General Objectives

The purpose of the presentation is to know related information and knowledge about the patient’s case/ condition and disease. This presentation will serve as guidelines for us student nurses in assessing and providing proper nursing care to our patient with the same problem or disease.

Specific Objectives

To understand condition of disease and associate it with the patient through the introduction of the case

To know the nursing history, personal data, health history and physical assessment of the patient

To illustrate the anatomy and physiology and pathophysiolgy of the affected organ.

To discuss and determine manifestation and complications To develop an effective skill on how to manage care in patient with the

disease To formulate a drug study with regards to the patients condition and

correlate lab results to its normal values. To provide the client a nursing care plan and discharge plan to assure for

clients total wellness during her hospitalization up to the time of her hospital discharge .

Overview of the disease

Ovarian cysts are small fluid-filled sacs that develop in a woman's ovaries. Most cysts are harmless, but some may cause problems such as rupturing, bleeding, or pain; and surgery may be required to remove the cyst(s). It is important to understand how these cysts may form.

Women normally have two ovaries that store and release eggs. Each ovary is about the size of a walnut, and one ovary is located on each side of the uterus. One ovary produces one egg each month, and this process starts a woman's monthly menstrual cycle. The egg is enclosed in a sac called a follicle. An egg grows inside the ovary until estrogen (a hormone), signals the uterus to prepare itself for the egg. In turn, the uterus begins to thicken itself and prepare for pregnancy. This cycle occurs each month and usually ends when the egg is not fertilized. All contents of the uterus are then expelled if the egg is not fertilized. This is called a menstrual period.

In an ultrasound image, ovarian cysts resemble bubbles. The cyst contains only fluid and is surrounded by a very thin wall. This kind of cyst is also called a functional cyst, or simple cyst. If a follicle fails to rupture and release the egg, the fluid remains and can form a cyst in the ovary. This usually affects one of the

ovaries. Small cysts (smaller than one-half inch) may be present in a normal ovary while follicles are being formed.

Ovarian cysts affect women of all ages. The vast majority of ovarian cysts are considered functional (or physiologic). In other words, they have nothing to do with disease. Most ovarian cysts are benign, meaning they are not cancerous, and many disappear on their own in a matter of weeks without treatment. Cysts occur most often during a woman's childbearing years.

Ovarian cysts can be categorized as noncancerous or cancerous growths. While cysts may be found in ovarian cancer, ovarian cysts typically represent a normal process or harmless (benign) condition.

Signs and Symptoms

Ovarian Cysts CausesOral contraceptive/birth control pill use decreases the risk of developing

ovarian cysts because they prevent the ovaries from producing eggs during ovulation.

The following are possible risk factors for developing ovarian cysts:

• History of previous ovarian cysts • Irregular menstrual cycles • Increased upper body fat distribution • Early menstruation (11 years or younger)• Infertility • Hypothyroidism or hormonal imbalance • Tamoxifen therapy for breast cancer

Ovarian Cysts Symptoms

Usually ovarian cysts do not produce symptoms and are found during a routine physical exam or are seen by chance on an ultrasound performed for other reasons.

However, the following symptoms may be present: • Lower abdominal or pelvic pain, which may start and stop and may be

severe, sudden, and sharp.• Irregular menstrual periods• Feeling of lower abdominal or pelvic pressure or fullness• Long-term pelvic pain during menstrual period that may also be felt in the

lower back• Pelvic pain after strenuous exercise or sexual intercourse • Pain or pressure with urination or bowel movements• Nausea and vomiting• Vaginal pain or spots of blood from vagina • Infertility

III. Personal data of Client

Patient: case # 09091009 Address: Brgy. San Francisco Lopez, Quezon Age: 42 Sex: Female Civil Status: Single Religion: Roman Catholic Nationality: Filipino Chief Complaint: On and Off Hypogastric pain Admitting Date: Sept. 16, 2009

IV. Present Health History

She is a 42-year old female, single, and was admitted to Quezon Medical Center, last September 16, 2009 due to on and off hypogastric pain.

V. Past Health History

A. General Health The patient is conscious and seems tiresome, quite passive yet coherent and partly cooperative.

B. Childhood Illnesses The patient had fever, flu and cough. She had no childhood

illness/es related to his present health status.

C. ImmunizationShe had incomplete vaccinations during childhood.

D. Major Illnesses Hospitalizations She has Diabetes Mellitus which was diagnosed when she was 32 years old. She was hospitalized last August 8-11, 2009 with chief complaint of abdominal pain.

E. Current Medication/s Her medications are as follows:

VI. Physical Assessment A. General Condition The patient is in a lying position:

B. Skin Dark complexion With good skin turgor Partly rough yet tender Warm upon palpation

C. Hair Black and thin hair Evenly distributed

D. Head Symmetrical

E. Eyes No secretion noted Eyebrows symmetrically aligned Pupils are equally round and reactive to light and accommodation Pale conjunctiva; yellowish sclera

F. Ears Symmetrical Upper pinna of the ear in line with the outer canthus of the eyes No swelling noted Adequate responses to sounds

G. Nose Symmetrical and straight Without nasal discharges

H. Mouth and Lips Pale and dry lips Tongue centrally located

I. Throat No tonsilo-pharyngeal inflammation No difficulty of swallowing

J. NeckMuscles equal in size and head centred

K. Chest Symmetrical upon inspection

L. Abdomen Symmetrical upon inspection With soft and non tender abdomen upon palpation

M. Extremities Symmetrical and proportion Not edematous

Anatomy and Physiology

Functional anatomy of the ovary

VIII. Pathophysiology

IX. Course in the Ward

On day one Sept. 16 2009, the patient was admitted on OB ward and under gone complete blood count, blood transfusion, urinalysis, and had post anesthesia order. On day two Sept. 17 2009, the patient undergone TAHBSO. On Sept. 18 2009, the patient was advise to have a repeat CBC.

TAHBSO

Total Abdominal Hysterectomy with Bilateral Salphingo-oophorectomy

Types of Hysterectomy

All hysterectomies include removal of the uterus, but the type of procedure used often depends on the condition being treated.

Complete or total hysterectomy involves the removal of both the uterus and the cervix. This is the most

common type of hysterectomy performed.

Hysterectomy with bilateral salpingo-oophorectomy is the removal of the uterus, cervix, fallopian tubes, and ovaries.

Surgical ProceduresTraditionally, hysterectomies have been performed using a technique known

as total abdominal hysterectomy (TAH).

In a total abdominal hysterectomy (TAH), the surgeon makes an incision approximately five inches long in the abdominal wall, cutting through skin and connective tissue to reach the uterus. The cut can be either vertical3 running from just below the navel to just above the pubic bone, or horizontal—running across the top of the public bone (known as a bikini-line incision).

Advantage of total abdominal hysterectomy is that the surgeon can get a complete, unobstructed look at the uterus and surrounding area. There is also more room in which to perform the procedure. This type of surgery is especially useful if there are large fibroids or if cancer is suspected.

Disadvantages include more pain and a longer recovery time than other procedures, and a larger scar.

Total Abdominal HysterectomyWith and Without Bilateral

Salpingo-oophorectomy

Total abdominal hysterectomy is utilized for benign and malignant disease where removal of the internal genitalia is indicated. The operation can be performed with the preservation or removal of the ovaries on one or both sides. In benign disease, the possibility of bilateral and unilateral oophorectomy should be thoroughly discussed with the patient. Frequently, in malignant disease, no choice exists but to remove the tubes and ovaries, since they are frequent sites of micrometastases.

The purpose of the operation is to remove the uterus through the abdomen, with or without removing the tube and ovaries.

Physiologic Changes. The predominant physiologic change from removal of the uterus is the elimination of the uterine disease and the menstrual flow. If the ovaries are removed with the specimen, the predominant physiologic change noted is loss of the ovarian steroid sex hormone production.

Abdominal hysterectomies take from one to three hours. The hospital stay is three to five days, and it takes four to eight weeks to return to normal activities.

The advantages of an abdominal hysterectomy are that the uterus can be removed even if a woman has internal scarring (adhesions) from previous surgery or her fibroids are large. The surgeon has a good view of the abdominal cavity and more room to work. Also, surgeons have the most experience with this type of hysterectomy. The abdominal incision is more painful than with vaginal hysterectomy and the recovery period is longer.

Purpose

The most frequent reason for hysterectomy in American women is to remove fibroid tumors, accounting for 30% of these surgeries. Fibroid tumors are non-cancerous (benign) growths in the uterus that can cause pelvic, low back pain, and heavy or lengthy menstrual periods. They occur in 30–40% of women over age 40. Fibroids do not need to be removed unless they are causing symptoms that interfere with a woman's normal activities.

In addition to a total hysterectomy, a procedure called a bilateral salphingo-oophorectomy is sometimes performed. This surgery removes the ovaries and the fallopian tubes. Removal of the ovaries eliminates the main source of the hormone estrogen, so menopause occurs immediately. Removal of the ovaries and fallopian tubes is performed in about one-third of hysterectomy operations, often to reduce the risk of ovarian cancer.

X. Laboratory/Diagnostic Examination

September , 2009

Complete Blood Count Results Normal Values

Hemoglobin 13.7 14-18gm/gl

Hematocrit 41 40-50vol

WBC count 16,000 5,000-10,000 cumm

Differential Count

Neutrophils 78 40-60

Lymphocyte 32 35-40

Eosinophils 3 2-4

September , 2009

NCPNursing Care Plan

ASSESSMENT

NURSING DIAGNOSI

S

PLANNING

INTERVENTION

RATIONALE EVALUATION

S: “Kumikirot ang tahi ko” as verbalized by the patientO: > with limited range of motion> weak in appearance> unable to move without assistance> with facial grimace> with guarding attitude in the post-operative site> with pain scale of 6 out of 10

Alteration in comfort related to surgical incision site

At the end of the shift the patients levelof pain will reduced from 7 out of 10 to 3 out of 10

Assess the characteristics of pain

Encourage verbalization of feelings

proper positioning provided

adequate rest periods

encourage early ambulation

promoted comfort measures

administer medication as indicated

toassess etiology/precipitating contributory factors

to determine client response to pain situation

for patient’s comfort

to promote peristalsis

to decrease stress

Goal met as evidenced by the patient’s verbalization of the lessening pain from 7 out of 10 to 3 out of 10

ASSESSMENT NURSING DIAGNOSIS

PLANNING INTERVENTION RATIONALE EVALUATION

S: “ Hindi ako makatulog ng maayos maya’t maya ako nagigising” as verbalized by the patient O: > redness of the conjuctiva

dark circles around the eyes

decrease attention span

frequent yawning

restless in appearance

Sleep pattern disturbance related to environmental changes

at the end of the shift the patient will be able to report satisfactory of sleep

maintain slightly dark, quiet and well ventilated environment

scheduled or organized nursing care through:

elimination of non-essential nursing actions

prepare patient for necessary anticipated interruption to her sleep

Assist patient in a comfortable position

Provide health teaching such as:

Increase physical activities

Avoid fluid and food before bedtime

Sleep is difficult without relaxation the unfamiliar hospital environment can hinder relaxation

In order to feel rested. A person usually must complete an entire sleep cycle

A familiar bedtime ritual may promote relaxation and sleep

Goal met as evidenced by the patient’s verbalization of the lessening pain from 7 out of 10 to 3 out of 10

Drug Study

Name of the Drug

Action Indication Dosage &Preparation

Adverse Reaction

Nursing Responsibility

Mefenamic Acid

Produces anti-inflammatory, analgesic & antipyretic effects possibly through inhibition of prostaglandin synthesis.

Mild to moderate pain, dysmenorrhea

500mg q6 CNS: drowsiness, dizziness, nervousnessCV: edemaGI: nausea, vomiting, diarrhea, peptic ulceration, hemorrhageGU:dysuria, hematuria, nephrotoxicity Hepatic: hepatotoxicity Skin:rash, urticaria

>Observe 10 rights in giving medication> Administered with food to minimize GI adverse reactions.>Contraindicated in GI ulceration r inflammation.>Teach patient sign and symptoms of GI bleeding, and tell patient to report these to the doctor immediately.>Severe hemolytic anemia may occur with prolonged use. Monitor CBC periodically.>Stop drug if rash, visual disturbances, diarrhea develops.

Name of the Drug

Action Indication Dosage and Preparation

Adverse Reaction Nursing Responsibility

Metronidazole (Flagyl) ANTI-INEFECTIVES (amebicides& antiprotozoals)

>Direct –acting trichomonacide and amebicide that works inside and outside in the intestines. It’s thought to enter the cells of microorganisms that contain nitroreductase, forming unstable compounds that binds DNA and inhibits synthesis, causing cell death.

The indication are based on the anti-parasitic and antibacterial activity. >Amebic liver abscess, Intestinal amebiasis, Trichomoniasis >Bacterial infections caused by aerobic microorganisms >To prevent postoperative infection in contaminated colorectal surgery >Bacterial Vaginosis >Clostridium difficle-associated diarrhea and colitis >Pelvic Inflammatory disease

1g / rectum 1hr prior to OR

CNS: headache, seizures, fever, vertigo, ataxia, dizziness, confussion,depression, irritability Vision disorder: transient vision disorders such as diplopia, myopia GI: epigastric pain, pain, nausea, vomiting, diarrhea, metallic taste, dry mouth Hypersensitivity Reactions: rash, pruritus, flushing, urticaria, anaphylactic shocks GU: darkened urine, polyuria, dryness of vagina,dysuria

>Always observe the 10 Rights when giving medication. >Give oral form with meals to minimize GI upset >Tell pt. he may experience a metallic taste and have dark or red-brown urine. >Instruct pt in proper hygiene >Tell pt to avoid alcohol during metronidazole therapy and for atleast one day afterwards beause of possibility of dislfiram-like (Antabuse effect) reaction. >May cause transient visual disorder, dizziness& confusion avoid activities requiring alertness like driving a vehicle.

Name of Action Indication Dosage Adverse Reaction Nursing

the Drug

&Preparation Responsibility

Bisacodyl

Stimulant laxative that increases peristalsis, probably by direct effect on smooth muscle of the intestine, by irritating the muscle or stimulating the colonic intramural plexus. Drug also promotes fluid accumulation in colon and small intestine.

Chronic constipation; preparation for child birth, surgery, or rectal or bowel examination.

2 tablets (hours of sleep)

CNS: dizziness, faintness, muscle weakness with excessive use GI: abdominal cramps, burning sensation in rectum with suppositories, nausea and vomiting METABOLIC: alkalosis, fluid and electrolyte imbalance, hypokalemia. MUSCULOSKELETAL: tetany

>Give drugs at times that don’t interfere with scheduled activities or sleep. >Before giving for constipation, determine whether patient has adequate fluid intake exercise and diet. >Tablets and suppositories are use together to clean the colon before and after surgery and before barium enema. >Insert suppository as high as possible in to the rectum, and try to position suppository against the rectal wall. Avoid embedding within fecal material because doing so may delay onset of action. >Bisco-Lax may contain tartazine.

Name of the Drug

Action Indication Dosage &Preparation

Adverse Reaction Nursing Responsibility

Morphine Sulfate

Binds with opiate receptor in the CNS, altering perception of and emotional response to pain.

>Severe pain >Moderate to severe pain requiring continuous, around the clock opioid >Single dose, epidural extended pain relief after major surgery.

3mg through Epidural catheter q12 x 3

CNS: dizziness, euphoria, light-headedness, nightmares, sedation, somnolence, seizures, depression, hallucinations, nervousness, physical dependence. CV: bradycardia, cardiac arrest, shock, hypertension, tachycardia GI: constipation, nausea and vomiting, anorexia, biliary tract spasm, dry mouth, ileus GU: urine retention, HEMATOLOGIC: thrombocytopenia RESPIRATORY: apnea, respiratory arrest, respiratory depression SKIN: diaphoresis, edema, pruritus and skin flushing OTHER: decreased libido

>Reassess patient’s level of pain at least 15 to 30 minutes. >Keep opioid anatagonist (naloxone) and resuscitation equipment available. >Monitor circulatory, respiratory, bladder and bowel function carefully. >Oral solutions of various concentrations and an intensified oral solution are available. >Oral capsules may be carefully opened and the entire contents poured into cool soft foods such as water, orange juice, apple sauce or pudding. >Morphine is drug of choice in relieving MI pain; may cause transient decrease in blood pressure.

Name of the Action Indication Dosage Adverse Nursing

Drug &Preparation Reaction Responsibility Cefuroxime Second

generation cephalosporin that inhibits cell wall synthesis promoting osmotic instability; usually bactericidal

>Serious lower respiratory tract infection, UTI, skin or skin structure infections, bone or joint infections, septicemia, meningitis and gonorrhea >Pre-operative prevention >Bactericidal exarbations of chronic bronchitis or secondary bacterial infection of acute bronchitis >Acute bacterial maxillary sinusitis >Pharyngitis and tonsillitis >Otitis media

1.5 qm IVP after negative skin testing

CV: phlebitis, thrombophlebitis GI: diarrhea, pseudo-membranous colitis, nausea, anorexia and vomiting GU: urine retention, HEMATOLOGIC: thrombocytopenia, hemolytic anemia, transient neutropenia, eosiniphilia. RESPIRATORY: apnea, respiratory arrest, respiratory depression SKIN: maculopapular and erythematous rashes, urticaria, pain, induration, sterile abscesses, temperature elevation, tissue sloughing at IM injection site OTHER: anaphylaxis, hypersensitivity reactions, serum sickness

> Before giving drug ask patient if she is allergic to penicillin or cephalosporin. >Obtain specimen for culture and sensitivity test before giving first dose. >Absorption of oral drug is enhanced >Tablets may be crushed, if absolutely necessary for patient who can’t swallow tablets.

XIII. Discharge Plan

MedicationOral contraceptives: Birth control pills may

be helpful to regulate the menstrual cycle, prevent the formation of follicles that can turn into cysts, and possibly reduce the size of an existing cyst.

Pain relievers: Anti-inflammatories such as ibuprofen (for example, Advil) may help reduce pelvic pain. Narcotic pain medications by prescription may relieve severe pain caused by ovarian cysts.

Exercise Relaxation exercise turning to sides every 2 hours if lying in bed for

long hours do light activities such as walking, or sitting

down Exercise social interaction with the family

TreatmentSurgical treatments for Ovarian Cysts

Functional ovarian cysts are the most common type of ovarian cyst. They usually disappear by themselves and seldom require treatment. Growths that become abnormally large or last longer than a few months should be removed or examined to determine if they are in fact something more harmful.Self-Care at Home

Pain caused by ovarian cysts may be treated at home with pain relievers, including nonsteroidal anti-inflammatory drugs such as ibuprofen (Motrin), acetaminophen (Tylenol), or narcotic pain medicine (by prescription). Limiting strenuous activity may reduce the risk of cyst rupture or torsion.

Medical TreatmentUltrasonic observation or endovaginal

ultrasound are used repeatedly and frequently to monitor the growth of the cyst.

Health Teachings:

Proper hygiene. Proper diet such as eating nutritional foods that

are rich in protein and Vit. C to promote well-being.

Increase physical activities. Avoid eating sweet foods. Adequate rest and sleep.

OPD (follow up)7 days after the patient was discharge,

patient should have his follow up check up on the nearest health center or hospitalDiet

Increase oral fluid intakePrevent eating of sweet foodsHave a high fiber diet