.
Labia Minora
Medial to the labia majora are the labia minora. The labia minora are the inner lips of the vulva. They are thin stretches of tissue within the labia majora that fold and protect the vagina, urethra, and clitoris. The appearance of labia minora can vary widely, from tiny lips that hide between the labia majora to large lips that protrude. There is no pubic hair on the labia minora, but there are sebaceous glands. The two smaller lips of the labia minora come together longitudinally to form the prepuce, a fold that covers part of the clitoris. The labia minora protect the vaginal and urethral openings. Both the inner and outer labia are quite sensitive to touch and pressure.
Clitoris
The clitoris, visible as the small white oval between the top of the labia minora and the clitoral hood, is a small body of spongy tissue that functions solely for sexual pleasure. Only the tip or glans of the clitoris shows externally, but the organ itself is elongated and branched into two forks, the crura, which extend downward along the rim of the vaginal opening toward the perineum. Thus the clitoris is much larger than most people think it is, about 4" long on average.
The clitoral glans or external tip of the clitoris is protected by the prepuce, or clitoral hood, a covering of tissue similar to the foreskin of the male penis. However, unlike the penis, the clitoris does not contain any part of the urethra.
During sexual excitement, the clitoris erects and extends, the hood retracts, making the clitoral glans more accessible. The size of the clitoris is variable between women. On some, the clitoral glans is very small; on others, it is large and the hood does not completely cover it.
Urethra
The opening to the urethra is just below the clitoris. Although it is not related to sex or reproduction, it is included in the vulva. The urethra is actually used for the passage of urine. The urethra is connected to the bladder. In females the urethra is 1.5 inches long, compared to males whose urethra is 8 inches long. Because the urethra is so close to the anus, women should always wipe themselves from front to back to avoid infecting the vagina and urethra with bacteria. This location issue is the reason for bladder infections being more common among females.
Hymen
The hymen is a thin fold of mucous membrane that separates the lumen of the vagina from the urethral sinus. Sometimes it may partially cover the vaginal orifice. The hymen is usually perforated during later fetal development.
Because of the belief that first vaginal penetration would usually tear this membrane and cause bleeding, its "intactness" has been considered a guarantor of virginity. However, the hymen is a poor indicator of whether a woman has actually engaged in sexual intercourse because a normal hymen does not completely block the vaginal opening. The normal hymen is never actually "intact" since there is always an opening in it. Furthermore, there is not always bleeding at first vaginal penetration. The blood that is sometimes, but not always, observed after first penetration can be due to tearing of the hymen, but it can also be from injury to nearby tissues.
A tear to the hymen, medically referred to as a "transection," can be seen in a small percentage of women or girls after first penetration. A transection is caused by penetrating trauma. Masturbation and tampon insertion can, but generally are not forceful enough to cause penetrating trauma to the hymen. Therefore, the appearance of the hymen is not a reliable indicator of virginity or chastity.
Perineum
The perineum is the short stretch of skin starting at the bottom of the vulva and extending to the anus. It is a diamond shaped area between the symphysis pubis and the coccyx. This area forms the floor of the pelvis and contains the external sex organs and the anal opening. It can be further divided into the urogenital triangle in front and the anal triangle in back.
The perineum in some women may tear during the birth of an infant and this is apparently natural. Some physicians however, may cut the perineum preemptively on the grounds that the "tearing" may be more harmful than a precise cut by a scalpel. If a physician decides the cut is necessary, they will perform it. The cut is called an episiotomy.
Internal Genitals
Vagina
The vagina is a muscular, hollow tube that extends from the vaginal opening to the cervix of the uterus. It is situated between the urinary bladder and the rectum. It is about three to five inches long in a grown woman. The muscular wall allows the vagina to expand and contract. The muscular walls are lined with mucous membranes, which keep it protected and moist. A thin sheet of tissue with one or more holes in it, called the hymen, partially covers the opening of the vagina. The vagina receives sperm during sexual intercourse from the penis. The sperm that survive the acidic condition of the vagina continue on through to the fallopian tubes where fertilization may occur. The vagina is a muscular tube that extends from above the inferior extent of the cervix of the uterus (that project into the upper position of the vagina) to its external opening in the vestibule. Its long axis is approximately parallel to the lower portion of sacrum. At its lower end, the vagina traverses the urogenital diaphragms and is the surrounded by two bulbocavernosus muscles that act as sphincters. The hymen, a fold of connective tissue, somewhat obscures the external vaginal orifice in childhood, and is fragmented into irregular remnants with sexual activity and in childbearing.
The vagina is related anteriorly to the base of the bladder and the urethra; posteriorly to the pouch of Douglas (posterior pelvic cul-de-sac), rectum and anal canal; and laterally to the levator ani muscle and the ureter,which passes near the lateral fornix. The major blood supply of vagina is the vaginal artery (branch of the hypogastric artery) and the veins that follow the path of the arteries. The vaginal wall consists of a mucous membrane, a submucosal layer of connective tissue, and an external muscular layer.
The vagina is made up of three layers, an inner mucosal layer, a middle muscularis layer, and an outer fibrous layer. The inner layer is made of vaginal rugae that stretch and allow penetration to occur. These also help with stimulation of the penis. The middle layer has glands that secrete an acidic mucus (pH of around 4.0.) that keeps bacterial growth down. The outer muscular layer is especially important with delivery of a fetus and placenta.
Purposes of the Vagina
• Receives a males erect penis and semen during sexual intercourse.
• Pathway through a womans body for the baby to take during childbirth.
• Provides the route for the menstrual blood (menses) from the uterus, to leave the body.
• May hold forms of birth control, such as a diaphragm, FemCap, Nuva Ring, or female condom.
Cervix
The cervix (from Latin "neck") is the lower, narrow portion of the uterus where it joins with the top end of the vagina. Where they join together forms an almost 90 degree curve. It is cylindrical or conical in shape and protrudes through the upper anterior vaginal wall. Approximately half its length is visible with appropriate medical equipment; the remainder lies above the vagina beyond view. It is occasionally called "cervix uteri", or "neck of the uterus".
During menstruation, the cervix stretches open slightly to allow the endometrium to be shed. This stretching is believed to be part of the cramping pain that many women experience. Evidence for this is given by the fact that some women's cramps subside or disappear after their first vaginal birth because the cervical opening has widened.
The portion projecting into the vagina is referred to as the portio vaginalis or ectocervix. On average, the ectocervix is three cm long and two and a half cm wide. It has a convex, elliptical surface and is divided into anterior and posterior lips. The ectocervix's opening is called the external os. The size and shape of the external os and the ectocervix varies widely with age, hormonal state, and whether the woman has had a vaginal birth. In women who have not had a vaginal birth the external os appears as a small, circular opening. In women who have had a vaginal birth, the ectocervix appears bulkier and the external os appears wider, more slit-like and gaping.
The passageway between the external os and the uterine cavity is referred to as the endocervical canal. It varies widely in length and width, along with the cervix overall. Flattened anterior to posterior, the endocervical canal measures seven to eight mm at its widest in reproductive-aged women. The endocervical canal terminates at the internal os which is the opening of the cervix inside the uterine cavity.
During childbirth, 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 os dilates.
Uterus
The uterus is shaped like an upside-down pear, with a thick lining and muscular walls. Located near the floor of the pelvic cavity, it is hollow to allow a blastocyte, or fertilized egg, to implant and grow. It also allows for the inner lining of the uterus to build up until a fertilized egg is implanted, or it is sloughed off during menses.
The uterus contains some of the strongest muscles in the female body. These muscles are able to expand and contract to accommodate a growing fetus and then help push the baby out during labor. These muscles also contract rhythmically during an orgasm in a wave like action. It is thought that this is to help push or guide the sperm up the uterus to the fallopian tubes where fertilization may be possible.
The uterus is only about three inches long and two inches wide, but during pregnancy it changes rapidly and dramatically. The top rim of the uterus is called the fundus and is a landmark for many doctors to track the progress of a pregnancy. The uterine cavity refers to the fundus of the uterus and the body of the uterus.
Helping support the uterus are ligaments that attach from the body of the uterus to the pelvic wall and abdominal wall. During pregnancy the ligaments prolapse due to the growing uterus, but retract after childbirth. In some cases after menopause, they may lose elasticity and uterine prolapse may occur. This can be fixed with surgery.
Some problems of the uterus include uterine fibroids, pelvic pain (including endometriosis, adenomyosis), pelvic relaxation (or prolapse), heavy or abnormal menstrual bleeding, and cancer. It is only after all alternative options have been considered that surgery is recommended in these cases. This surgery is called hysterectomy. Hysterectomy is the removal of the uterus, and may include the removal of one or both of the ovaries. Once performed it is irreversible. After a hysterectomy, many women begin a form of alternate hormone therapy due to the lack of ovaries and hormone production.
Fallopian Tubes
At the upper corners of the uterus are the fallopian tubes. There are two fallopian tubes, also called the uterine tubes or the oviducts. Each fallopian tube attaches to a side of the uterus and connects to an ovary. They are positioned between the ligaments that support the uterus. The fallopian tubes are about four inches long and about as wide as a piece of spaghetti. Within each tube is a tiny passageway no wider than a sewing needle. At the other end of each fallopian tube is a fringed area that looks like a funnel. This fringed area, called the infundibulum, lies close to the ovary, but is not attached. The ovaries alternately release an egg. When an ovary does ovulate, or release an egg, it is swept into the lumen of the fallopian tube by the frimbriae.
Once the egg is in the fallopian tube, Cilia tiny hairs in the tube's lining assist the oocyte transport to fertilization site and help push it down the narrow passageway toward the uterus. The oocyte, or developing egg cell, takes four to five days to travel down the length of the fallopian tube. If enough sperm are ejaculated during sexual intercourse and there is an oocyte in the fallopian tube, fertilization will occur. After fertilization occurs, the zygote, or fertilized egg, will continue down to the uterus and implant itself in the uterine wall where it will grow and develop.
If a zygote doesn't move down to the uterus and implants itself in the fallopian tube, it is called a ectopic or tubal pregnancy. If this occurs, the pregnancy will need to be terminated to prevent permanent damage to the fallopian tube, possible hemorrhage and possible death of the mother.
URINARY SYSTEM

The urinary system eliminates waste products from the body and maintains fluid/salt balance. The system consists of paired kidneys with ureters, a urinary bladder, and urethra.

The Kidney - An Overview
The kidney is covered by a thin connective tissue capsule and consists of an outer cortex and medullary pyramid or papillae (Kidney). Within these two regions are found the components of the structural and functional unit of the kidney, the nephron. The nephron is composed of: (1) the glomerulus, a tuft of capillaries, which produces the glomerular filtrate, housed in the renal corpuscle; followed by a series of tubules, specialized for excretion and reabsorption, including (2) the proximal convoluted tubule, (3) the descending and ascending loop of Henle, and (4) the distal convoluted tubule. Each nephron drains into a collecting tubule, which serves as a duct system to conduct the urine out of the Kidney. The glomeruli and the proximal and distal convoluted tubules are found in the cortex. The descending loop of Henle leaves the cortex and enters the medulla, returning to the cortex as the ascending loop. Therefore, the medulla consists of portions of the loops of Henle and the collecting tubules.
Kidney Cortex
The outer most region of the kidney, which lies just below the convex surface of the organ, is the cortex, where three components of the nephron can be found. The renal corpuscles (or Bowman's capsules) containing glomeruli are surrounded by a labyrinth of proximal and distal convoluted tubules (Cortex). The collecting tubules also penetrate the cortex, to connect with the distal convoluted tubules. These extensions are called medullary rays and represent the cores of the kidney lobules (Medullary Rays).
The glomeruli consist of a tuft of capillaries housed in an epithelial lined Bowman's capsule (Renal Corpuscle). The parietal epithelium of Bowman's Capsule is a layer of simple squamous epithelium lining the outer border of the corpuscle. The visceral epithelium of Bowman's capsule (or podocytes) surrounds the capillary endothelial cells, with mesangial cells filling in the spaces between closely apposed capillaries. The afferent arteriole enters the corpuscle and the efferent arteriole leaves the corpuscle, both at a region called the vascular pole.
The glomerular filtrate leaves the corpuscle via the proximal convoluted tubule. The proximal convoluted tubule travels a tortuous course, therefore will appear as tubes cut in various orientations (i.e. cross-sectional or oblique). They are the most prominent tubule seen in the cortex. The cells stain highly acidophilic and possess a brush border (Proximal Tubules). The distal convoluted tubules differ from the proximal tubules in that: (1) the total diameter of the tubule is smaller, (2) but, the cells are lower producing a larger lumen, (3) the cells are less acidophilic, and (4) the cells do not have a brush border (Distal Tubules). The distal tubules also travel a tortuous course, producing different cut orientations. Before joining the collecting tubules, the distal convoluted tubules abut the renal corpuscle at the vascular pole. At this site, the distal tubule wall has an increased number of nuclei, producing a structure called the macula densa (Macula Densa).
Kidney Medulla
The medullary portion of the kidney is organized as a single medullary pyramid (unilobar kidney) or multiple pyramids (multilobar kidney). Each pyramid of medullary tissue and its associated "cap" of cortical tissue is defined as a kidney lobe (Kidney Lobe). The pyramids appear striated, due to the parallel alignment of the loops of Henle and collecting tubules (Medulla 1). Histologically, the loop of Henle appear acidophilic as the descending/ascending loop (Medulla 2) and becomes a thin squamous lined tube near the tip of the papillae (Medulla 3). Collecting tubules are not considered part of the nephron; they are the duct system of the kidney. The bulk of the medullary pyramid is composed of collecting tubules. The collecting tubules are lined with simple cuboidal epithelium. They meet at the apex or papillae of the medullary pyramid, merging together to form large ducts, the ducts of Bellini which empty into the renal pelvis (Papillae).
Urinary Tubular System
The urine in the collecting tubules is collected in the renal pelvis and exits the kidney in the ureter. The ureter travels to the bladder, where the urine can be stored. The bladder is drained by the urethra which leads to the external orifice.
Ureter
The ureter is composed of a folded mucus membrane, a muscle coat, and a fibroelastic adventitia (Ureter 1). The mucus membrane consists of two layers: (1) transitional epithelium and (2) lamina propria (Ureter 2). The muscle coat consists of two layers of smooth muscle.
Bladder
The urinary bladder is lined with transitional epithelium underlined by a collagenous lamina propria. A submucosa of elastic fibers and a muscular layer of three coats of smooth muscle permit expansion of the structure (Bladder).

Urethra
In the male, the urethra runs within the prostate gland and penis, and will be studied in the male reproductive section. In the female, it is a separate tube consisting of a mucus membrane (epithelium and lamina propria), submucosa and muscular coat of two layers of smooth muscle. The epithelium varies: transitional by the bladder, changing to stratified squamous non-keratinizing (Female Urethra), and finally stratified squamous at the opening. Client in Context | Present State | Interventions | Evaluation | BIOGRAPHICAL DATA N.M.C., a 47 years old female, married, Filipino, Roman Catholic and a housewife who is residing at Cebu City, was admitted for the fourth time at Cebu Velez General Hospital last March 14, 2013 due to heavy menstrual bleeding. She was accompanied by her husband and sister via a taxi cab and was admitted to PPW 4th floor Room 400B under the services of Dr. Zanoria of the Department of Internal Medicine and Dr. Hipolita Libre of Department of OB-GYNE with a case and hospital number of 8239/12-22560, respectively. HISTORY OF PRESENT ILLNESS One year and five months prior to admission, patient noted heavy menstrual bleeding lasting to 5 days, consuming 4-5 napkins per day and not associated with dysmenorrhea, headache, nausea, vomiting, fever or back pain. No consult nor medication taken and condition was tolerated. Nine months prior to admission, condition persisted with a longer duration of 7 days still consuming 4-5 pads per day. Patient also noted clotted blood on her napkin and when she urinates. There was no associated dysmenorrheal, fever, back pain, nausea or vomiting. Patient tolerated the condition, no medications were taken and no consult was done. Six months prior to admission, patient’s condition persisted now associated with spotting lasting for one week after her last day of menstrual cycle. No dysmenorrhea, fever, nausea or vomiting noted. Patient tolerated the condition, no medications were taken and no consult was done. Five months prior to admission, condition persisted , no longer associated with spotting after her menstrual cycle. However, now associated with dysmenorrheal with a pain scale of 9/10 (1 as the lowest and 10 as the highest). There were no associated fever, nausea or vomiting. Patient sought consult with her OB at Cupsi. TVS was done showing 2 well circumscribed heterogenous structure within the myometrium suggestive of myomas. Patient was scheduled for an unrecalled operation; however due to financial constraints for lack of insurance, the operation was cancelled. Patient was prescribed with Tranexamic acid (Hemostan) 500mg/ tab, 2 tabs TID for every menstrual period, taken with good compliance. Twenty-two days prior to admission, after acquiring insurance, the patient sought consult due to persistence of her condition. A pap smear was done with unremarkable results. The patient was then scheduled for a total abdominal hysterectomy with bilateral salpingo oophorectomy on July 26, 2012 at Cebu Velez General Hospital. Thus admission was done on July 25,2012.Past Health History Last 1998 during her last pregnancy, the patient was diagnosed with pre-eclampsia. Successive BP taking after the pregnancy showed BP elevation of 150/90. The patient did not seek consult and self-medicated with Metropolol (Neobloc) 500mg/tab, 1 tab per day with good compliance. Last 2005, patient was diagnosed with UTI for 7 days, unrecalled medications were taken with good compliance and improved condition was noted thereafter. Previous hospitalizations were due to labor and delivery, as well as dilatation and curettage due to the incomplete abortion of her second pregnancy. Patient is a non smoker, non-alcoholic beverage drinker. Her usual diet consists mostly of meat, rice and sometimes vegetables. Patient claimed to have heredofamilial diseases such as hypertension on both maternal and paternal sides and asthma on her paternal side.ENVIRONMENTAL HISTORY Patient is a housewife and lives with her husband and 2 children. She finished Bachelor Science in Business Administration. Patient and her family resides in Cebu City. It was a 1 storey house made out of mixed material and still in good condition. It had a separate kitchen, dining room, living room and bathroom. The type of toilet was flushed type and the drainage is open. The electricity used is VECO and their source of water for domestic purposes is a pump type and utilizes a mineral water for drinking. Water was stored in a pail with cover. Garbage was collected every Mondays or Wednesdays. Patient’s husband claimed to clean their house everyday by mopping and sweeping. The crowding index is 2. Patient claimed that they do not have any pets at home. The mode of transportation includes tricycle, PUJ, and taxi. The distance from the main road to the house is 5 meters. Nearest: grocery store is 1 km, drug store is 1 km, health center is 5 min. away when riding a tricycle; nearest hospital is 1hour ride, church and Brgy. Hall is 5 min. away when riding a tricycle. Medications are stored in a Tupperware, cleaning supplies are placed outside the house and toxic substances such as chlorine are placed in one corner of the bathroom. GORDON’S FUNCTIONAL HEALTH PATTERNDate of Assessment: July 26- 28, 20121.HEALTH PERCEPTION AND HEALTH MANAGEMENT PATTERN Patient described health as, “pag-ayo sa lawas”. Her immediate health concern is how to properly take care of her wound from the incision site of her surgey. Patient’s health rating before she was hospitalized was 8/10 and verbalized,”arang-arang ra man akong lawas pero panagsa ra jud ko maka-exercise”. During hospitalization, patient’s health rating was 6/10. Patient claims to follow health advices given to her. Preventive Health Screening Activities Patient claimed that she performs breast self examination after the last day of her menstruation. Patient claimed that she does not go to the doctor for regular checkups but instead consults only when undesirable changes in the body are observed. Patient claimed that she often self medicates and takes medications that are being prescribed to her upon her consultation. Patient had not tried having any dental and eye examinations. 2. NUTRITIONAL-METABOLIC PATTERN Patient claimed that her current weight was 71kgs. Patient’s height is 5’5”. When asked about her feelings regarding her weight, patient verbalized, “okay ra man ko sa akong lawas”. Patient claims to have a fair appetite and has no therapeutic diet prior to admission. However, upon hospitalization, patient had a soft diet. MEAL | 24 HR. RECALL | USUAL DIET | BREAKFAST | A bowl of mais lugaw, a bowl of chicken soup, 1 glass of grape juice and 1 glass of water | A bowl of oatmeal, 1 cup of hot milo and 1 glass of water | LUNCH | A bowl of mais lugaw, a bowl of pork soup, 1 hard boiled egg, 1 glass of grape juice and 1 glass of water | 1 cup of rice, 1 serving of fish, 1 glass of juice and 1 glass of water | SNACKS | 1 skyflakes crackers and 1 glass of grape juice | 2 – 3 sliced breads and 1 glass of water | DINNER | A bowl of mais lugaw, a bowl of beef soup, 1 glass of grape juice and 1 glass of water | 1 cup of rice and 1 serving of fish, 1 bowl of vegetable soup and 1 glass of water | Patient claims to have no food or drink preferences and dislikes. Her husband verbalized, “mu kaon ra man na siya ug bisan unsa”. Patient claimed that they are only 4 who lives together at home. Patient claimed that she considers walking around jones avenue several times a week as her exercise. 3.ELIMINATION PATTERN Patient usually have an approximate # of 4 or 5 voidings per day and 3 or 4 voidings per night time. Her voiding amounts 24o mL with a yellow and clean characteristics and claimed that this is her typical pattern. Her approximate daily fluid intake is 7-8 glasses and doesn’t have a daily caffeine intake. She claimed that she is not taking any diuretics. Patient doesn’t know about Kegel’s exercise and doesn’t practice it. Patient claimed that she doesn’t have any problems in her ADLs. She has a history of UTI last 2005 and was diagnosed for 7 days, unrecalled medications were taken with good compliance and improved condition was noted thereafter. Patients usual bowel movements per day is 1. Its consistency is semi-soft with a brown formed stools. She claimed that she usually move her bowel at 5am and doesn’t postpone defecation. She defined diarrhea and constipation as verbalized, “and diarrhea kay sigeg kalibang sa usa ka adlaw nya ang constipation kay di ka makalibang og pila ka adlaw”. Patient claimed that she ate papaya and drinks hot milk if she experiences constipation. 4. ACTIVITY-EXERCISE PATTERN Patient’s usual activities upon waking up are to cook for breakfast and clean the house. Her usual leisure activities are watching t.v and resting. Patient spent 2 hours per day for her leisure time. Her exercise pattern is walking and do some household chores for 30 minutes. She claimed that she doesn’t have any problem in managing her home. 5. COGNITIVE – PERCEPTUAL PATTERN Patient is able to read and write and claimed that she understands and speaks English, tagalog and bisaya. She is college graduate of Bachelor Science in Business Administration. Her understanding of illness is as verbalized, “Kanang mga sakit-sakit sa lawas” and her understanding of treatment is as verbalized, “Ang makaayo sa sakit sa lawas”. Patient was still able to recall the important dates/ events that happened to her life. One of these events was the date of her marriage which was on December 10, 2003. She claimed that she does not have any problems regarding her vision and hearing.6. SLEEP – REST PATTERN Patient usually has 6 hours of sleep at night. She claimed that she takes a nap every 2 to 3pm in the afternoon everyday. She falls asleep by 9 pm and wakes up by 5am and claimed that this is her typical pattern. She claimed that she sleeps very well and have no difficulty in falling asleep. Extreme noise prevents her from sleeping. She usually does not have awakenings during the night but when she does, it is due to extreme noise and the urge to void. Before going to sleep, she usually takes a half bath, washes her face and brushes her teeth. In the hospital area, she claimed that her bedtime routine changed because of her condition and she has been interfered by the nurses who keep on going in and out of her room for her daily monitoring. At home, she usually sleeps in one bed together with her husband. She claimed that she uses 1 warm blanket and 2 pillows which are placed under her head and the other one serves as her “tanday”. She usually sleeps in a side-lying position. What prevents her from sleeping in that position at present is her condition in the hospital setting. 7. SELF PERCEPTION and SELF CONCEPT PATTERN Patient sees herself as a simple person, a loving mother and a wife, and friendly neighbor. She also described herself as a silent type of person. She is passionate with being a housewife. Based on her achievements and how she lived her life through the years, she considers herself as hardworking. Her husband described her as loving and understanding. Patient has always lived a simple and ordinary life. She claimed to be contented and grateful with how many things have gone for her. She considers her family as her strength. ROSENBERG'S SELF-ESTEEM SCALE ITEMS | SA | A | D | SD | 1. On the whole, I am satisfied with myself | | * | | | 2. At times I think I'm no good at all | | | * | | 3. I feel that I have a number of good qualities | | * | | | 4. I am able to do things as most other people | | * | | | 5. I feel I don't have much to be proud of | | | * | | 6. I certainly feel useless at times | | | * | | 7. I feel that I am a person of worth, at least on an equal plane with others | | * | | | 8. I wish I could have more respect for myself | | | * | | 9. All in all, I am inclined to feel that I am a failure | | | * | | 10. I take a positive attitude toward myself | | * | | | 8. ROLE – RELATIONSHIP PATTERN Patient is a loving mother and wife and a caring person to her friends. Patient claimed that the pressure she encounters includes budgeting their family’s income and catering to the needs of the sick family members associates her role both as a mother and a wife. She claimed that her health status did not alter her relationship to others. She has a strong family ties and she lives with her husband and her 2 children. She turns to her husband, siblings, parents and friends if she needs some help. She made decisions concerning her family with the help of her husband. She claimed that she has no problems within her family but have a little misunderstanding with some of her relatives.FAMILY GENOGRAM MATERNAL PATERNAL O.A O.A O.A A HPN HPN HPN TB G,L LEGEND: FEMALE MALE DECEASED ALIVE & WELL PX’S PARENTS PATIENT OA – OLD AGEA – ASTHMAHPN – HYPERTENSIONTB – TUBERCULOSISG – GOITERL – LEUKOMAECOMAP:F CF
R
PX S
P
LEGEND: F – FAMILY CF – CLOSE FRIENDS R – RELATIVES S – SIBLINGS P – PARENTS WEAK RELATIONSHIP GOOD RELATIONSHIP STRONG RELATIONSHIP ------------------ IN CONFLICT9. SEXUALITY REPRODUCTIVE PATTERN Patient is grossly female. Her first sexual contact was when she was 19 years old with only her husband as her sole sexual partner. Last sexual contact was on April 2012. She claimed that she did not use any contraceptions, does not have any problems with sexual activities and no further reports of STDs. Patient’s age of menarche was 14 years old and her last menstrual period was on July 16, 2012 with the length of 7days consuming 3-4 pads of sanitary napkins per day and claimed that it is fully soaked upon changing with a regular menstruation. No dysmenorrhea noted during menstruation. Last BSE was on December 2011 and last availability of pap smear was on June 2012. Patient is G3P2(2012) mother with the following OB history: * G1: 1987 NSVD assisted by a private OB at CVGH. Live baby boy, BW 6 – 2 lbs with no complications noted. * G2: 1988 in complete abortion, completion curettage done at CVGH * G3: 1998 LCTCS primary assisted by private OB at CVGH, live baby boy, BW 6 -2 lbs, patient was diagnosed with pre-ecclampsia during a prenatal check-up and patient was admitted & LSTCS was done. Age of her living children are 25 years old & 14 years old both are boys. First prenatal check – up was at a clinic on 1987 during her first pregnancy at 6 months and her third pregnancy at 4 months. 10. COPING – STRESS TOLERANCE PATTERN Patient defined stress as verbalized, “Kapoy”. She has no major changes or losses in the past year. The situations that cause her stress in the past are budgeting their money while in the present is her hospitalization. According to her, a stressor is as verbalized. “Ang hinungdan sa stress” and that stressful situations has been bad for her. She claimed that she can’t control her temper when she is stressed. She deals with stress by talking to others, trying to forget the stressors, do something, pray, try to solve the problem, go to sleep and seek help. Her husband, mother and friends are the ones she rely on to help her solve her problems. For her the nurses can do something to make hospitalization less stressful by having a conversation with them and monitoring her condition so that she will not worry too much.11. VALUE – BELIEF PATTERN Patient’s ethnic background is Filipino and she believes in “pa-tutho” and “pa-hilot”. Her philosophy in life is “Always ask for God’s guidance”. Together with her husband and children, they go to church every Sunday and they light a candle and pray. She claimed that her relationship with God is fine and her family & parents support her spiritually. She believes on superstitious beliefs like: “Di mag labang2x sa patay” og “Kung nay magkasakit sa pamilya kay dili angay mu-adto og lubong”. “Pa-hilot”, “Pa-tutho” and use of herbal medicines are the health practices that influenced her by culture. She makes use of religious symbols such as the cross and images of saints. She doesn’t have any conflicts with belief and values associated with traditional western health care. | PHYSICAL EXAMINATIONDay 1Date performed: March 15, 2013 (Friday)General Appearance: examined px lying on stretcher, awake, responsive, coherent, gowned and with head caps on, with IVF bottle D5LR 1L @ 30 gtts/min infusing well on left arm, with the ff v/s:BP= 130/80 PR= 88bpm RR=20cpm T=36.1 *CHeight: 5’5” or 165 cmWeight: 71 kgIBW: 58.5kg (Tannhauser’s Method: IBW in kg = (Height in cm - 100) less 10%)BMI: 26.1 kg/m2 = overweightSKIN: Fair complexion, good skin turgor, no impaired skin noted.NAILS: Clean, well-trimmed, not brittle, smooth, firmly attached nailplate, no nail clubbing noted, CRT = 1 sec in all peripheries.HEAD and FACE: consistently round, no involuntary movements or twitching noted, no lesions noted.HAIR and SCALP: Hair is black and evenly distributed with very minimal strands of white hair, no parasite infestations, scalp is clean.EYES: Eyeballs symmetrically aligned in sockets without protrusion. Eyebrows same as hair color, symmetric and is evenly distributed. Lashes short, evenly spaced, curled outward; Redness, discharges, / crusting not noted on lid margins. Bulbar conjunctiva is pink bilaterally. Anicteric sclerae.EARS: Pinna is in line with outer canthus of the eyes.NOSE AND SINUSES: color same as face, intact nasal septum; purulent drainage not noted.MOUTH & THROAT: Lips have very fine but minimal cracks, pinkish buccal mucosa with no ulcerations. Wears removable dentures in replacement of 3 molars on the right and 2 on the left. Tongue is moist, and at midline. Uvula hangs freely in midline, without redness or exudates, pink, symmetric without swelling or lesions. Grade +1 tonsils bilaterally. THORAX & LUNGS: RR = 20 cpm, regular, quiet, effortless. Sternum at midline, clear breath sounds.BREAST: unassessed.HEART: HR = 88bpm, regular, distinct S1 and S2 upon auscultation. Grade +2 pulse on radial artery.ABDOMEN: slightly protruding, nontender, skin is lighter compared to the rest of skin complexion, very fine striae noted on lower segment. Presence of approximately 4 ½ inch vertical incision scar just below the umbilicus (previous Cesarean Section, 1998). GENITO-URINARY: well-shaved pubic hair, slightly dark in complexion.MUSCULOSKELETAL: Upper and lower extremities symmetric, no deformities. With full ROM. R | L | 5 / 5 | 5 / 5 | 5 / 5 | 5 / 5 |
Scale for grading muscle strength:5- active motion against full resistance4- active motion against some resistance3- active motion against gravity2- passive ROM 1- slight flicker of contraction 0- no muscular contractionNeurologic AssessmentA. Mental Status/ Cerebral Function:Patient is oriented to time of day and place. She is coherent when asked how she feels about the incoming operation.B. Sensory FunctionPatient can sense pain when needle for anesthesia was about to be inserted by facial grimacing. C. Motor FunctionPatient was able to help lift herself when being transferred from the stretcher to the operating room bed.Cranial nerve Assessment:CN I (Olfactory): Intact sense of smell.CN II (Optic): Can distinguish people around her.CN III, IV, VI (Occulomotor, Trochlear, Abducens): able to follow movements of up and down, (+) PERRLA CN V (Trigeminal): blink reflex presentCN VIII (Vestibulocochlear): able to follow verbal instructions correctlyCN IX, X (Glossopharyngeal, Vagus): (+) gag reflex, (+) swallowing reflex.CN XI (Spinal Accessory): can turn head from side to side, can shrug shoulders and resist against pressureCN XII (Hypoglossal): can move tongue at any directions when protrudedDay 2Date performed: March 16, 2013 (Saturday)General Appearance: examined px lying on stretcher, awake, responsive, coherent, gowned and with head caps on, with IVF bottle D5LR 1L @ 30 gtts/min infusing well on left arm, with the ff v/s:BP= 130/70 PR= 79bpm RR=16cpm T=36.3 *CHeight: 5’5” or 165 cmWeight: 71 kgIBW: 58.5kg (Tannhauser’s Method: IBW in kg = (Height in cm - 100) less 10%)BMI: 26.1 kg/m2 = overweightSKIN: Fair complexion, good skin turgor, no impaired skin noted.NAILS: Clean, well-trimmed, not brittle, smooth, firmly attached nailplate, no nail clubbing noted, CRT = 1 sec in all peripheries.HEAD and FACE: consistently round, no involuntary movements or twitching noted, no lesions noted.HAIR and SCALP: Hair is black and evenly distributed with very minimal strands of white hair, no parasite infestations, scalp is clean.EYES: Eyeballs symmetrically aligned in sockets without protrusion. Eyebrows same as hair color, symmetric and is evenly distributed. Lashes short, evenly spaced, curled outward; Redness, discharges, / crusting not noted on lid margins. Bulbar conjunctiva is pink bilaterally. Anicteric sclerae.EARS: Pinna is in line with outer canthus of the eyes.NOSE AND SINUSES: color same as face, intact nasal septum; purulent drainage not noted.MOUTH & THROAT: Lips have very fine but minimal cracks, pinkish buccal mucosa with no ulcerations. Wears removable dentures in replacement of 3 molars on the right and 2 on the left. Tongue is moist, and at midline. Uvula hangs freely in midline, without redness or exudates, pink, symmetric without swelling or lesions. Grade +1 tonsils bilaterally. THORAX & LUNGS: RR = 20 cpm, regular, quiet, effortless. Sternum at midline, clear breath sounds.BREAST: unassessed.HEART: HR = 88bpm, regular, distinct S1 and S2 upon auscultation. Grade +2 pulse on radial artery.ABDOMEN: slightly protruding, nontender, skin is lighter compared to the rest of skin complexion, very fine striae noted on lower segment. Presence of approximately 4 ½ inch vertical incision scar just below the umbilicus (previous Cesarean Section, 1998). GENITO-URINARY: well-shaved pubic hair, slightly dark in complexion.MUSCULOSKELETAL: Upper and lower extremities symmetric, no deformities. With full ROM. R | L | 5 / 5 | 5 / 5 | 5 / 5 | 5 / 5 |
Scale for grading muscle strength:5- active motion against full resistance4- active motion against some resistance3- active motion against gravity2- passive ROM 1- slight flicker of contraction 0- no muscular contractionNeurologic AssessmentA. Mental Status/ Cerebral Function:Patient is oriented to time of day and place. She is coherent when asked how she feels about the incoming operation.B. Sensory FunctionPatient can sense pain when needle for anesthesia was about to be inserted by facial grimacing. C. Motor FunctionPatient was able to help lift herself when being transferred from the stretcher to the operating room bed.Cranial nerve Assessment:CN I (Olfactory): Intact sense of smell.CN II (Optic): Can distinguish people around her.CN III, IV, VI (Occulomotor, Trochlear, Abducens): able to follow movements of up and down, (+) PERRLA, can correctly read student’s nameplate 14 inches away.CN V (Trigeminal): blink reflex presentCN VIII (Vestibulocochlear): able to follow verbal instructions correctlyCN IX, X (Glossopharyngeal, Vagus): (+) gag reflex, (+) swallowing reflex.CN XI (Spinal Accessory): can turn head from side to side, can shrug shoulders and resist against pressureCN XII (Hypoglossal): can move tongue at any directions when protrudedDay 3Date performed: March 17, 2013 (Sunday)General Appearance: examined px lying on stretcher, awake, responsive, coherent, gowned and with head caps on, with IVF bottle D5LR 1L @ 30 gtts/min infusing well on left arm, with the ff v/s:BP= 120/80 PR= 85bpm RR=16cpm T=36.1 *CHeight: 5’5” or 165 cmWeight: 71 kgIBW: 58.5kg (Tannhauser’s Method: IBW in kg = (Height in cm - 100) less 10%)BMI: 26.1 kg/m2 = overweightSKIN: Fair complexion, good skin turgor, no impaired skin noted.NAILS: Clean, well-trimmed, not brittle, smooth, firmly attached nailplate, no nail clubbing noted, CRT = 1 sec in all peripheries.HEAD and FACE: consistently round, no involuntary movements or twitching noted, no lesions noted.HAIR and SCALP: Hair is black and evenly distributed with very minimal strands of white hair, no parasite infestations, scalp is clean.EYES: Eyeballs symmetrically aligned in sockets without protrusion. Eyebrows same as hair color, symmetric and is evenly distributed. Lashes short, evenly spaced, curled outward; Redness, discharges, / crusting not noted on lid margins. Bulbar conjunctiva is pink bilaterally. Anicteric sclerae. Patient is hyperopic, doesn’t wear glasses. Can correctly read SN’s nameplate 14 inches away from eyes.EARS: Pinna is in line with outer canthus of the eyes.NOSE AND SINUSES: color same as face, intact nasal septum; purulent drainage not noted.MOUTH & THROAT: Lips have very fine but minimal cracks, pinkish buccal mucosa with no ulcerations. Wears removable dentures in replacement of 3 molars on the right and 2 on the left. Tongue is moist, and at midline. Uvula hangs freely in midline, without redness or exudates, pink, symmetric without swelling or lesions. Grade +1 tonsils bilaterally. THORAX & LUNGS: RR = 20 cpm, regular, quiet, effortless. Sternum at midline, clear breath sounds.BREAST: unassessed.HEART: HR = 88bpm, regular, distinct S1 and S2 upon auscultation. Grade +2 pulse on radial artery.ABDOMEN: slightly protruding, nontender, skin is lighter compared to the rest of skin complexion, very fine striae noted on lower segment. Presence of approximately 4 ½ inch vertical incision scar just below the umbilicus (previous Cesarean Section, 1998). GENITO-URINARY: well-shaved pubic hair, slightly dark in complexion.MUSCULOSKELETAL:Upper and lower extremities symmetric, no deformities. With full ROM. R | L | 5 / 5 | 5 / 5 | 5 / 5 | 5 / 5 |
Scale for grading muscle strength:5- active motion against full resistance4- active motion against some resistance3- active motion against gravity2- passive ROM 1- slight flicker of contraction 0- no muscular contractionNeurologic AssessmentA. Mental Status/ Cerebral Function:Patient is oriented to time of day and place. She is coherent when asked how she feels about the incoming operation.B. Sensory FunctionPatient can sense pain when needle for anesthesia was about to be inserted by facial grimacing. C. Motor FunctionPatient was able to help lift herself when being transferred from the stretcher to the operating room bed.Cranial nerve Assessment:CN I (Olfactory): Intact sense of smell.CN II (Optic): Can distinguish people around her.CN III, IV, VI (Occulomotor, Trochlear, Abducens): able to follow movements of up and down, (+) PERRLA, can read students’ nameplate 14 inches away.CN V (Trigeminal): blink reflex presentCN VIII (Vestibulocochlear): able to follow verbal instructions correctlyCN IX, X (Glossopharyngeal, Vagus): (+) gag reflex, (+) swallowing reflex.CN XI (Spinal Accessory): can turn head from side to side, can shrug shoulders and resist against pressureCN XII (Hypoglossal): can move tongue at any directions when protrudedLABORATORIESULTRASOUND REPORT- GYNECOLOGY (2/11/12)Uterus: 14.5x10.9x10.4 cm avertedCervix: 2.9x3.3x2.5 cm with nabothian cystEndometrium: 0.77cmRight Ovary: 2.3x1.4x1.6 cmLeft ovary: 3.0 x 5.8 x 1.7 cmOthers: No free fluid in cul de sacRemarks:The uterus is anteverted with regular contour and inhomogeneous myometrium.
There are two well-circumscribed heterogenous structures noted within the myometrium, suggestive of uterine myomas, described as ff:

MF = 9.4x10.0x8.7 cm, posterior intramural with minimal submucous component.
MZ = 0.9 cm x 0.9 cm x0.8 cm, anterior lower corpus, intramural.

The cervix is closed with nabothian cyst.
The endometrium is thin and heterogeneous. It is pushed anteriorly by the myoma.
The right ovary is posterolateral to the uterus while the left is lateral. Both contains follicles.
There are no adnexal masses seen.
There is no free fluid in the cul de sac.Impression:
Enlarged anteverted uterus with myomas as described.
Thin and heterogeneous endometrium.
Both ovaries normal.
No adnexal masses seen in this scan.
No cul de sac fluid.
Please consider clinically.Purpose: * Pelvic ultrasound is used to find out the cause of a pelvic pain and cause of a vaginal bleeding. It is also used to look at the size and shape of the ovaries, uterus and the thickness of the uterine lining (endometrium) and to check for uterine fibroids found during a pelvic examination. Pelvic ultrasound may also be done to check the growth of uterine fibroidsImplications: * There is an enlarged anteverted uterus due to the patient’s uterine leiomyoma or also called myomasCHEST X-RAY (7/23/12)Reports:Lung fields are clear. Heart is top normal in size. The tracheal air column is at the midline. Aorta is tortuous. Both hemidiaphragms and costophrenic sulci are intact. The visualized osseous structures are unremarkable.

Impression: 1. Essentially clear lung fields 2. Top normal-sized cardiac shadow 3. Tortuous aortaPurpose: * Preoperative chest x-rays are done to rule out any lung or heart disease that needs to be addressed before surgery or other procedure. Fluid in the lungs, lung infection, cancer and congestive heart failure can all be detected from the x-ray and will be accounted for before and during surgeryImplications: * A tortuous aorta is an aorta with anatomical abnormalities which cause it to be distorted in shape or path. Individuals with this condition can be at risk for high blood pressure caused by the interruption to their blood flow, and they can also experience atherosclerosis, in which the vessels are lined with a layer of plaque which impedes the movement of blood through the vesselsPROTHROMBIN TIME (7/23/12) | Results | Reference Range | Patient | 11.9 seconds | - | Activity | 127% | >70% | INR | 0.87 | < or = 1.21 | Control | 13.2 seconds | - | Control Activity | 100% | - |
Purpose: * Prothrombin time (PT) is a blood test that measures the time it takes for the liquid portion (plasma) of your blood to clot * The PT test is used to monitor patients taking certain medications as well as to help diagnose clotting disordersImplications: * Within the normal rangePARTIAL THROMBOPLASTIN TIME (7/23/12) | Results | Reference Range | Patient | 31.3 secs | 2.64 – 36.7 secs | Control | 32.8 secs | - |
Purpose: * Blood clotting (coagulation) depends on the action of substances in the blood called clotting factors. Measuring the partial thromboplastin time helps to assess which specific clotting factors may be missing or defective * Certain surgical procedures and diseases cause blood clots to form within blood vessels. Heparin is used to treat these clots. The PTT test can be used to monitor the effect of heparin on a patient's coagulation systemImplications: * Within the normal rangeBLEEDING TIME (7/23/12) | Results | Reference | Bleeding Time - Adult (Simplate) | 5 mins & 43 secs | 2.3 – 4.5 mins | | | |
Purpose: * Bleeding time is used most often to detect qualitative defects of platelets, such as Von Willebrand's disease. The test helps identify people who have defects in their platelet function. This is the ability of blood to clot following a wound or trauma. Normally, platelets interact with the walls of blood vessels to cause a blood clot. * The bleeding time test is usually used on patients who have a history of prolonged bleeding after cuts, or who have a family history of bleeding disorders. * Also, the bleeding time test is sometimes performed as a preoperative test to determine a patient's likely bleeding response during and after surgery. However, in patients with no history of bleeding problems, or who are not taking anti-inflammatory drugs, the bleeding time test is not usually necessary.Implications: * Within the normal range. This lab finding may indicate that there is no defect on the patient’s platelet function and the 5 minutes and 43 seconds is the patient’s bleeding response during and after surgeryCOMPLETE BLOOD COUNT (7/23/12) | Results | Reference Range | WBC | 7.23/uL | 4.8 – 10.8 /uL | RBC | 4.51 /uL | 4.2 – 5.4 /uL | Hgb | 13.1 g/dL | 12.0 – 16 g/dL | HCT | 39.11 % | 37 – 47 % | PLT | 343 /uL | 130-400 /uL |
Blood Indices | Results | Reference Range | MCV | 87.3 fL | 81-99 fL | MCH | 29.1 pg | 27.0-31.0 pg | MCHC | 33.3 g/dL | 33-37 g/dL | RDW | 14.9 % | 11-16 % | PDW | 59.1 % | 25-65 % | MPV | 7.9 fL | 7.2 – 11.1 fL |
Relative Differential Count | Results | Reference Range | Neutrophils | 60% | 40-74% | Lymphocytes | 30.9% | 18-48% | Monocytes | 4.9% | 3.4-9.0 | Eosinophils | 1.3% | 0.0-7.0% | Basophils | 0.5% | 0.0-4.5% | LUC | 2.1% | 0.0-4.0% |
Purpose: * A basic screening test which provides valuable diagnostic information about the body’s prognosis, response to treatment and recovery. The CBC consists of a series of * tests that determine number, variety, percentage, concentrations and quality of blood cells (wbc,rbc,plt,hbg,hct). * It is also a preoperative test to ensure both adequate oxygen carrying capacity and hemostasis and to identify persons who may have an infection. It is also used to identify anemia or white blood cell disorders or bleeding tendencies. It is also used to determine the effects of chemotherapy and radiation therapy on blood cell production.Implications: * Within normal range. This lab finding may indicate that there is adequate oxygen carrying capacity, hemostasis and no signs of infection.URINALYSIS REPORT 7/23/2012 | SI | FULLY AUTOMATED ROUTINE URINALYSIS UNCENTRIFUGED SPECIMEN | RESULT | REFERENCE RANGE | UNIT | Physical Characteristics | | | | Color | Yellow | | | Transparency | Slightly cloudy | | | pH | 5.0 | 5-6 | | Specific gravity | 1.025 | 1.003-1.035 Random | | Chemical Characteristics | | | | Protein | 25 | Negative | mg/dL | Glucose | NEGATIVE | Negative | mg/dL | Ketone | NEGATIVE | Negative | mg/dL | Urobilinogen | NORMAL | Up to 2 | mg/dL | Leukocytes | 25 | Negative | wbc/µL | Blood/Hb | 25 | Negative | rbc/µL | Bilirubin | NEGATIVE | Negative | mg/dL | Nitrite | NEGATIVE | Negative | | Microscoping Findings | | | | Red Blood Cell | 37 | 0-11 | /µL | White Blood Cell | 33 | 0-17 | /µL | Bacteria | 298 | 0-278 | /µL | Squamous Epithelialm Cells | 29 | 0-17 | /µL | Hyaline Cast | 1 | 0 | /µL | Cast | NONE | 0-1 | /µL |
Purpose: * Urinalysis are usually used to as a general health screening test to detect renal and metabolic diseases, diagnosis of diseases or disorders of the kidneys or urinary tract monitoring of patients with diabetes. In addition, quantitative urinalysis tests may be performed to help diagnose many specific disorders,such as endocrine diseases, bladder cancer,osteoporosis, and porphyries(a group of disorders caused by chemical imbalance.Implications: * Urine may be cloudy because of the presence of RBCs, WBCs, epithelial cells, or bacteria * The number of WBCs in urine sediment is normally low. When the number is high, it indicates an infection. WBCs can also be a contaminant, such as those from vaginal secretions * Protein in urine indicates there is an infection. Role of protein in living organism involves fighting infection, balancing of body fluids * From the results of the test, it draws to the conclusion that the patient is experiencing UTI.CLINICAL CHEMISTRY REPORT (7/23/12) TEST | RESULT | REFERENCE RANGE | UNIT | Glucose | 107 | 60-100 | mg/dL | Creatinine | 0.7 | 0.6-1.5 | mg/dL | Cholesterol | 211 | 130.0-200.0 | mg/dL | Triglycerides | 218 | 60.0-130.0 | mg/dL | VLDL | 43.6 | 0.0-50.0 | mg/dL | LDL | 124.5 | 0.0-150.0 | mg/dL | HDL | 42.9 | 35.0-65.0 | mg/dL | SGPT-ALT | 41 | 5.0-50.0 | u/L | Sodium (serum) | 137.0 | 134.0-148.0 | mmol/L | Potassium | 3.8 | 3.3-5.3 | mmol/L |
Purpose: * Measuring the amount or activity of a particular enzyme or protein in a sample of blood or urine or other tissue from the bodyImplications: * Patient has metabolic syndrome where clinical manifestations of this syndrome may include hyperglycemia, hypertriglyceridemia, cholesterol abnormalities * High levels of triglycerides can increase the risk of coronary artery diseaseNURSING CARE PLAN (BASED ON SEVERITY)PRE-OPERATIVE PHASE1. Knowledge Deficit related to lack of exposure, information interpretation and unfamiliarity evidence by questions, request for information and statement of misconception as verbalized: “gatuo ko na ang pagsakit sa akong likod og bagtak kay wa ra, apil na diay to sa mga simptomas sa akong sakit”SB: Knowledge deficient is a learning need regarding the patient’s condition, prognosis, treatment, self-care and discharge.Source: http://nurseslabs.com/knowledge-deficit-hysterectomy-nursing-care-plans/ 2. Anxiety related to the upcoming surgical procedure as manifested by fear, fatigue, sleep disturbance, restlessness, irritability, nausea and abdominal pain and as verbalized: “Di man jud na malikayan na makulbaan day, sa karon kulbaan ra ko gamay.” SB: Due to upcoming surgical procedure, patients are usually experiencing anxiety. The brain signals our body part to initiate responses such as fatigue, nausea and abdominal pain. Source: http://nurseslabs.com/tahbso-nursing-care-plans/4/3. Risk for Perioperative Positioning Injury related to sensory and perceptual disturbances due to anesthesia.INTRA-OPERATIVE PHASE1. Decreased Cardiac Output related to hemorrhage (50 cc) secondary to surgery as manifested by borderline blood pressure of 90/60mmHg and urine output of less than 30mL.SB: Although most patients do not hemorrhage or go into shock, changes in circulating volume, the stress of surgery, and the effects of medications and preoperative preparations all affect cardiovascular function.Source:Smeltzer, S., Bare, B., Hinkle, J. and Cheever, K. (2010). “Medical-Surgical Nursing”. New York: Lippincott Williams & Wilkins2. Ineffective Tissue Perfusion (Renal) related to blood loss of 50cc and reduced vascular resistance-effect of Midazolam (Versed), as manifested by blood pressure of 90/60mmHg and less than 30mL of urine output in one hour.SB: Midazolam(Versed) can cause hypotension by reducing systemic vasculature resistance. Losing about 1/5 or more of the normal amount of blood in your body can trigger hypovolemia to the point of shock. Maintaining the circulating blood volume supports perfusion.Sources:"Midazolam (Rx) - Versed." Versed (midazolam) Dosing, Indications, Interactions, Adverse Effects, and More. N.p., n.d. Web. 31 July 2012. <http://reference.medscape.com/drug/versed-midazolam-342907>."MemoiroFaschizo." Risk for Ineffective Peripheral Tissue Perfusion. N.p., n.d. Web. 31 July 2012. <http://memoirofaschizo.blogspot.com/2011/08/risk-for-ineffective-peripheral-tissue.html>.POST-OPERATIVE PHASEDate Identified: July 26, 20121. Acute Pain related to surgical procedure: total abdominal hysterectomy salphingo-oophorectomy; tissue trauma, interruption of nerves, dissection of muscles as evidenced by gnawing pain on hypogastric region aggrevated by movement and relieve with rest with a pain scale of 5/10 SB: Pain after surgery is a compilation of several unpleasant sensory, emotional, and mental experiences, associated with autonomic, endocrine-metabolic, physiological, and behavioral responses Mechanisms of Acute Postoperative Pain • Patients with surgery experience pain caused by damage to a variety of tissues. • Commonly injured tissues include skin, muscle, bone, tendons, ligaments, and visceral organs. • Symptoms vary depending upon the type of tissue injured and the extent of the injury. • Sensory pathways for pain caused by tissue damage transmit information from the damaged tissue to the central nervous system (nociception). • Nociceptive pain is accompanied by inflammatory, visceral, and neuropathic pain mechanisms. • Sensitization of peripheral and central neuronal structures amplifies and sustains postoperative pain. Source: International Association For the Study of Pain. (2011).
Retrieved August 1,2012, from: http://www.iasppain.org/AM/Template.cfm?Section =Fact_Sheets3&Template=/CM/ContentDisplay.cfm&ContentID=12977
2. Impaired Skin Integrity related to incision secondary to TAHBSO as evidenced by the presence of approximately 4 ½ inches incision on abdomen.SB: To know if the patient’s skin integrity is kept clean and maintained intact and dry at all times. Date Identified: July 26, 20123. Risk for Injury: Falls related to effects of anesthesia as evidenced by altered level of consciousness, loss of muscle function CUES: Limited bed spaceLoss motor function especially on the lower extremities Altered level of consciousness: Lethargy3. Risk for Infection related to tissue destruction secondary to s/p total abdominal hysterectomy with bilateral salpingo oophorectomy.Cues: * inadequate primary defenses (traumatized tissue [abdomen], broken skin due to presence of approx. 4 ½ vertical incision on hypogastric region of the abdomen)SB: The skin serves as the primary defense against bacterial invasion. When skin is incised for surgical procedure, this important line of defense is lost. Strict adherence to aseptic technique during surgery and in the days following the procedure is necessary to compensate for impaired defense. In addition to assessment of the surgical wound, you should evaluate the patient's general condition and laboratory test results. If the patient complains of increased or constant pain from the wound, or if wound edges are swollen or there is purulent drainage, further assessment should be made and your findings reported and documented. Generalized malaise, increased pain, anorexia, and an elevated body temperature and pulse rate are indicators of infection. Important laboratory data include an elevated white blood cell count and the causative organism if a wound culture is done. Staples or sutures are usually removed by the doctor using sterile technique. The most common cause of nosocomial infections is carelessness in observing medical and surgical asepsis when changing dressings. It is especially important to wash hands thoroughly before and after changing dressings and to follow the Centers for Disease Control (CDC) guidelines.Source:Smeltzer, S., Bare, B., Hinkle, J. and Cheever, K. (2010). “Medical-Surgical Nursing”. New York: Lippincott Williams & Wilkins4. Enhanced Self Care Management related to able to accept new ideas and ways on how to improve health condition as verbalized by “ Ahh ingana diay na. Sakto jud mu dong. Na answer jd ninyo akng mga pangutana. Salamat kaayo nnyo “SB: To ascertain patient’s learning needs about her condition and to give patient the ways on how to do self –care and manage herself optimally. | DOCTORS ORDERS3/14/13 5:15PM> Please admit Mrs. Edna Alo
> TPR q 4 hours> Full diet, then NPO post-midnight> Crossmatched 1 unit packed RBC blood type A+ Rh+> Scheduled for TAH possible BSO on 7/26/12 8AM> Consent slip> Dr. G. Antigua – anesthesiologist> Notify me on admission3/14/13 6PM * Pls carry out AP’s orders * Problem: Uterine Leiomyoma * Pls attach labs taken as OPD * Give Phosphosoda 45cc in 1 glass of Sprite now then give Gatorade s volume per volume replacement * Full body bath in AM * AP prep in AM with vaginal prep * Start venoclysis with D5LR 1L @ 30gtts/min 1 hour prior to OR * Give Cefoxitin 1 gram IVTT ANST prior to incision at OR * I & O q shift * Monitor v/s q 4 hours * Inform OBROD once scheduled * Refer for any unusualities * Refer accordingly * Dr. Libre informed of admission Sandy Chua, MD3/14/13 Maria Delfa T. ZanoriaMedical Clearance (Internal Medicine – Cardiology)“Miss Edna Alo is medically-cleared for surgery. Sh has controlled HPN, on Neobloc 50g 2x a day & Felodipine 5g 2x a day. I’m giving her Cefuroxime 5 mg BID for UTI. * For co-management with Dr. Zanoria * Dr. Libre with orders3/14/13 7:50PM * Thank you for the co-management * Dr. Zanoria informed * Pls attach medical clearance done as out patient * Meds: 1.) Cefuroxime 500mg/tab 1 tab BID pc. 2.) Metoprolol 50 g/tab 1 tab BID pc 3.) Felodipine (Derpene) 5g/tab 1 tab BID pc3/14/13 8:15PM * My schedule OR pending blood3/14/13 9:30PM * Please inform MROD once px is wheeled to OR.-------------------POST OP ORDERS---------------------3/15/13 10:35 AM * To RR * TPR q 4h * NPO * Present IVF A regulated @ 30gtts/min * Labs: Repeat Hematocrit tomorrow * Meds: 1.) Cefoxitin 1gram IVTT q 8H x 3doses only 2.) Sensorcaine-Nubaine via epidural catheter 5-10cc q4H with strict BP precautions. 3.) Ketorolac (Ketorol) 30mg IVTT q 6H PRN for breakthrough pain. 4.) Omeprazole 40mg IVTT OD x 1 dose only. * Flat on bed for 6-8H then turn to sides q 2H * Send specimens (Uterus with ovaries & FTS) to Histopath for biopsy. * I/O q hourly & chart absolute figures without fail pls. * Monitor v/s q 15 mins x 2H q 30mins x 2H, q hourly thereafter. * Refer for abdominal distention, hypotension, tachycardia, UO < 30cc/hr, & other unusualities * Refer accordingly * Thank You! Dr. Libre3/15/13 12:30PM * May transfer px to room * Please carry out all post-op orders * Refer accordingly * Monitor for further orders3:10PM * IVF rate increased to 40 gtt/min3:30PM * Captopril 25mg/tab 1 tab SL q 6Hrs while on NPO PRN for SBP >160 * Inform MROD once on diet. Sumalinug7PM * decrease IVF rate to 30gtt/min3/16/13 6:20AM * May sit up on bed & dangle legs * May have general liquids and crackers * Shift Cefoxitin IV to Cefuroxime 500mg/tab 1 tab q 2H PO after 7AM dose. * Terminate present IVF once consumed. * Dr. Libre update10 AM * Resume: Metoprolol 50mg/tab 1 tab BID pc, Felodipine 5mg/tab BID pc, Captopril 25 mg/tab, 1 tab SL q 6H PRN for SBP >160. Sumalinug3:20PM * May have soft diet tomorrow AM * Remove FBC tomorrow @ 6AM, refer if unable to void 4-6H after * Start Celecoxib (Celebrex)200mg/tab 1 tab q 12 H to start @ 8PM today * May release blood Dr. Libre3/17/13 6:20 AM * Please prepare OS 4x4, Betadine, cotton pledgets, plaster9:50AM * Decrease Felodipine to 5mg/tab 1 tab OD pc BF. Dr. Zanoria3/17/13 5:05PM * May go home tomorrow AM * Full diet * Take home meds:
1.) Cefuroxime 500mg/tab 1 tab BID PO x 6days more
2.) Celecoxib (Celebrex) 200mg/cap 1 cap q 12 H for pain. * Daily dressing with Betadine BID * Follow up check up with Dr. Libre on Friday (8/3/12) * IM Dept for further orders. Dr. Libre3/18/13 10:45AM * MGH * Continue Neobloc 50mg/tab 1 tab PO
Felodipine 5mg/tab 1 tab q AM * RTC – 1 week after.Independent Interventions 1. Note length of procedure and position. Provide for potential complications.
R: Supine position may cause low back pain and skin pressure at heels, elbows, and sacrum; lateral chest position can cause shoulder and neck pain as well as eye and ear injury on the client’s downside. 2. Check client’s history, noting age, weight, height, nutritional status, and physical limitation or preexisting conditions that may affect choice of position and skin and tissue integrity during surgery.
R: Many conditions, such as lack of subcutaneous padding in elderly person, arthritis, thoracic outlet or cubital tunnel syndrome, diabetes, obesity, presence of abdominal stoma, peripheral vascular disease, level of hydration, and temperature of extremities, can make individual prone to injury. 3. Stabilize both client cart and OR table when transferring client to and from OR table, using an adequate number of personnel for transfer and support of extremities.
R: Unstabilized cart or table can separate, causing client to fall. Both side rails must be in the down position for caregiver(s) to assist client transfer and prevent loss of balance. 4. Protect body from contact with metal parts of the operating table.
R: Reduces risk of electrical injury. 5. Prepare equipment and padding for required position, according to operative procedure and client’s specific needs. Pay special attention to pressure points of bony prominences on arms and ankles, and neurovascular pressure points and soft tissues such as breasts and knees.
R: Depending on individual client’s size, weight, and preexisting conditions, extra padding materials may be required to protect bony prominences, prevent circulatory compromise or nerve pressure, or to allow for optimal chest expansion for ventilation. 6. Position extremities so they may be periodically checked for safety, circulation, nerve pressure, and alignment. Monitor peripheral pulses and skin color and temperature.
R: Prevents accidental trauma to hands, fingers, and toes which could inadvertently be scraped, pinched, or amputated by moving table attachments. Reduces risk of positional pressure on brachial plexus, peroneal, and ulnar nerves, which can cause serious neurovascular impairment in extremities; or prolonged plantar flexion which may result in footdrop.Independent: 1. Monitored vital signs; palpate peripheral pulses; and note skin temperature, color, and capillary refill.R: To obtain baseline data and denote significant changes. 2. Monitored urine output regularly.R: To detect perfusion of target organs. 3. Assessed the patency of the IV lines and ensured that correct fluids are administered and regulated at prescribed rate.R: Fluid replacement must be carefully managed. 4. Positioned patient accordingly.R: Proper positioning is required for good venous return.Collaborative: * Dopamine DripR: Dopamine takes an active role in the treatment of low blood pressure in situations of shock and acute heart failure.Independent: 1. Monitored vital signs; palpate peripheral pulses; and note skin temperature, color, and capillary refill. R: Indicators of adequacy of circulating volume and tissue perfusion or organ function. 2. Monitored urine output regularly.R: Reflects perfusion to the end organs and peripheries. 3. Regulated IVF on prescribed rate.R: To replace lost fluid and maintain blood volume to optimal level.Collaborative: * Dopamine DripR: Dopamine takes an active role in the treatment of low blood pressure in situations of shock and acute heart failure

Independent Interventions: 1. Assess reports of pain and sensory alterations, noting location, duration, and intensity (scale of 0–10). Note reports of stiffness, swelling, and numbness or burning in chest, shoulder, and affected arm. Identify verbal and nonverbal cues
Rationale: Examines the degree of discomfort and verifies the need for analgesia and evaluates its effectiveness. The amount of tissue, muscle, and lymphatic system removed can affect the amount of pain experienced. 2. Explain the causes of pain to the client.
Rationale: Provides understanding of sensory alterations. 3. Provide basic comfort and diversional activities. Encourage early ambulation and use of relaxation techniques, guided imagery, and Therapeutic Touch.
Rationale: Promotes relaxation, refocuses attention away from the discomfort, and may enhance coping abilities. 4. Provide opportunities for uninterrupted sleep.
Rationale: Relieves fatigue, increasing coping ability. 5. Splint or support chest during coughing and deep-breathing exercises.
Rationale: Facilitates participation in activity without undue discomfort. 6. Provide appropriate pain medication on a regular schedule before pain is severe and before activities are scheduled.
Rationale: Maintains comfort level and permits client to ambulate without pain hindering efforts. 7. Describe the adverse effects of unrelieved pain
Rationale: Explains complications resulting from poor pain management both physiologically and emotionally 8. Encouraged to have adequate rest and sleep Rationale: It aids in decreasing the intensity of pain and to prevent fatigue. 9. Provided a quiet and non-disrupted environment with dim lights and a comfortable temperature for the patient.Rationale: Comfort and a quiet atmosphere promote a relaxed feeling and permit the patient to focus on the relaxation techniques rather than the external distraction. 10. Provided comfort measures such as changing positions.Rationale: To provide non-pharmacological pain management. 11. Encouraged verbalization of feelings about painRationale: To slightly relieve pain using a non-pharmacologic method to alleviate pain. 12. Instructed the patient to evaluate and report effectiveness of measures used.Rationale: Pain relief strategies can be modified to promote more satisfactory comfort levels. 13. Monitored vital signs every 15 minsRationale: To note any fluctuations, for it is usually altered in pain but not always.Collaborative Interventions: 1. Celebrex 200mg/cap 1 cap daily q 12 hours for pain 2. Ketorolac (Toradol) givenIndependent Interventions: 1. Assessed patient’s present condition.R: to establish baseline data. 2. Assessed for signs of infection such as redness, fever, swelling, pain, heat, and purulent discharges.R: impaired skin serves as portal of entry for pathogens. 3. Advised to keep skin dry and intact at all timesR: facilitates faster wound-healing 4. Instructed to do hand washing before and after handling incision siteR: first line of defense against cross contamination and infection. 5. Instructed to report if signs of infection will occurR: to treat accordingly. 6. Advised to change dressing when soaked.R: facilitates faster wound healing and infection prevention. 7. Encouraged to eat foods high in protein such as meat, egg, fish, and vitamin C.R: dietary requirements for collagen formation (vitamin C) and tissue repair (protein). 8. Advised to open mouth when sneezing or coughing.R: to prevent wound dehiscence and evisceration. 9. Instructed to avoid activities that increase abdominal pressure such as lifting, straining, etc.R: to prevent wound dehiscence and evisceration. 10. Instructed to avoid prolonged sitting.R: may cause strain on the abdominal musculature.Independent Interventions: 1. Assessed level of consciousnessRationale: To note and monitor the effects of the anesthesia to the patient 2. Locked wheels of bed and raised side railsRationale: To prevent the bed from moving and prevent patient from falling from the bed. 3. Kept side rails upRationale: To prevent from injury and falls 4. Assessed for the motor function on the lower extremitiesRationale: To know whether the anesthesia is slowly wearing off 5. Kept watched and always stay at the patient’s bedsideRationale: So that the patient can easily be accommodated if she has any concerns 6. Encouraged verbalization for any concernsRationale: To accommodate the patient’s concerns 7. Instructed patient to call for assistance with movement or changing positionsRationale: To help patient in moving and decrease risk for fallsIndependent Interventions: 1. Assessed skin for color, moisture, texture, and turgor (elasticity). R: Intact skin is nature's first line of defense against microorganisms entering the body 2. Assessed for localized signs of infection on incision sites e.g redness, warmth, foul smelling discharges.R: to obtain baseline data 3. Assessed the dressing.R: to make sure it is kept clean and dry. 4. Handwashing done before and after patient contact.R: prevents cross contamination 5. Monitored V/S esp temperature.R: Reflective of inflammatory process/infection requiring evaluation 6. Instructed patient not to touch site as much as possible, or if ever, wash hands before and after touching the site with anti bacterial soap.R: to avoid cross contamination 7. Taught patient the importance of handwashing and and the right way to do so.R: to avoid cross contamination 8. Monitored V/S esp temperature.R: Reflective of inflammatory process/infection requiring evaluation and treatment 9. Encouraged a balanced diet, emphasizing proteins and vit c.R: protein helps in tissue repair and vit c boosts immune system10. Strict aseptic techniques done when performing procedures that involve increased risk for infection.R: To prevent introduction of pathogens to portal of entries. Collaborative Interventions: * Cefuroxime 500 mg/tab 1 tab BID POR: inhibits bacterial cell wall synthesis, rendering cell wall osmotically unstable. Independent Interventions: 1. Assessed learning needs.R: to establish baseline data. 2. Explained what’s the objective of our health teachingsR: promotes cooperation and enhances readiness to learn 3. Assessed what the patient knows.R: to evaluate level of knowledge in relation to her condition. 4. Clarified concerns about her health.R: to confirm and resolve any cues 5. Taught the patient ways on how to improve her present conditionR: to enhance self-care management 6. Explained all the must-done ways appropriately to the patientR: to enhance self-care management 7. Encouraged to comply to health teachings and doctor’s ordersR: for faster recovery and enhance health 8. Instructed to take meds with good complianceR: for faster recovery and prevention of complications. | Desired Outcome: After 5 hours of patient and student nurse interaction, the patient will be able to verbalize the awareness of feelings of anxiety.Actual outcome: After 5 hours of patient and student nurse interaction, the patient was able to verbalize the awareness of feelings of anxiety.Desired Outcome: After 5 hours of patient and student nurse interaction, the patient will be able to verbalize the understanding of condition and potential complications, identify relationship of signs/symptoms related to surgical procedure and actions to deal with them and verbalize the understanding of therapeutic needs.Actual outcome: After 5 hours of patient and student nurse interaction, the patient was able to verbalize the understanding of condition and potential complications, identified relationship of signs/symptoms related to surgical procedure and actions to deal with them and verbalized the understanding of therapeutic needs.Desired Outcomes Within 2 hours of nursing interventions: * Be free of injury related to perioperative disorientation. * Report of localized numbness, tingling, or changes in sensation related to positioning within 24 to 48 hours, as appropriate. * Be free of skin or tissue injury, or changes lasting beyond 24 to 48 hours following procedure.Actual OutcomesWithin 2 hours of nursing interventions: * Patient is free of injury related to perioperative disorientation * Patient verbalized, “ngul ngul akong samad uy ug akong bukton” * No skin or tissue injury noted.Desired Outcome:Within 3 hours of nursing intervention: * Vital signs will be within normal range, peripheral pulses will be present and grade +2, capillary refill <3 seconds. * Urine output of >= to 30cc/hr.Actual Outcome:After 8 hours of nursing interventions: * Blood pressure increased to 110/70mmHg.Urine output drained: 350 cc for 2 hours.Desired Outcome:Within 3 hours of nursing intervention: * The px’s vital signs esp the blood pressure will be within normal range. * Urine output greater than 30mL will be drained in the preceeding hours.Actual Outcome:After 3 hours of nursing intervention: * The patient’s vital signs esp the BP (110/70mmHg) were within normal range. * Urine output was 350mL.Desired Outcome: Within 2 hours of student nurse-patient interaction, the patient will be able to demonstrate methods that provide relief such as deep breathing exercises and distraction techniques, vital signs will have remained within normal range, pain scale will have reduced from 5/10 and incidents of pain will have minimized. Actual Outcome: July 26, 2012 After 2 hours of student nurse-patient interaction, the patient’s pain scale was still 5/10, with 10 as the highest and 1 as the lowest. Her vital signs are within normal range. June 27-28 2012 After 2 hours of student nurse-patient interaction, the patient’s scale was still 5/10, with 10 as the highest and 1 as the lowest. Her vitals are within normal range and with a verbalization of “Madada raman ang sakit kay mu work raman dayon ang tambal ug mawa rapod panagsa ang sakit”.Desired OutcomeWithin 30 minutes of student nurse-interaction, the patient would be able to maintain intact skin integrity.Actual OutcomeWithin 30 minutes of student nurse-interaction, the patient was able to maintain cleanliness of skin incision and no signs and symptoms of infection present.Desired Outcome:Within 2 hours of student nurse-patient interaction, there will be no signs of injury notedActual Outcome:After 2 hours of student nurse-patient interaction, the patient can slightly move her extremities and no signs of injury was noted.Desired Outcomes:Within 5 hours of nursing interventions, the patient: * Will not manifest any signs and symptoms of infection. * Will maintain a clean and dry dressing and will know the significance of it. * Will correctly re-demonstrate handwashing techniques and state it’s significance. * Will have vital signs within normal range. * Will know the importance of having a diet rich in protein and vitamin C.Actual Outcome:After 5 hours of nursing interventions: * The patient did not manifest any redness, warmth, pruritus, foul smelling discharges that are indicative of infection. * The patient’s dressing was clean and dry, 48 hours after the operation. * The patient correctly re-demonstrated the steps in handwashing and verbalized, “basta dugay lang mahuman unya ma-limpyohan tanan parte sa kamot OK na day.” * Vital signs, esp the temperature, are within normal limits. * The patient enumerated list of foods high in vitamin C: “mga orange, lemonsito…” and high in protein “mga itlog ug karne..”.Desired Outcome * Within 30 minutes of student nurse-interaction, the patient would be able to understand the concept of post-op self care management.Actual Outcome * Within 30 minutes of student nurse-interaction, the patient was able to fully comprehend the health teachings afterhand and ready to apply it. |

APPENDIX A
DRUG STUDY DRUG | CLASSIFICATION | ACTION | INDICATION | CONTRAINDICATIONS | ADVERSE REACTION | NSG.CONSIDERATIONS | CEFUROXIME | Second-generation cephalosporin | inhibits cell-wall synthesis, promoting osmotic instability; usually bactericidal. | Serious lower respiratory tract infections, uncomplicated UTIs, skin and skin-structure infections, bone and joint infections, septicemia, meningitis, and gonorrhea | Use cautiously in patients hypersensitive to penicillin because of possibility of cross-sensitivity with other beta-lactam antibiotics.
Use with caution in breast-feeding women and in patients with history of colitis or renal sufficiency. | pseudomembranous colitis, nausea, anorexia, vomiting, diarrhea transient neutropenia, eosinophilia, hemolytic anemia, thrombocytopenia
May increase ALT, AST, alkaline phosphatase, bilirubin, and LDH levels. May decrease hemoglobin and hematocrit level. | * Before administering, make sure patient is not allergic to penicillins or cephalosporins.
* Absorption of cefuroxime axetil is enhanced by food.
* Cefuroxime axetil tablets may be crushed if swallowing is a difficulty. Cefuroxime axetil tablets may be dissolved in small amounts of apple, orange or grape juice, even chocolate milk. However, drug’s bitter taste is difficult to mask even with food.
* High-fat meals increased drug bioavailability. | METOPROLOL | Beta1-selective adrenergic blocker, Antihypertensive | Competitively blocks beta-adrenergic receptors in the heart and juxtaglomerular apparatus, decreasing the influence of the sympathetic nervous system on these tissues and the excitability of the heart, decreasing cardiac output and the release of renin, and lowering BP; acts in the CNS to reduce sympathetic outflow and vasoconstrictor tone. | Hypertension, alone or with other drugs, especially diureticsPrevention of reinfarction in MI patients who are hemodynamically stable or within 3–10 days of the acute MI | Hypersensitivity; Sinus bradycardia (HR <> 0.24 sec), cardiogenic shock, CHF, systolic BP <> | Dizziness, vertigo, tinnitus, fatigue, emotional depression, paresthesias, sleep disturbances, hallucinations, disorientation, memory loss, slurred speech CHF, cardiac arrhythmias, peripheral vascular insufficiency, claudication, CVA, pulmonary edema, hypotension | Do not discontinue drug abruptly after long-term therapy (hypersensitivity to catecholamines may have developed, causing exacerbation of angina, MI, and ventricular arrhythmias). Taper drug gradually over 2 wk with monitoring.Ensure that patient swallows the ER tablets whole; do not cut, crush, or chew.Consult physician about withdrawing drug if patient is to undergo surgery (controversial).Give oral drug with food to facilitate absorption.Provide continual cardiac monitoring for patients receiving IV metoprolol. | OMEPRAZOLE | Antisecretory agent; Proton pump inhibitor | Gastric acid-pump inhibitor: Suppresses gastric acid secretion by specific inhibition of the hydrogen-potassium ATPase enzyme system at the secretory surface of the gastric parietal cells; blocks the final step of acid production. | Short-term treatment of active duodenal ulcerFirst-line therapy in treatment of heartburn or symptoms of GERDShort-term treatment of active benign gastric ulcerGERD, severe erosive esophagitis, poorly responsive symptomatic GERD | Contraindicated with hypersensitivity to omeprazole or its components.Use cautiously with pregnancy, lactation. | Diarrhea; gas; headache; nausea; stomach pain; vomiting. | Administer before meals. Caution patient to swallow capsules whole—not to open, chew, or crush them. If using oral suspension, empty packet into a small cup containing 2 tbsp of water. Stir and have patient drink immediately; fill cup with water and have patient drink this water. Do not use any other diluent.WARNING: Arrange for further evaluation of patient after 8 wk of therapy for gastroreflux disorders; not intended for maintenance therapy. Symptomatic improvement does not rule out gastric cancer, which did occur in preclinical studies.Administer antacids with omeprazole, if needed. | SENSORCAINE | amide type local anaesthetic | Blocks the conduction of nerve impulses, presumably by increasing the threshold for electrical excitation in the nerve, slowing the propagation of nerve impulse, and reducing the rate of rise of action potential. The order of loss of nerve function is Pain, Temperature, Touch, Proprioception, Skeletal Muscle Tone. | For the production of local or regional anesthesia or analgesia for surgery, for oral surgery procedures, for diagnostic and therapeutic procedures, and for obstetrical procedures. | contraindicated in obstetrical paracervical block anesthesia. Its use by this technique has resulted in fetal bradycardia and death. Sensorcaine is contraindicated in patients with a known hypersensitivity to it or to any local anesthetic agent of the amide type or to other components of bupivacaine solutions. | dizziness or drowsiness. Severe allergic reactions (rash; hives; itching; difficulty breathing; tightness in the chest; swelling of the mouth, face, lips, or tongue); blurred vision; changes in hearing; chest pain; excitement; irregular heartbeat; nausea; numbness that lasts for more than a few hours; restlessness; ringing in the ears; seizures; severe dizziness or drowsiness; tremors; vomiting. | When appropriate, patients should be informed in advance that they may experience temporary loss of sensation and motor activity, usually in the lower half of the body following proper administration of caudal or lumbar epidural anesthesia. Also, when appropriate, the physician should discuss other information including adverse reactions in the Sensorcaine package insert. Inform the patient before using this medication, to tell his/her doctor or pharmacist of all prescription and nonprescription/herbal products he/she may use. Do not start or stop any medicine without doctor or pharmacist approval. | CAPTOPRIL | Antihypertensive, Angiotensin-converting enzyme (ACE) inhibitor | Blocks ACE from converting angiotensin I to angiotensin II, a powerful vasoconstrictor, leading to decreased blood pressure, decreasedaldosterone secretion, a small increase in serum potassium levels, and sodium and fluid loss; increased prostaglandin synthesis also may be involved in the antihypertensive action. | Treatment of hypertension alone or in combination with thiazide-type diureticsTreatment of CHF in patients unresponsive to conventional therapy; used with diuretics and digitalisTreatment of diabetic nephropathyTreatment of left ventricular dysfunction after MI | Allergy to captopril; impaired renal function; CHF; salt/volume depletion, lactation, pregnancy. | Tachycardia, angina pectoris, MI, Raynaud's syndrome, CHF, hypotension in salt/volume depleted patients, Rash, pruritus, pemphigoid-like reaction, scalded mouth sensation, exfoliative dermatitis, photosensitivity, alopecia,Gastric irritation, aphthous ulcers, peptic ulcers, dysgeusia, cholestaticjaundice, hepatocellular injury, anorexia, constipation, Proteinuria, renal insufficiency, renal failure, polyuria, oliguria, urinary frequency, cough. | Administer 1 hr before or 2 hr after meals.· Alert surgeon and mark patient's chart with notice that captopril is being taken; the angiotensin II formation subsequent to compensatory renin release during surgery will be blocked; hypotension may be reversed with volume expansion.· Monitor patient closely for fall in BP secondary to reduction in fluid volume (excessive perspiration and dehydration, vomiting, diarrhea); excessive hypotension may occur.· Reduce dosage in patients with impaired renal function. | KETOROLAC | Nonsteroidal anti-inflammatory agents, nonopioid analagesics | Inhibits prostaglandin synthesis, producing peripherally mediated analgesia
- Also has antipyretic and anti-inflammatory properties.
- Therapeutic effect:Decreased pain | Short term management of pain (not to exceed 5 days total for all routes combined) | -Hypersensitivity
- Cross-sensitivity with other NSAIDs may exist¨Pre- or perioperative use
- Known alcohol intolerance | CNS: 1) drowsiness 2) abnormal thinking 3) dizziness 4) euphoria 5) headache-
- RESP: 1) asthma 2) dyspnea
- CV: 1) edema 2) pallor 3) vasodilation | Patients who have asthma, aspirin-induced allergy, and nasal polyps are at increased risk for developing hypersensitivity reactions. Assess for rhinitis, asthma, and urticaria.
- Assess pain (note type, location, and intensity) prior to and 1-2 hr following administration.
- Ketorolac therapy should always be given initially by the IM or IV route. Oral therapy should be used only as a continuation of parenteral therapy.
- Caution patient to avoid concurrent use of alcohol, aspirin, NSAIDs, acetaminophen, or other OTC medications without consulting health care professional.
- Advise patient to consult if rash, itching, visual disturbances, tinnitus, weight gain, edema, black stools, persistent headche, or influenza-like syndromes (chills,fever,muscles aches, pain) occur.
- Effectiveness of therapy can be demonstrated by decrease in severity of pain. Patients who do not respond to one NSAIDs may respond to another. | CELEBREX | COX-2 inhibitors | Physiologic Mechanism• Decreased pain and inflammation caused by arthiritisPharmacologic Mechanism• Prevention of M Inhibits the enzyme COX-2. This enzyme is required for the synthesis of prostaglandins.• Has analgesic, anti-inflammatory, and antipyretic properties. | • Relief of signs and symptoms of osteoarthritis.• Relief of signs and symptoms of rheumatoid arthritis in adults. * Pain reliever | In patients with known hypersensitivity to celecoxib, aspirin, or other NSAIDs.In patients who have demonstrated allergic-type reactions to sulfonamides.In patients who have experienced asthma, urticaria, or allergic-type reactions after taking aspirin or other NSAIDs | Constipation; diarrhea; dizziness; gas; headache; heartburn; nausea; sore throat; stomach upset; stuffy nose. | Assess patient’s range of motion, degree of swelling, and pain in affected joints before and periodically throughout therapy.• Assess patient for allergy to sulfonamides, aspirin, or NSAIDS. Patients with these allergies should not receive celecoxib.• May be administered without regard to meals.• Instruct patient to take celecoxib exactly as directed. Do not take more than prescribed dose. Increasing doses does not appear to increase effectiveness.• Advise patient to notify health care professional promptly if signs or symptoms of GI toxicity (abdominal pain, black stools), skin rash, unexplained weight gain, edema occurs.•Patient should discontinue celecoxib and notify health care professional if signs and symptoms of hepatotoxicity (nausea, fatigue, lethargy, pruritus, jaundice, upper right quadrant tenderness, flu-like symptoms) occur. | CEFOXITIN | Second-generation cephalosporin | activity against some gram-positive cocci, gram-negative rod infections, and anaerobic bacteria. Inhibits bacterial cell wall synthesis by binding to one or more of the penicillin-binding proteins; inhibits final transpeptidation step of peptidoglycan synthesis, resulting in cell wall death | Surgery prophylaxis, uncomplicated infections | Documented hypersensitivityNeonate (<3 mo) | Diarrhea AnemiaEosinophiliaTransient leukopeniaThrombocytopenia | Baseline assessment: allergies, particularly cephalosporines, PNC. Obtain C & S before giving the first does even therapy may begins before results are known. Temp
Interventions/eval: VS. Eval site for phliebitis, irritation. Check mouth for white patches on mucous menbranes and tongue or soreness. monitor BM for consistency. Assess skin for any rash. Monitor I&O. UA, renal. Be alert for superinfection. Sever genital/anal pruritus. GI sx. Assess drug effectiveness. |

APPENDIX B
DISCHARGE PLAN

HEALTH TEACHINGS * Reminded SO to always assess patient needs. * Instructed patient to observe good & effective personal hygiene and sanitary conditions. * Encouraged SO to monitor the patient’s pain level and response to medications. * Encouraged patient to have a plenty of rest. * Instructed patient to get enough exercise such as walking. It may decrease other risk factors, such as obesity and high blood pressure. * Encouraged patient to talk with primary healthcare provider about the best exercise program. * Encouraged patient to lose weight if she needs to. Weighing more than your primary healthcare provider suggests increases the chance of having diabetes, high blood pressure, and high estrogen levels. If patient need to lose weight, she should talk with her primary healthcare provider about a healthy weight-loss plan. * Encouraged the patient to understand the need to control risk factors through medication therapy, dietary modifications, exercise guidelines, stress-reduction methods, and follow-up care. * Encouraged patient to have stress-reduction groups, dietary changes, and an exercise program, particularly aerobic walking, to improve cardiac status and reduce obesity and serum cholesterol levels, * Instructed patient to avoid vigorous activities. * Instructed patient to refer to IM dept for further orders.

ANTICIPATORY GUIDANCE * Encouraged the patient to return for follow up check up with Dr. Hipolita Libre on Friday (8/3/12). * Encouraged patient to consult immediately to physician in case condition worsens. * Encouraged patient and SO to follow health teachings given by the doctor and student nurses in order to avoid complications in the future. * Encouraged patient to write down questions & ask them during visits.

SAFETY, SECURITY, SPIRITUALITY * Instructed SO to provide time to listen to patient’s concerns and worries. * Encouraged verbalization of feelings. * Encouraged to maintain a positive outlook in life. * Instructed SO to assist and provide emotional support to patient to achieve successful coping. * Encouraged SO to be available in supporting the patient from his therapy and worries to facilitate his coping. * Instructed SO to assist patient with care and hygiene while encouraging the patient to participate activities within his tolerance. * Encouraged to continue strengthening his faith in God in everything that he does. * Encouraged to continue praying to God and to attend masses and thank the Lord for all the blessings and to ask for His constant guidance. * Encouraged patient to keep and uphold pre-existing family values such as close family ties, respect and love. * Encouraged to surrender worries, anxieties and fears to God.

MEDICATIONS * Instructed patient to take the following take home medications: * Cefuroxime 500mg/tab 1 tab twice a day by mouth x 6days more * Celecoxib (Celebrex) 200mg/cap 1 cap every 12hours by mouth for pain * Instructed patient to take the medication at the right dosage, right time, right route and right frequency. * Informed the patient about the indication, contraindications and adverse effect of the medication. * Encouraged patient to be diligent enough in taking his medications * Encouraged patient to place medications in a proper and safe location. * Encouraged patient to comply with medications to prevent further complications. * Reminded to avoid taking over the counter drugs without consultation. * Encouraged to report to any health care members when experiencing some unusualities. * Encouraged the patient to keep a current list of the medicines, vitamins, and herbs taken. Include the amounts, and when, how, and why they are taken. * Instructed the patient to take the list or the pill bottles to follow-up visits. * Encouraged patient to keep medicine list always in handy in case of an emergency.

INCISION CARE * Instructed patient to keep the incision site & dressings clean, dry and intact. * Instructed patient to have a daily dressing with betadine twice a day. * Instructed patient not to frequently touch incision site esp. with dirty hands.

NUTRITION * Instructed patient to eat fruits and vegetables. * Instructed patient to eat foods rich in Vitamin C such as guava and oranges to promote wound healing. * Instructed patient to eat foods rich in protein such as fish and peanuts to promote tissue repair.

ENVIRONMENT * Encouraged S.O to maintain a calm and peaceful environment to promote rest periods for the patient: a well ventilated and well lighted room. * Encouraged SOs to provide an emotional support to patient,: talking to the patient, understanding his condition ,needs or unmet ADLs. * Instructed S.O. to assist patient in incorporating actual changes into ADLs, social life, interpersonal relationships, and occupational activities. Opportunities for positive feedback and success in social situations may hasten adaptation. * Encouraged S.O. to demonstrate positive caring in routine activities of the patient * Taught the patient about adaptive behavior (e.g., use of clothing that conceals altered body part or enhances remaining part or function). This compensates for actual changed body structure and function. * Encouraged S.O. to help patient identify ways of coping that have been useful in the past. Asking patient to remember other body image and how they were managed may help patient adjust to the current issue. * Encouraged S.O. to refer the patient to support groups composed of individuals with similar alterations.