Arellano University Pag-Asa St.

Caniogan Pasig City College of Nursing

In Partial Fulfilment of the Requirements In

NCM 103 (RLE) CASE STUDY (Ovarian New Growth Malignant)

Submitted by: Dela Rosa, Jesusa Estacio, Frederick Eleazar, Jonathan Espinosa, Maybeth Lara Francicsco, Genevieve Galang, Emma Angela Gallardo, Leny Garcia, Hanna Mae Gigante, Maricris Ligon, Anne Nichole Lozano, Mario

Table of Contents  Introduction  Acknowledgement  Objectives y General y Specific  Patients Profile y Initial Database y Patients Data  Nursing History y Chief Complaint y History of Present Illness y History of Family Illness  Patterns of Health Care  Patients Physical Assessment  Anatomy and Physiology  Pathophysiology  Drug Study  Nursing Care Plan  Evaluation y Discharge Plan

INTRODUCTION A wise man should consider that health is the greatest of human blessings, and learn how by his own thought to derive benefit from his illnesses. - Hippocrates Every individual aspires to be as healthy as they currently can, but as it turns out life isnt that simple. Its not merely hand-me-downs but rather a struggle that we continually strive for to provide at any given time a most pleasant experience there is. Through life, we also have our unfavourable experiences regarding health. To just sit back and think of it as an unfortunate circumstance or a faulty decision made should not be the primary reason we remain satisfied with what we have but rather prioritize on how to manage such condition towards the betterment of ones health.

The development of ovarian cysts is a common condition in which one or more cysts form on the ovary or ovaries of a woman's reproductive system. An ovarian cyst consists of a sac filled with fluid, blood, or tissue. Ovarian cysts are generally not dangerous and often go away by themselves within weeks to a few months. However, some ovarian cysts can remain and cause serious problems to health or fertility.

During ovulation (the process during which the egg ripens and is released from the ovary) the ovary produces a hormone to make the follicles (sacs containing immature eggs and fluid) grow and the eggs within it mature.

Once the egg is ready, the follicle ruptures and the egg is released. Once the egg is released, the follicle changes into a smaller sac called the corpus luteum. Ovarian cysts occur as a result of the follicle not rupturing, the follicle not changing into its smaller size, or doing the rupturing itself. Ovarian cysts can develop due to a woman's changing hormones that normally occur during the monthly menstrual cycle. There are many types of ovarian cysts, including endometriomas, dermoid cysts, and functional cysts. Cysts vary in size, from the size of a pea to the size of a softball. When a woman develops multiple ovarian cysts during each menstrual cycle that do not go away, it is called polycystic ovarian syndrome or PCOS.

There are often no symptoms of ovarian cysts, but sometimes they can result in abdominal pain, infertility and other health problems.

Benign cysts can cause pain and discomfort related to pressure on adjacent structures, torsion, rupture, hemorrhage (both within and outside of the cyst), and abnormal uterine bleeding. They rarely cause death. Mucinous cyst adenomas may cause a relentless collection of mucinous fluid within the abdomen, known as pseudomyxoma peritonei, which may be fatal without extensive treatment.

Functional ovarian cysts occur at any age (including in utero), but are much more common in reproductive-aged women. They are rare after menopause. Luteal cysts occur after ovulation in reproductive-aged women. Most benign neoplastic cysts occur during the reproductive years, but the age range is wide and they may occur in persons of any age.

Ovarian cancer tumors sometimes include ovarian cysts, but the average ovarian cyst is benign. Chances of developing an ovarian cyst are higher during a woman's reproductive years, as both follicular and corpus luteum cysts are tied to the ovulation cycle. An ovarian cyst is much less common after menopause. However, if postmenopausal women develop an ovarian cyst, there is a higher risk of the cyst developing into ovarian cancer. To be safe, any ovarian cyst symptoms should be reported to a health professional, such as ovarian cyst pain. Watchful waiting is the most common treatment, as an ovarian cyst will usually disappear within a few months.

GENERAL OBJECTIVES To develop mastery towards the patients condition. To develop and maintain a good clinical practice to the patient. To create a study that will serve as a guideline to our co-nursing students in providing a better and proper care in the near future for patients with same condition as our patient.

y y y

SPECIFIC OBJECTIVES Knowledge y y Skills y y y y y To know the causes as well as manifestations of the clients condition. To explain the anatomy and pathophysiology about the case of the patient.

To practice good history-taking and physical assessment. To enhance the effective interventions needed in taking care of the post-operative client. To formulate a drug study about the patient on what medications that was administered to the client. To create a Nursing Care Plan to provide interventions that is applicable to the client during hospitalization. To formulate a discharge plan for the continuity of care after hospitalization.

Attitude y y Promoting a good nurse-patient interaction to the patient. Developing and helping a trust and establish therapeutic relationship to the patient.

Biographic Data Patients Name: Mrs. T Address: San Andres, Cainta Age: 48 yrs. old Gender: Female Citizenship: Filipino Civil Status: Married Occupation: none Religious Affiliation: Roman Catholic Source of Health Care Finance: family

Chief Complaint /Concern or Reason for Visit/ Seeking Healthcare: Abdominal Enlargement

Health History

A. History of Present Illness On October 2010, the patient felt pain on her abdomen and sought consultation to a manghihilot. The manghihilot told her that she was pregnant. The patient felt presumptive signs of pregnancy such as nausea and vomiting yet she claims to have her menstrual period irregularly. The client also experienced painful defecation. On June 2011, the client went to De Luna Clinic in Masbate for an ultrasound, it was then she discovered that she was not pregnant and it was a huge cystic mass inside her abdomen. The client was also positive in uterine enlargement. She was referred at Philippine General Hospital. The client along with her husband decided to flew to Manila to seek for further health care. Instead of following the referral, the client chose Rizal Medical Center for further health care.

B. Past History The Client said that she could not recall if she had chickenpox, mumps, measles, rubella and rheumatic fever as a child. She also said that she has no allergy to anything whatsoever. She doesnt remember if she had complete immunization, her last shot was given when she was still in second year High School. The client was hospitalized once on 1983 because of experiencing menstrual flow with fever. C. Family History of Illness Both parents of the patient are already dead. The client could not recall what caused the death of her mother, her father died because of kidney cancer. D. OB History The clients menarche started when she was 13 yrs. old. Since she was hospitalized (1983), the clients menstrual period became irregular. The patient is nullipara because of her husbands infertility.

Pain Assessment Presence of discomfort or pain was noticed during the interview due to the back pain the client is experiencing.

ANATOMY AND PHYSIOLOGY

FEMALE REPRODUCTIVE ORGANS

Front View Ovaries

Side View

The ovaries are the main reproductive organs of a woman. The two ovaries, which are about the size and shape of almonds, produce female hormones (estrogens and progesterone) and eggs (ova). All the other female reproductive organs are there to transport, nurture and otherwise meet the needs of the egg or developing fetus. The ovaries are held in place by various ligaments which anchor them to the uterus and the pelvis. The ovary contains ovarian follicles, in which eggs develop. Once a follicle is mature, it ruptures and the developing egg is ejected from the ovary into the fallopian tubes. This is called ovulation. Ovulation occurs in the middle of the menstrual cycle and usually takes place every 28 days or so in a mature female. It takes place from either the right or left ovary at random.

Fallopian tubes The fallopian tubes are about 10 cm long and begin as funnel-shaped passages next to the ovary. They have a number of finger-like projections known as fimbriae on the end near the ovary. When an egg is released by the ovary it is caught by one of the fimbriae and transported along the fallopian tube to the uterus. The egg is moved along the fallopian tube by the wafting action of cilia hairy projections on the surfaces of cells at the entrance of the fallopian tube and the contractions made by the tube. It takes the egg about 5 days to reach the uterus and it is on this journey down the fallopian tube that fertilization may occur if a sperm penetrates and fuses with the egg. The egg, however, is only usually viable for 24 hours after ovulation, so fertilization usually occurs in the top one-third of the fallopian tube.

Uterus The uterus is a hollow cavity about the size of a pear (in women who have never been pregnant) that exists to house a developing fertilized egg. The main part of the uterus (which sits in the pelvic cavity) is called the body of the uterus, while the rounded region above the entrance of the fallopian tubes is the fundus and its narrow outlet, which protrudes into the vagina, is the cervix. The thick wall of the uterus is composed of 3 layers. The inner layer is known as the endometrium. If an egg has been fertilized it will burrow into the endometrium, where it will stay for the rest of its growth. The uterus will expand during a pregnancy to make room for the growing fetus. A part of the wall of the fertilized egg, which has burrowed into the endometrium, develops into the placenta. If an egg has not been fertilized, the endometrial lining is shed at the end of each menstrual cycle. The myometrium is the large middle layer of the uterus, which is made up of interlocking groups of muscle. It plays an important role during the birth of a baby, contracting rhythmically to move the baby out of the body via the birth canal (vagina). Vagina The vagina is a fibro muscular tube that extends from the cervix to the vestibule of the vulva. The vagina is a passage connecting the uterus with the external genitals, receives the penis and the sperm ejaculated from it during sexual intercourse. It also serves as an exit passageway for menstrual blood and for the baby during birth. The external genitals, or vulva, include the clitoris, erectile tissue that responds to sexual stimulation, and the labia, which are composed of elongated folds of skin. Breasts (Mammary Glands) After birth the infant is fed with milk from the breasts, or mammary glands, which are also sometimes considered part of the reproductive system. Fallopian tube One of two ducts in female leading from the ovaries to the upper part of the uterus. They are also known as oviducts. In the human female the fallopian tubes are about 2 cm (about 0.75 in) thick and 10 to 13 cm (4 to 5 in) long. As the ovum leaves the ovary it passes into the mouth of the adjoining fallopian tube and is propelled toward the uterus by hair-like projections called cilia on the inner surface of the tube. If the ovum is fertilized inside the tube, where most fertilization takes place, it usually implants in the uterus.

PATHOPHYSIOLOGY
PRECIPITATING FACTORS y y y Nausea and Vomiting Hormonal Imbalance Increased human chorionic Gonadotropin Lifestyle y PREDISPOSING FACTORS Hormonal imbalance Irregular menstruation

IDIOPATHIC
Stress

Menorrhagia

Suppression of FSH and LH (helps organ to mature Ovarian follicles)

Altered maturation of ovarian follicle

Irregular menstruation

Failure of the follicle ovulates and continues to grow

Dull, Unilateral lower quadrant pain

Cyst may grow in size up to 15cm in diameter

Increased abdominal girth

Hemorrhage and Acute pain

Rupture of the cyst Increased pelvic pressure Sepsis Fatigue & sense of heaviness in the pelvis Urinary frequency, constipation & painful defecation Abdominal bloating

LEGEND:
Death

SIGNS & SYMPTOMS DISEASE PROCESS

TAH&BSO

FACTOR ETIOLOGY

SURGICAL PROCEDURE

Physical Assessment: General Heath: Patient is a 48 female nulligravida, standing 54. Conscious and coherent upon interaction, but answer only the question she is comfortable with. Vital sign was taken. She is lightly nervous. Skin: Her skin tone is brown intact and there are no reddened areas. Skin surface vary from moist to dry. Her skin is smooth and soft to touch without lesions, stretch mark, freckles or birth marks. Skin pinches easily and immediately returns to its original position. Hair: Her hair color is black evenly distributed with some sparse dandruff. Hair is short, dry and she doesnt wear wig. Nails: Nail beds are pink in color without clubbing. Cuticles are smooth no detachment of nailed. Nails are slightly long and dirty. Head: Head is symmetrically round in shape hard and smooth without lesion. No report of severe headache, fainting and dizziness or head trauma. No history of head operation over the past years. Eyes: Eyes are symmetrical and almond in shape. Eyeballs are symmetrically aligned in sockets without protruding or sinking. Eyelashes are equally distributed and skin around the eyes is intact. Client denies recent changes in vision, denies excessive tearing, redness swelling or pain of eyes. No history of eye operation over the past years. Doesnt wear eyes glasses. No eye examination and check-up ever since. Ears: Ears are equal in size bilaterally. The skin is smooth without lesion, lumps or nodules. Client denies recent changes in hearing, no drainage, no pain or ringing over the ears. Has had no surgery and doesnt wear hearing aid device. Nose: No swelling of the mucus membrane and presence of nasal hair were seen. Client noted occasional common colds but relieved with over the counter oral decongestant. No reports of nosebleeds, allergies pain and tenderness. Mouth and Throat: She has an incomplete set of teeth. Oral mucosa and gingival are pinkish in color, but her lips are pale and dry. Tongue is pinkish and free of swelling and lesion. She brushes three times a day. No report of difficulty of swallowing, voice changes or hoarseness. The client doesnt wear dentures. Her last dental appointment when she was in high school. Neck: The patient is able to freely move her neck. No reports of pain, swelling and stiffness. Breast: Bilateral breast moderate in size. No history of breast disease, biopsies or surgery. Reports no breast lesion, lumps, swelling pain rashes or discharge. Her last mammogram and breast examination before and after her surgery. Respiratory System: No reports of pain during inhalation and exhalation. No history of past respiratory disease. No adventitious sounds heard such as crackles or wheezes when auscultated. The client last chest x-ray is before her operation for her cardio pulmonary clearance.

Cardiovascular System: Clients reports no chest pain, dyspnea, dizziness or palpitation. Her current blood pressure is 120/80 mmHg. She had an ECG done last July 8, 2011 the interpretation was Non Specific ST-T wave Changes Apico Septal Wall Correlate Clinically. Gastrointestinal System: There is incision in the lower abdominal area due to her operation. One week after her operation she is suffering from mild pain in the incision site up to her back. She told us that she has had no changes in her usual bowel habits. Client report she never had ulcer, GERD, inflammatory and obstructive bowel disease, pancreatitis, inflammation of gallbladder, liver disease, diverticulosis or appendicitis. She is currently having Jackson-Pratt drainage since after she got operated. Genitourinary System: Client states regular menstruation cycle last August 18, 2011. No vaginal discharge, pain itching, genital lumps, swelling or masses. No difficulty urinating or controlling urine. No problems with fertility. Client denies smoking and drinking alcohol. She is still in catheterization. Musculoskeletal System: The client is able to move but preferred with companion. Client report back pain due to long stayed at bed. No weakness or joint swelling. She walks around every morning 3-5 minutes every morning for her daily exercise. She is currently working as a caretaker in her in-laws house. Neurologic System: The client is oriented and coherent while lying in her bed. No history of head trauma or injury. No dizziness, Tinnitus, severe and chronic headache. No difficulty swallowing or communicating problem. She has an open communication with her husband and sibling. She can directly look into our eyes while talking and she talked in soft voice. She can communicate well to the people around her. Endocrine System: The client denies history of goiter, no heat or cold intolerance, diabetes mellitus, excessive thirst or excessive eating.

DIAGNOSTICS AND LABORATORY PROCEDURES Ultrasound result Date: June 21, 2011 Examination: Pelvis Findings: uterus is not enlarged and displaced to the right homogenous parenchymal echo pattern. It measures about 7.5 cm x 5.5 cm x 5.1 cm (lxwxh).endometrial stripe is thin measuring about 0.3 cm. no focal mass noted. There is a huge cystic mass with evidence of septa noted in the pelvic-abdominal area. Impression: huge cystic mass, as described consider ovarian neoplasm unremarkable uterus. X-ray results Date: July 27, 2011 Examination: Chest There are no active pulmonary infiltrate The heart is not enlarged Pulmonary vascular markings within normal limits Diaphragm and sulki are intact Impression: normal chest Clinical chemistry section blood chemistry Blood chemistry was done on July 20, 2011 however all result showed normal. Electrocardiographic report Date Examined: July 18, 2011 Rhythm: Sinus QRS Axis: Normal Auricular: 97/min Ventricular: 97/min QT Interval: 0.36/min QRS: 0.08 sec. PR Interval: 0.16 sec

Interpreting findings Non- specific ST wave changes apico septal wall Correlate clinically Clinical Chemistry Section Date: September 08, 2011 Reference 135.00 148.00 3.50 4.50 98.00 107.00 1,120 1,320 Hematology result Date: July 20, 2011 TEST NAME Hemoglobin Hematocrit Erythrocyte Mean Corpuscular Volume Mean Corpuscular Hemoglobin Mean Corpuscular Hemoglobin Concentration Red Cell Distribution Width Leukocytes LEUKOCYTE DIFFERENTIAL COUNT Neutrophils Eosinophils Basophils Monocytes Lymphocytes Platelet Count Mean Platelet Volume RESULT 122 0.373 L 4.62 80.7 26.40 L 32.70 L UNIT g/L g/L X10^g/L fL Pg g/dL REFERENCE VALUE 120.00 180.00 0.380 0.470 4.20 5.40 80.00 96.00 27.00 31.00 33.00 37.00 INTERPRETATION Test Na+ K+ Cl+ Ica++ Sodium Potassium Chloride Ionized calcium Result 142.8 mmo/l N 3.92 mmo/L N 106.20 mmo/L N 1,110 mmo/L v

14.90 H 7.07

fL % X10^g/L

11.70 14.40 5.00 15.00

0.54 0.13 H 0.08 0.25 380 9.70

% % % % X10^g/L fL

0.35 0.65 0.00 0.05 0.00 0.08 0.20 0.40 150 450 9.00 13.00

Date: September 03, 2011 TEST NAME Hemoglobin Hematocrit Erythrocyte Mean Corpuscular Volume Mean Corpuscular Hemoglobin Mean Corpuscular Hemoglobin Concentration Red Cell Distribution Width Leukocytes LEUKOCYTE DIFFERENTIAL COUNT Neutrophils Eosinophils Basophils Monocytes Lymphocytes Platelet Count Mean Platelet Volume Date: September 05, 2011 TEST NAME Hemoglobin Hematocrit Erythrocyte Mean Corpuscular Volume Mean Corpuscular Hemoglobin Mean Corpuscular Hemoglobin Concentration Red Cell Distribution Width RESULT 84 L 0.247 L 3.00 L 82 28.0 34.1 UNIT g/L g/L X10^g/L fL Pg g/dL REFERENCE VALUE 120.00 180.00 0.380 0.470 4.20 5.40 80.00 96.00 27.00 31.00 33.00 37.00 INTERPRETATION RESULT 97 L 0.314 L 3.73 L 84 26.0 L 30.9 L UNIT g/L g/L X10^g/L fL Pg g/dL REFERENCE VALUE 120.00 180.00 0.380 0.470 4.20 5.40 80.00 96.00 27.00 31.00 33.00 37.00 INTERPRETATION Normal Normal Normal Normal Normal Normal

12.4 16.4 H

fL % X10^g/L

11.70 14.40 5.00 15.00

Normal Normal Normal Normal

0.86 H 0.01 0.06 0.07 238 7.94

% % % % X10^g/L fL

0.35 0.65 0.00 0.05 0.00 0.08 0.20 0.40 150 450 9.00 13.00

Normal Normal Normal Normal Normal Normal Normal

12.6

fL %

11.70 14.40

Leukocytes LEUKOCYTE DIFFERENTIAL COUNT Neutrophils Eosinophils Basophils Monocytes Lymphocytes Platelet Count Mean Platelet Volume Date: September 08, 2011 TEST NAME Hemoglobin Hematocrit Erythrocyte Mean Corpuscular Volume Mean Corpuscular Hemoglobin Mean Corpuscular Hemoglobin Concentration Red Cell Distribution Width Leukocytes LEUKOCYTE DIFFERENTIAL COUNT Neutrophils Eosinophils Basophils Monocytes Lymphocytes Platelet Count Mean Platelet Volume

8.9 H

X10^g/L

5.00 15.00

0.74 H 0.06 H 0.04 0.16 234 8.32

% % % % X10^g/L fL

0.35 0.65 0.00 0.05 0.00 0.08 0.20 0.40 150 450 9.00 13.00

RESULT 120 0.357 L 4.43 80.6 27.10 33.60

UNIT g/L g/L X10^g/L fL Pg g/dL

REFERENCE VALUE 120.00 180.00 0.380 0.470 4.20 5.40 80.00 96.00 27.00 31.00 33.00 37.00

INTERPRETATION

15.40 10.60

fL % X10^g/L

11.70 14.40 5.00 15.00

0.89 H 0.06 H 0.01 0.10 L 238 7.94

% % % % X10^g/L fL

0.35 0.65 0.00 0.05 0.00 0.08 0.20 0.40 150 450 9.00 13.00