Name of Patient: Mrs.

Capuyan, Mary Ward #: Gyne 10, 4B WARD,CDUH Age: 49 years old HISTORY
The patients name is Mrs. Capuyan, Mary, a 49 year-old female, single with a weight of 95 kilograms. Shes currently living in Purok Ternate, Ibabao, Mandaue City. Patient is in middle adulthood stage of maturity. The patient has a history of hypercholesterolemia and hypertension. Patient has no allergies in food and neither smoker nor alcoholic drinker. Patient is now on her menopausal stage.

Cebu Doctors University College of Nursing Cebu City NURSING ASSESMENT INSPECTION PALPATION >symmetrical >lumps >black, long, and evenly distributed >white in color >intact and firm >symmetrical >fair in color, dry >able to open and close, with sunken eyes >black and equally distributed >black and equally distributed >anecteric sclera >no inflammation, pink in color >equally round, reactive to light and accommodation >located at the center/midline, no discharges >present >not congested, not inflammed >pale and dry >positioned at the center, reddish, and presence of taste buds are evident >positioned at the center >symmetrical, pinna is elevated >normal in length, same color with the body >has equal chest expansion, no scars >spine is vertically aligned >no lesions >no lumps, masses or lesions >no lesions
PERCUSSSION AUSCULTATION

BODY PARTS Head Hair Scalp Face -Forehead -Eyes -Eyebrows -Eyelashes -Sclera -Conjuctiva -Pupils -Nose -Patency -Sinuses -Lips -Tongue -Uvula -Ears Neck Anterior Chest Posterior Chest

>(+) temporal pulse

The patient has scheduled TAHBSO on February 3, 2011 @ 7:30AM. She was admitted in CDUH on February 2, 2011 at 8:45AM. The patient was noted of severe dysmenorrheal pain on hypogastric area during menses. Menses at that time were regular and with moderate flow consuming 3-4 pads per day, lasting 3 days and this happened 3 years ago. She then sought consultation and TVS showed myoma, 2 in number, largest cm according to patient.

>no unusual lumps

>soft >no lumps

>no lumps >no lumps

>(+) carotid pulse >(+) apical pulse

>no lumps

Name of Patient: Mrs. Capuyan, Mary Ward #: Gyne 10, 4B WARD,CDUH Age: 49 years old HISTORY BODY PARTS

Cebu Doctors University College of Nursing Cebu City NURSING ASSESMENT INSPECTION PALPATION >engorged >relatively equal with slight variation >round and pendulous in shape >same color with the skin of the body >dark brown in color >round and oval in shape >no discharges >no lumps, lesions, or edema >smooth
PERCUSSSION AUSCULTATION

She also claimed that she has a cyst on right Breasts ovary. She was given Depo injections for 6 months. A month prior to her admission, she decided to seek consultation with her OB-GYNE. TVS was done showing posterior wall adenomyosis with multiple myoma located at left posterior which measured 6.2 x 4.4 x 5.2 cm, and right ovarian cyst that measured 7.1 x 4.6 x 6.4 cm. she was then advised for surgery.

-Nipples and Areolas

>no lesions and rashes >smooth >no bruits >no bowel sounds present in all quadrant

Abdomen

>globular, >non-tender symmetrical, with stretchmarks, with dressing at the incision site (lateral) > with indwelling catheter connected to the Foley bag

Genitalia

Extremities: Vital Signs: T: 36.7C P: 72 bpm R: 20 breaths/min BP: 120/80 -Lower >no deformities >extremities are symmetrical >weak and has difficulty in ambulating due to pain at the abdominal area >(+)popliteal pulse >(+)dorsalis pedis pulse -Upper >arms are symmetrical in shape >presence of IV in left arm (IVF #1 D5LR 1L @30 gtts/min >(+) radial and ulnar pulse >(+) brachial pulse

Name of Patient: Mrs. Capuyan, Mary Ward #: Gyne 10, 4B WARD, CDUH Age: 49 years old PSYCHOSOCIAL or CULTURAL Erik Eriksons Psychosocial task: Generativity vs. Stagnation > Following the successful development of an intimate relationship, the adult can focus on supporting future generations.

Name of Student Nurse: Regis, Minfred Olen Cybill V. Physician: Dr. Raida Varona NURSING ASSESMENT DIAGNOSTIC RESULTS TEST Date Taken: February 2, 2011 HEMATOLOGY: Hemoglobin Hematocrit 11.4 36.7 4.6 6,900 79.4 24.7 31 328,000 49 5 7 9 12.3-15.3 35.9-44.6 4.50-5.90 4,000-11,000 80-96 27-31 32.0-36.0 150,000-450,000 40-70 1-5 0-8 20-40 Decreased in various anema Decreased in anemia Decreased in hemorrhage Increased with acute infections Decrease in blood loss Decrease in blood loss Decrease in blood loss Normal Normal Normal Normal Decreased with aplastic anemia
SOURCE: -Brunner and Suddharths Textbook of MedicalSurgical Nursing, 11th edition.Volume 2. Philadelphia: Lippincott Williams & Wilkins, 2008.pp.2577- 2580.

SPIRITUAL Religion: Mrs. Capuyan is a Roman Catholic Christian. Religious Practice:

NORMAL VALUES

SIGNIFICANCE

Red Blood Cells White Blood Cells Mc Hgb Mc Volume McHc Platelets Neutrophils Eosinophils Monocytes Lymphocytes

The patient is a church goer Role Relationship: and attends The patient is a mass every mother of two. It is Sunday if she a nuclear type of has an available family. She does time and free the household time from work. chores and takes care of the familys needs. Relationship with God: Coping/ Stress Tolerance: Mrs. Capuyan Mrs. Capuyan is firmly believes a Roman Catholic that God is the and believes to Supreme Being, surrender to God, as her Creator unload her burdens and Savior to Him. Prayer is her way of coping with stress. She always face those challenges that she will encounter bravely. Likewise, she diverts her attention to her work and solves problem independently.

Name of Patient: Mrs. Capuyan, Mary Age: 49 years old Ward #: Gyne 10, 4B ward, CDUH NURSING CARE PLAN PROBLEMS/ CUES I. Physiologic Overload Alteration in Comfort Objective Cues: -PR=72 bpm -RR=18 breaths per minute -BP= 120/80 mmHg -respiration almost below baseline since patient felt pain upon breathing -facial grimace noted upon movement -pain at the incision site in the abdomen that last for 15-20 seconds and is a sharp, stabbing pain upon movement and is treated with Tramadol (Tramal) 50 mg IVTT every 6 hours. Subjective Cues: Kung maglihok-lihok ko, musakit ug samot akong tinahian.Maskina nghigda rako, sakit gihapon, as verbalized by the patient. -Painscore of 8, in a painscale of 0-10 where 10 being the most painful and 0 as no pain NURSING DIAGNOSIS SCIENTIFIC BASIS OBJECTIVE OF CARE After 8 hours of rendering holistic Nursing Care, the patient will be able to: 1.report alleviation of pain as evidenced by decrease painscore from 8 to 5, with 10 being the highest and 1 as the lowest NURSING INTERVENTIONS Measures to: A. Alleviate or control pain 1. use relaxation and distraction technique 2. promote diversional activities such as back rubs or massage, etc. RATIONALE 1. relaxes muscle and restricts attention away from pain. 2. diverting the activities of the patient allows her to think or feel less about the pain. 3. too much tension on the body occurs when there is lack of sleep which worsens the feeling of pain. 4. promotes comfort and prevents pressure on the joints. 5. reduce pain with anxiety and fear of unknown outcomes. 6. serves as pain control. SOURCE: Doenges, Moorhouse and Murr-Nursing Care Plans, 7th Edition

As clients awaken from Alteration in general Comfort: anesthesia, the Acute Pain sensation of related to pain becomes abdominal prominent. incision Pain can be perceived before full consciousness is regained. Acute incisional pain causes clients to become restless and may be responsible for temporary changes in vital signs. It is difficult for the client to do coughing and deep breathing exercises when they experience pain.

3. encourage client to have a complete bed rest 4. reposition client every 2-3 hours

5. provide information regarding causes of discomfort 6.administer analgesics as prescribed by the physician

SOURCE: Perry, A. and Potter, P., Fundamentals of Nursing, 6th Edition, p. 1634

Name of Patient: Mrs. Capuyan, Mary Age: 49 years old Ward #: Gyne 10, 4B ward, CDUH NURSING CARE PLAN OBJECTIVE OF CARE 2. Promote and increase strength of the affected part

PROBLEMS/ CUES II. Physiologic Deficit A. Altered Physical Mobility Objective Cues: -impaired ability to move around/walk, from bed to chair, from sitting to lying to bed -abdominal pain due to a midline incision -needs assistance when trying to move -noted facial grimace when trying to move Subjective Cues: Lisod kaau ilihoklihok jud.Sakit akong tahi, as verbalized by the patient.

NURSING DIAGNOSIS

SCIENTIFIC BASIS Acute incisional pain causes to become restless and may be responsible for temporary changes in vital signs. Many alterations in physiological, socio-cultural and developmental functioning are related to immobility. Often the focus of immobility is on the easily visible physical problems, such as skin impairment, but the psychosocial and developmental aspects of immobility should not be overloaded. SOURCE: Perry, A., and Potter, P., Fundamentals of Nursing, 6th Edition, p. 1442

NURSING INTERVENTIONS Measures to: Promote and increase strength of the affected part 1. Observe movement when client is unaware of observation 2. Note emotional or the behavioral responses to problems of immobility 3. Instruct patient in use of side rails or roller pads 4. Support affected body part using pillow or rolls, foot support 5. Schedule activities with adequate rest periods during the day 6. Encourage participation in self-care, occupational or diversional or recreational activities

RATIONALE 1.To note any incongruencies with reports of abilities. 2.Feelings of frustrations or powerlessness may impede attainment of goals. 3.For position changes and transfer. 4.To maintain position of function and reduce risk of pressure ulcers which adds the burden. 5.To reduce fatigue. 6.Enhances selfconcept and sense of independence. SOURCE: Doenges, Moorhouse and Murr-Nursing Care Plans, 7th Edition

Altered Physical Mobility: Weakness related to abdominal pain at the incision site

Name of Patient: Mrs. Capuyan, Mary Age: 49 years old Ward #: Gyne 10, 4B ward, CDUH NURSING CARE PLAN OBJECTIVE OF CARE 3. establish adequate sleep pattern, from 5 hours of sleep 67hours of sleep without awakenings

PROBLEMS/ CUES B. Disturbed Sleeping Pattern

NURSING DIAGNOSIS Disturbed Sleeping Pattern: sleeplessness related to uncomfortable sleep environment and prolonged discomfort

SCIENTIFIC BASIS Both the quality and quantity of sleep are affected by a number of factors. Illness causes pain or physical distress can result in sleep problems. People who are ill require more sleep than normal. Environment can promote higher rate of decreased sleep. Manipulation of the environment is necessary. source: Maternal and Child Health Nursing 5th Edition, Adele Pillitteri, p. 564

NURSING INTERVENTIONS Measures to promote sleep: 1.provide adequate sleep and rest, restrict daytime as appropriate then reduce mental activity late in the day 2.encourage to have a comfortable positioning 3.provide evening snack, warm milk, bath, backrub/ general massage with lotion 4.encourage to listen soft music and have an environment conducive for sleeping 5.provide some reading materials before sleeping

RATIONALE

Objective cues: - restlessness -irritability -sunken eyes -wakefulness -weak -dark circles under eyes -5 hours of sleep with awakenings

1.although prolonged method and physical active results in fatigue, which can increase confusion programmed action without over stimulation promotes sleep 2.promotes wellbeing and relaxation 3. promotes drowsiness and relaxation , it helps to address skin care meds 4.promotes relaxation and drowsiness 5. promotes peace of mind and relaxation

Subjective cues: Naglisod pa jud ko katulog kay musakit man gud akong tahi, as verbalized by the patient.

source: NCP, 11th ed., by Marilyn Doenges , et.al.

Name of Patient: Mrs. Capuyan, Mary Age: 49 years old Ward #: Gyne 10, 4B ward, CDUH SOAPIE # 1 S - Kung maglihok-lihok ko, musakit ug samot akong tinahian.Maskina nghigda rako, sakit gihapon, as verbalized by the patient. O the patient is seen with facial grimace caused by the acute pain being felt. The pain occurred about an hour ago after the sorgery with a painscore of 8/10 at the abdominal area. The pain lasted for approximately 15-20 seconds and is characterized by a sharp pain, aggravated by ambulation and rush movements; relieved by lying or resting in bed and can be treated by administration of Tramadol as pain reliever. A- Alteration in Comfort: Acute pain related to surgical incision at the abdomen P After 8 hours of student nurse-patient interaction, the patient will be able to : alleviate pain as evidenced by a painscore of 5/10 from a painscore of 8/10 in a painscale of 0-10 where 10 is the most painful and 0 is painless I > promoted position of comfort like flexing the knees, sitting up or leaning forward >provided alternative measures like quiet diversional activities >encouraged to perform deep breathing exercises >performed perilite exposure on affected area for 15 minutes >encouraged verbalization of feelings >administered analgesics as prescribed by the physician E After giving holistic nursing care to the patient, the patient verbalized that the degree of pain felt was reduced to a tolerable level, as evidenced by a pain score of 5 from 8 in the painscale of 0-10 where 10 is the most painful and 0 is painless.

Name of Patient: Mrs. Capuyan, Mary Age: 49 years old Ward #: Gyne 10, 4B ward, CDUH SOAPIE # 2 S- Lisod kaau ilihok-lihok jud.Sakit akong tahi, as verbalized by the patient. O- altered ability to move around/walk; difficulty in transferring from bed to chair and from sitting to lying down to bed; needs assistance upon movement; noted facial grimace when trying to move; respirations=18 breaths/min; abdominal incision at the midline A- Altered Physical Mobility: weakness related to acute pain at the incision site P- Promote and increase strength of the affected part for early ambulation I- instructed to use side rails upon movement; scheduled activities with adequate rest periods during the day; assisted client upon movement; provided comfort measures when pain felt upon movement;Observed movement when client is unaware of observation; Supported affected body part using a pillow; encouraged participation in self-care, occupational or diversional or recreational activities

E- sakit mn gihapon siya pero dili na kaau pareha ganiha ky naa namay pain reliever. Makalihok-lihok nako ginagmay, as verbalized by the patient.

Name of Patient: Mrs. Capuyan, Mary Age: 49 years old Ward #: Gyne 10, 4B ward, CDUH DRUG THERAPEUTIC RECORD DRUG 1.Tramadol (Tramal) 50 mg IVTT q 6H
CLASSIFICATION/ MECHANISM INDICATIONS/ CONTRAINDICATIONS

PRINCIPLE OF CARE -For better analgesic effect, give drug before onset of pain. -Because constipation is a common adverse effect, anticipate need for laxative therapy.

TREATMENT -asses patients condition before starting the therapy

EVALUATION

Pharmacologic Class: Opioid agonist, analgesics Mechanism of Action: Centrally acting synthetic analgesic compound not chemically related to Opioisd that is thought to bind to Opioid receptors and inhibit reuptake of norepinephrine and serotonin. Relieves pain.

CI: hypersensitivity to drug or any of its components, patients at risk for seizures I: moderate to moderately severe pain AE: CNS- anxiety, confusion, coordination disturbance, malaise, dizziness CV- vasodilation GI- abdominal pain, anorexia, diarrhea, nausea and vomiting, constipation

The pain is relieved to a tolerable level, from a painscore of -assess patients 8 to 5 in a familys painscale of knowledge of 0-10 where the drug therapy 10 is the most painful -check renal and and 0 is hepatic function painless. periodically -encourage patient to take drug with food if stomach upset occurs -monitor intake and output of patient closely -administer drug as ordered by the physician

Name of Patient: Mrs. Capuyan, Mary Age: 49 years old Ward #: Gyne 10, 4B ward, CDUH DRUG THERAPEUTIC RECORD DRUG 2. Metronidazole (Dazomet) 500 mg IV drip q 8H x 3 doses
CLASSIFICATION/ MECHANISM INDICATIONS/ CONTRAINDICATIONS

PRINCIPLE OF CARE -Give drug with meals to minimize GI distress. -Use only after T. vaginalis has been confirmed. -Give drug for 7 days instead of 2g single dose.

TREATMENT -Tell patient not to use alcohol or drugs that contain alcohol.

EVALUATION

Pharmacologic class:Antibacterial, antiprotozoal, amebicide Mechanism of Action: Direct-acting trichomonacide and amebicide that work at both intestinal and extraintestinal sites. Hinders growth of selected organisms, including most anaerobic bacteria and protozoa.

CI: hypersensitivity to drug, used cautiously in patients with history of blood dyscrasia or CNS disorder, pregnant women I: amebic hepatic abscess, trichomoniasis, bacterial infections caused by anaerobic microorganisms, PID, Giardiasis AE: CNS- confusion, depression, drowsiness, fatigue, fever CV- edema, thrombophlebitis GI- abdominal cramping

Patient is free from infection. The occurrence of -A metallic taste infection is and darks/red prevented. brown urine may occur. -Take in with meals. -Proper hygiene.

Name of Patient: Mrs. Capuyan, Mary Age: 49 years old Ward #: Gyne 10, 4B ward, CDUH HEALTH TEACHING PLAN

Objectives General Objectives: After 8 hours of student nurse-patient interaction, the client will be able to gain knowledge, attitude and skills in the care of postoperative patients of Total Abdominal Hysterectomy with Bilateral Salpingooophorectomy. Specific Objectives: After 45 minutes of student nurse-patient interaction, the client will be able to: 1. define TAHBSO;

Content

Methodology

Evaluation

I. Definition TAHBSO (Total Abdominal Hysterectomy with Bilateral Salpingooophorectomy) is the removal of the entire uterus and ovaries as well as the cervix. II. Potential Complications 1. Incisional infection- an acute or chronic condition in which the uterus, fallopian tubes and ovaries are infected. The inflammation is the result of infection spreading from an adjacent organ or ascending from the vagina. 2. Hemorrhage- the escape of blood from a ruptured blood vessel, externally or internally. Loss of several liters of blood in a few minutes may result in shock, collapse or death. 3. Urinary Tract Infection- are caused by the presence of pathogenic microorganisms in the urinary tract with or without signs and symptoms, maybe due to inability to or failure to empty the bladder completely, catheterization and decreased host defenses. 4. Bowel Obstruction- physical blockage of the passage of intestinal contents with subsequent distention by fluid and gas. 5. Thrombophlebitis- inflammation of the wall of a vein with secondary thrombosis occurring within the affected segment of vein. III. Measures to relieve pain 1. Bed rest for the first 24 hours. 2. Splint incision when moving or

Informal Discussion

The patient was able to define TAHBSO in her own words. The patient was able to restate the possible complications discussed by the student-nurse.

2. identify the different potential postoperative complications;

Informal Discussion

3. enumerate measures for patient relief

Informal Discussion

The patient was able to identify bed rest and deep