Guide for Pre-clinical practice research and planning:

Demographic Data:
Initials:

A.A

Gender:

Female

Age:

42

Nature of Residence:

Cornwall

Support system
Cultural
considerations
Code status

Lives with family

None

Religion
Occupation

N/A
other

Full code

Occupation preretirement
Allergies

Not retired

Financial
Considerations?
Social work
consults?

N/A

Admitting and hospitalization details:

Date of admission:

12 January 2016

Circumstances
surrounding admission
Admitting medical
diagnosis

Heavy painful menses

Surgical intervention (if

applicable) with dates

None

Other relevant health

problems/diagnoses

None

Past medical history

3 normal vaginal deliveries, no serious illness

Attending physician

Dr. Fikny Ywakim

Dysmenorrhea

NKA

Activities of Daily living and current plan of care:

Nutrition/diet

She is NPO. She does not need assistance with feeding.

Hygiene/bathing

Independent

Activity/mobility

Independent

Toileting/elimination

Independent

Dressing/clothing

Independent

Skin and wound care

considerations if
applicable
Communication
considerations

N/A
Primary language is English. She is very talkative and pleased.

Special monitoring and assessments:

Neurological:
Alert, conscious and
oriented.

- pupils were equal and

reactive to light and
accommodation, sclera
anicteric and conjunctiva
not congested.

Lung sounds are present

bilaterally

Intake and output

summary

Just took ice chips and

jellos.

-pale skin
Cardiovascular
assessment and heart rate
was normal. No murmurs
and gallops present

GI/Abdominal

Bowel sounds heard in all

four quadrants
-abdomen soft blotted
and non tender

Vital signs:AM-0800

After lunch-1230

BP=105/69
P-78
R-17
T-36.6

BP=109/73
Pulse=
O2=99%
Temp.=36.4

Respiratory and O2
therapy

Circulatory and vascular

Urologic
Tubes- IV ,Foley cath,
drains, etc

Skin/wound
Catheter was removed at around 1200. Output was 700 ml

Specimen collection

Diagnosis Research Card:

Pathophysiology :
(concise/bullets)
Usual
manifestations(S&S)
(bullet list)

During LAVH, several small incisions (cuts) are made in the

abdominal wall through which slender metal tubes known as "trocars"
are inserted to provide passage for a laparoscope and other
microsurgical tools. The laparoscope acts as a tiny telescope. A
camera attached to it provides a continuous image that is magnified
and projected onto a television screen for viewing.

Heavy menses
Pain in the abdomen
Fever
Foul smell vaginal discharge

In the course of LAVH, the uterus is detached from the ligaments that
attach it to other structures in the pelvis using the laparoscopic tools.
If the Fallopian tubes and ovaries are to be removed, they are also
detached from their ligaments and blood supply. The organs and
tissue are then removed through an incision made in the vagina.

Usual medical treatment

Pain medication after treatment and no food after the surgery

Usual diagnostic tests

Ultrasound

Usual Nursing
considerations

1. Support adaptation to change.

2. Prevent complications.
3. Provide information about procedure/prognosis
and treatment needs.

Possible complications
1. Infection, deep or at the skin level.
2. Bleeding, either during or after the operation, which may
require a blood transfusion.
3. Skin scars that may be painful or ugly.

TEST
Blood Studies:

RATIONALE FOR TEST:

CLIENT VALUE
( normal value in brackets)
Why is the test ordered for this patient?
What is being investigated and why?
Female: 120 (135-175) g/L
Low

Testing hemoglobin is part of a CBC; it is use

associated with anemia, to determine the seve
the response to treatment for anemia. It show

Hematocrit
(PCV)

0.27 (0.400-0.500)
low

Indirectly measures the RBC mass and it used

has anemia or polycythemia (increase in hem

Erythrocytes

3.20 (4.5-5.6)
Low
8.9 (4.0-11.0)

Haemoglobin Male
Female

Leukocytes
(include differential if applicable)
(include differential if applicable
(include differential if applicable)

fL

10^12/L
10^9/L

(27-34)
l

MCH
INR
Sodium

133 (137-145)
low

Red blood cells carry blood from the lungs to

dioxide to the lungs. To determine the numbe
To determine the severity of the disease proce
of leucocyte response for different diseases w
percent of different types of leucocytes.

measures the average mass of hemoglobin pe

2014). His MCH value is 26 in the range of 2
shows the condition of anemia in which red b
To monitor the effectiveness of warfarin (Cou
mmol/L

Detects changes in water balance, electrolyte

dehydration.

Potassium

(3.6-5) mmol/L

Potassium controls the rate and force of contr

Creatinine

85 (58-110) umol/L

Estimates the glomerular filtration rate and ev

Urea (BUN)
Gamma glutyl trans

5.2 (3.2-7.1) mmol/L

Index of glomerular function in production an

321 (H) (38-126)u/L

This shows the disease affecting the bile duct

.
Interpretation:
The pO2 evaluates the ability of the lungs to o
increase level may be associated with hyperv
of inspired oxygen, or an increase in hemoglo
elevated which indicates an alkaline state and
and steroids taken. High bicarbonate levels in
which is related to renal function.

Arterial Blood Gases:

pH
P02
PCO2
bicarbonate
O2 saturation

Other blood tests

Urine Studies
Urinalysis
C&S
Cytology
Other (specify)
Sputum

N/A

N/A

C&S
Cytology
Other (specify)
Pulmonary Function Tests
Endoscopies
ERCP
Bronchoscopy
Colonoscopy
Other (specify)

Radiographic tests
CT scan
MRI
CXR
Angiography
Other (specify)
Ultrasonography
(Specify)
Cardiology & vascular

N/A

N/A

ultrasound

Ultrasound or computed tomography (CT) s

Aids in identifying size/location of pelvic ma

N/A

ECG
Echocardiogram
Catheterization & angiography
Doppler flow studies
Other (specify)

List 3 3 Part statement priority nursing diagnosis according to NANDA

Nursing diagnosis:
1) Pain/ discomfort related to heavy periods.
2) Risk for infection may be related to postoperative surgery.