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Myoma
Presented by:
Abu, Camile
Granada, Glyde Pebbles
Landicho, Katrina
Linatoc, Jeanne Lyn
Luza, Ailen
Maralit, Ma. Krishna
Sim, Khay
Ulan, Darlene
Umali, Marianne Lyn
Avena, Gaudencio
Dimaculangan, Argenald Joseph
Hernandez, Michael Franklin
GENERAL OBJECTIVE
To be able to:
Hypothalamus
↓
GnRH
↓
Anterior Pituitary Gland
↓
FSH
↓
Graafian Follicle
↓
Estrogen
V. PATHOPHYSIOLOGY
Menorrhagia
Myoma
VI. COURSE IN THE WARD
Day 1
A 48 years old female was admitted at exactly 2:16:07 p.m last
August 22, 2008, accompanied by her son, with a chief complaint
of body weakness. She was admitted under the service of Dra.
Lovely Cacho and Dra. Alice Lojo and following orders were
given. Diet as tolerated, temperature, pulse rate and respiratory
rate must be recorded every shift, for chest x-ray posterior-
anterior, for electrocardiogram x 12 leads, for complete blood
count blood typing and for chem. 7. It was done at the same day.
The physician ordered a 5% Dextrose in Lactated Ringers 1 liter
plus 1 ampule of EC to be regulated at 20 gtts/min. The physician
ordered four units of whole blood that are properly typed and
cross matched to be run for 4-6 hours. The physician also ordered
“Lady L” that may have full diet at 4:40 p.m. The first unit of
whole blood with a serial number B-08-4660 started at 10:00
p.m.. Diphenhydramine 1 ampule intravenous 30 min. prior to
blood transfusion.
Day 2
The above unit of blood finished at August 23, 2008, 2:20 a.m. There
is no reaction during and after the blood transfusion. At the same
time, the second unit of whole blood with a serial number B-08-4681
was hooked and consumed at 7:20 a.m. The third unit of blood with a
serial number B-08-4666 was started at same time. The blood
transfusion site was transferred from left to right at 11:20 a.m. At
12:30 p.m., the third unit of whole blood with a serial number B-08-
4668 was consumed and followed up of fourth unit of whole blood
and consumed at 4:30 p.m. Intravenous fluid number one consumed
and followed the number two 5% Dextrose in Lactated Ringers 1 liter
plus one ampule of EC regulated at the same rate. By 11:10 p.m.
“Lady L” is under nothing per orem. “Lady L” informed about Total
Hysterectomy Bilateral Salphingo Oophorectomy with signed consent
of her husband and her son at the same day. Anesthesiologist on deck
was informed. Cefuroxime 750 mg, intravenous started every 8 hours
after negative skin testing. At 11:40 p.m. Valium tablet 5 mg one
tablet was given as pre-operative drugs.
Day 3
August 24, 2008, at exactly 7:00 a.m. “Lady L” was brought to
the operating room. At 4:50 p.m. post-op orders were given.
Monitor vital signs every 15 minutes until fully stable. Nothing
per orem temporarily. The patient was instructed to lie flat on bed
and low back rest for pneumonia precaution. Oxygen inhalation
administered at 3 liters per minute. Suction secretion when
necessary. Intake and output were recorded hourly. 5% Dextrose
Lactated Ringers 1 liter post-op to run at 15gtts/min then to
follow 5% Dextrose Lactated Ringers 1 liter at same rate. Last
dose of Cefuroxime to consumed, Metronidazole 500 mg slow
intravenous push every 6 hours. Tramadol 500 mg after negative
skin testing every 6 hour. Intravenous fluid regulated at 30
gtts/min when blood transfusion finished. Repeat hemoglobin
and hematocrit.
At 5:20 p.m. the operation ended and at 6:40 p.m. patient was
bought to the intensive care unit and hooked to ventilator and
Furosemide 40 mg IV was given. At around 8:45 p.m
Omeprazole 40 mg IV was given. Serum, sodium, potassium,
chloride, prothrombin time, partial prothrombin time done and
result in “Lady L” was nebulized if Combivent 1 neb and
maintained every 8 hours potassium 30 millequivalent
incorporate to her intravenous fluid and decrease it to 8 hours.
Another one unit of packed red blood cell, Calcium gluconate
one ampule was given thru slow intravenous push.
Day 4
August 25, 2008, 5a.m. patient was brought to room 206 and then
nebulization started and extubated at the time and secretion
suctioned. Oxygen maintained at 4 liters per minutes via nasal
canula. Diphenhydramine one ampule was given at 3:30 p.m, 30
minutes prior to blood transfusion. Blood type “B” with a serial #
of BO8-445 run at 4-6 hours. At 6:05 p.m “Lady L” was
confirmed that she has a positive flatulence. Measuring drained
output was recorded shiftly.
Day 5
1 a.m. of August 26, 2008, to follow intravenous fluid 5%
Dextrose Lactated Ringers 1 liter regulated at same rate and
encouraged patient to turn side to side. Serum, creatinine, and
complete blood count done. At 9:37 a.m. the physician advised to
continue medications. At 10:00a.m. patients temperature is
38.2˚C and paracetamol 200 mg one ampule was given thru
intravenous. At 11:03 a.m. nebulization was stopped. The
physician suggests changing Cefuroxime to Tazocin 4.5 grams
intravenous every 8 hours. Above intravenous fluid consumed
and followed up of 5% Dextrose in Lactated Ringers 1 liter
regulated at same rate. At 3:15 p.m. incentive spirometer every 8
hours and two minutes oxygen inhalation was discontinued.
Patient was encouraged to ambulate. At 8:30 p.m. intravenous to
follow of 5% Dextrose Lactated Ringers 1 liter regulated at same
rate. Foley catheter was removed at 9:15 p.m. At 10:45 p.m
“Lady L” gargled one tablespoon of Orahex solution plus 30 cc
water every 6 hours.
Day 6
Nursing care done. Vital signs are monitored and recorded.
Intravenous fluid regulated at 15 gtts/min “Lady L” has no
further complaint. The patient is ambulatory. Tazocin 4.5 grams
intravenous every 8 hours was given. Attending Physician did not
visit’s the patient and no new orders were made that day.
Day 7
August 28, 2008, patient may have clear liquid then soft diet at 4
p.m., above intravenous fluid consumed and followed up of 5%
Dextrose Lactated Ringers 1 liter regulated at the same rate. For
possible discharge on the next day.
Day 8
August 29, 2008, removal of jackson-pratt drain was done and
intravenous fluid was terminated. There is no o objection for
discharge. Home medications instructed and patient may go
home and start oral medication. At 8 p.m. patient was discharged
accompanied by her son via the wheelchair.
VII. LABORATORY
AUGUST 22, 2008
ULTRASOUND
Transvaginal Ultrasound
Impression:
Enlarged uterus with large sub serous myoma wit
intramural component, posterior lower segment consider ovarian
cyst at the right. Normal left ovary.
AUGUST 22, 2008
CLINICAL CHEMISTRY
HEMATOLOGY
Diagnostic/Laborator Normal Value Result Significance/Interpretati
y Test on
Hemoglobin M 13.0-18.0 g/dL 12.5 g/dL Normal
F 12.0-16.0 g/dL
Impression:
> Tortous Aorta
`
AUGUST 24, 2008
ABDOMEN AP
Impression:
>Pneumoperitoneum, likely post surgical.
AUGUST 25, 2008
HEMATOLOGY
Diagnostic/Labo Normal Result Significance/Interp
ratory Test Value retation
HEMATOLOGY
Aftercare
Administer IV helps
fluids as indicated maintain fluids
in the body
To reduce
Give medications blood loss
as ordered by the
attending physician
ASSESSMENT DIAGNOSIS PLANNING NURSING INTERVENTIONS EVALUATION
Medication
Ciprofloxacin 500 mg 1tablet 3x a day for 1 week
Metronidazole 500 mg 1 tablet 3x a day for 1
week
Tramadol (Dolcet) 1 tablet 3x a day for pain
Environment
Instruct patient’s relative to provide the patient an
environment conducive for her easy recovery. Her
place/room in their house must be the most accessible
area. Her environment should be free from
contamination and infection.
Treatment
The patient should follow the physician’s prescription and
should take his home medication on the right time and right dose.
Health Teaching
Instruct the patient the importance of proper taking of medication
on time.
Instruct the patient and her family the proper wound care to avoid
contamination and infection at surgical site.
Instruct the patient to eat nutritious foods.
Encourage ambulation for early recovery.
Good sanitation is advised.
Out Patient Department
The patient should return on the scheduled date of her
follow up check-up on September 5, 2008 in Metro Lipa Medical
Center from 4:30 pm to 6:30 pm and should continuously take
her home medication as prescribed by her physician. The patient
should visit her physician whenever she feels any discomfort.
Diet
Diet as Tolerated. In order to attain proper diet, the
patient should be guided to the prescribed foods as advised by her
physician. Her meals should include Vitamin C-rich foods for
wound healing.
Spiritual
Patient should enhance her spiritual relationship with
God. Have faith and trust in God’s divine power, and believed
that the lord will help in her early recovery. Keep on praying,
because praying is the number one key to live a healthy life and
to be close to God.
XII. PROGNOSIS
The mortality rate in uterine myoma is low provided early
diagnosis and management are made and no complication will
occur. According to the attending physician the case of Lady L
greatly improved after the management, therefore, the prognosis
is good.
XII. EVALUATION
Date 22 23 24 25 26 27 28 29
D5LR 1L √ √ √ √ √ √ √
BT FWB√ √
TPR
temp 36.7 36.2 36 37.3 36.8 36.2 37.6 36.2
RR 24 20 21 24 22 20 28 22
PR 80 90 72 91 68 75 80 68
MEDS 22 23 24 25 26 27 28 29
Omeprazol √
e
Salbutamo √ √ √ √ √
l
(combiven
t)
Piperacilli √ √ √ √ √ √
n
(Tazocin)
Tramadol √ √
(ultram)
Diphenhyd √ √ √ √
ramine
HCl
(Benadryl)
Metronida √ √ √ √ √ √
zole
(Flagyl)
Metronidazole √ √ √ √ √ √
(Flagyl)
Cefuroxime √
(Zinacef)
Paracetamol √
CXR AP √
Abdomen AP √
UTZ √
Clinical √ √ √
Chemistry
Cross Matching √
Hematology √ √ √ √ √
DIET 22 23 24 25 26 27 28 29
DAT √ √
Soft diet √
NPO √ √ √ √
The patient is able to recognize her role in
maintaining and improving her help and adheres
and complies with her medical regimen prescribed
by her health care providers as exhibited by
avoiding everything that would aggravate her
condition or would rise to complications and is able
to verbalize her concerns about her condition and
role in maintaining her health.