PATIENT’S PROFILE

NAME: Patient “x”

ADDRESS: Alano extension, Pagadian City
SEX: Female
BIRTHDATE: May 18, 1968
AGE: 41 y/o
BIRTHPLACE: Davao del Sur
NATIONALITY: Filipino
RELIGION: Roman Catholic
CIVIL STATUS: single
FATHER’S NAME: Juanito Pantullana
MOTHER’S NAME: Remedios Pantullana
ADMISSION: DATE: February 28, 2010
TIME: 10:40 am
Room/Ward: OB-WARD
Chief complain: Hypogastric pain
ADMISSION DIAGNOSIS: Uterine Myoma
ATTENDING PHYSICIAN: Dr. Chandra Salvador

HISTORY OF PAST ILLNESS:

The patient was never been hospitalized

before and had not experienced any kind of diseases. She only
had mild illness such as cough, fever and headache. She also
experienced dysmenorrhea in the 1st – 2nd day of her menstruation
.
HISTORY OF PRESENT ILLNESS:

3 years prior to admission, the patient

noticed a mass on hypogastric area of her abdomen. She thought
that it was only due to her loaded works and stress and so, she
only consulted a “hilot”. She didn’t mind to have a consultation on
a doctor because of lack of financial budget.
1 year prior to admission, the patient had
undergone free medical check up from the company where she
was working with and so, the UTZ’s result found out that she had
an enlarged uterus with intramural myoma uterine.

PHYSICAL ASSESSMENT
GENERAL SURVEY:
Received lying on bed conscious and coherent without IVF. Patient is
conscious and coherent, and also responsive to certain questions and
instructions given to her. Tension and increased alertness was noted on the
patient upon receiving her.

VITAL SIGNS:
T = 36.3oC
P = 70 bpm
R = 26 cpm
BP = 120/70 mmHg

SKIN
• warm to touch on upper extremities like in the palm of her hands

• cold temperature on the sole of the client

• Fair skin and brown in color

• Has a good skin turgor upon palpation

• Presence of scars on both upper and lower extremities

HAIR
• Equally distributed hair

• Black with some white hair in color

• Slightly coarse

• No nodules, lumps and tenderness noted upon palpation

• Absence of lice and dandruff

NAILS
• Nail beds are pinkish in color

• Smooth texture

• short nails with dirt noted

• good capillary refill, less than 2 seconds

EYES
• symmetrical

• pupils are equally round and reactive to light accommodation

• pupils are black in color

• sclera is white

• eyebrows and eyelashes are equally distributed

 • eyelashes are slightly curve

• pupils constricts symmetrically when lighted with a penlight

• Blurred vision on her both eyes

EARS
• no deformities

• symmetrical

• no cerumen and dirt noted

• uniform in color

• no discharges noted

• mobile, firm, and not tender upon palpation

• helix of ears are in line with the outer canthus of the eye

NOSE AND SINUSES

• nose is located in the midline of the face

• symmetrical

• proportionate to the face

• absence of discharges

• no nasal flaring

• uniform in color

• no skin breakdown

• nasal septum intact

• nasal hairs are evenly distributed

• no tenderness and pain upon palpation on facial sinuses

MOUTH
• dry lips

• pinkish colored gums

• uvula is located at the midline of the soft palate

 • teeth are yellowish in color

• with dental caries on his upper teeth

• hard palate is light pink in color

• tonsils are not inflamed

• buccal cavity is pinkish in color

• restricted tongue movement

NECK AND THROAT

• neck muscles are equal in size

• absence of swollen lymph nodes

• trachea is centrally aligned

• no tenderness noted

• no thyroid gland enlargement noted

• thyroid gland ascends during swallowing

• equal strength during the assessment for his muscle strength

ANTERIOR AND POSTERIOR CHEST

• quiet respiration

• no palpitations, no deformities

• symmetrical in shape

• absence of adventitious breath sound upon auscultation

• vesicular breath sound was present

• heart is not enlarged

• spine is vertically aligned

• absence of masses

• right and left shoulders are at same height

• full and symmetric chest expansion

• percussion notes resonate except over the scapula

• no visible pulsations on anterior and posterior areas of thorax from

observing them to the side

AXILLA
• presence of axillary hair
 • skin is intact

• little perspiration noted

• no nodules and tenderness noted

ABDOMEN
• has an enlarge mass noted on hypogastric area

• uniform in color

• no skin problems

• absence of bruits on all 4 quadrants

• no evidence of enlargement of liver and spleen

• liver is not palpable as well as the bladder

MUSCULOSKELETAL

• has 10 fingernails and toenails

• uniform in color

• presence of scar in his calf and elbow

• presence of dirt in the fingernails and toenails

• no contractures noted

• Absence of tremors

• Has good muscle gait

NEUROLOGIC

• Able to talk with sense

• Oriented

• Able to remember past events in life

• Coordinated and verbally responsive

DOCTOR’S ORDER
 Date & Order
Time
2-28-10  Pls. admit
 TPR every 4H
 Soft diet

 Labs: CBC
FBS
ECG
CXR

 for TAH once cleared

 refer to Dr. Uy for CP clearance

 Secure unit of FWB properly

2-28-10  Start Bisacodyl @ HS

 Metronidazole 500mg 1 tab TID

 Seen and axamined

 History reviewed
 No previous admission

 BP: 100/60 HR= 76 RR= 16

3-01-10
 Soft diet

 Tea and crackers for lunch and dinner

 NPO post midnight

 For elective TAH

 Secure Consent

 Inform anesthesia on care OR personel

 Start IVF D5LR @ 30gtts @6H

 Cefuroxime 750mg IVTT every 8H ANST

 Bisacodyl suppository II/ rectum @ 6pm
 SS enema @ 9pm or 6
 Cleaning enema @ 5am until rectum is
clear
 All prep
 FF up blood for standby
 Continue V/S monitoring

3-01-10
1:00pm
 DIAGNOSTIC TEST

Ultrasound Report
Date: 04-13-09

Examination Performed: Pelvic ultrasound

Impression: Enlarge uterus w/ intramural myoma

Laboratory
Result:

Hematology Date: 02- Normal Indication

25-10 Values

WBC- 3, 250 5,000- infection

cu/mm 10,0000/cumm

Hemoglobin- 14-17gms% anemia

13.4 gms %
Differential count:
Segmented
neutrophils- 74% 55-66% Bacterial infection

Lymphocytes- 20 % 20-35% Within normal range

Eosinophils- .6 % 0.5-1% Within normal range

Hematology Date: 03-

02-10
Hemoglobin- 12.4 gms %

Electrocardiogram Report
2-28-10
Analysis: 801 sinus rhythm, 401 short P-R
internal

DRUG STUDY
Doctor’s Order: Metronidazole 500mg 1tab q 8 hrs P.O.
Generic Name: Metronidazole
Brand name: Metrocream, MetroGel, Vaginal, Metrolotion, Noritate
Classification: Anti-infectives. Antiprotozoals, Anti-ulcer
Indication: Inflammatory papules and pustules of acne rosacea, bacterial
vaginosis
Mechanism of action: Unknown. May cause bacterial effect by interacting
with bacterial DNA
Dosage: 500mg P.O.
Adverse Effects: dizziness, headache, cramps,pain, nausea, diarrhea,
constipation, rash
Contraindication: Contraindicated in patients hypersensitivity to the drug.
Nursing Responsibilities:
• Take full course of drug therapy; take the drug with food if GI upset occurs.
• Do not drink alcohol
• Your urine may appear dark; this is expected.

Doctor’s Order: Cefuroxime 750mg q 8hrs ANST(-)

Generic Name: Cefuroxime sodium
Brand name: Kefurox, zinacef
Classification: antibiotic, second generation cephalosporin
Indication: pharyngitis, tonsillitis, infection of urinary and lower respiratory
tract
Mechanism of action: hinders and kills susceptible bacteria
Adverse Effects: dizziness, headache, malaise, diarrhea, nausea
Contraindication: hypersensitivity to cephalosporin
Nursing Responsibilities:
1. Asssess pt’s infection before therapy and regularly
thereafter
2. Be alert for adverse reactions and drug interactions

Generic Name: Ranitidine

Brand Name: Zantac
Classification: Histamine 2 antagonist
Mode of Action: Competitively inhibits the action of
histamine at the H2 receptors of the parietal cells f the
stomach, inhibiting basal gastric acid secretion and gastric acid secretion
that is stimulated by food, insulin, histamine, cholinergic agonist, gastrin,
and pentagastrin.
Dosage: Ranitidine 50mg q8 IVTT
Indication: Post surgery antacid to prevent ulcer formation
Contraindication: Hypersensitivity to ranitidine, lactation.
Adverse Effects: malaise, insomnia, somnolence, urticaria, tachycardia,
bradycardia, leukopenia, pancytopenia, thrombocytopenia, gynecomastia,
impotence, hepatitis
Nursing Responsibilities:
Instruct patient to take his meal if nausea or vomiting occurs.

metoclopramide
Apo-Metoclop (CAN), Maxeran (CAN), Maxolon, Nu-Metoclopramide (CAN),
Drug classes: GI stimulant, Antiemetic, Dopaminergic-blocking agent
Therapeutic actions
Stimulates motility of upper GI tract without stimulating gastric, biliary, or pancreatic secretions;
Indications
• Relief of symptoms of acute and recurrent diabetic gastroparesis
 • Short-term therapy (4–12 wk) for adults with symptomatic gastroesophageal reflux
who fail to respond to conventional therapy
• Parenteral: Prevention of nausea and vomiting associated with emetogenic cancer
chemotherapy
• Prophylaxis of postoperative nausea and vomiting when nasogastric suction is
undesirable
Contraindications: Contraindicated with allergy to metoclopramide; GI hemorrhage, mechanical
obstruction or perforation; pheochromocytoma
Adverse effects
• CNS: Restlessness, drowsiness, fatigue, lassitude, insomnia, extrapyramidal
reactions, parkinsonism-like reactions, akathisia, dystonia, myoclonus, dizziness,
anxiety
• CV: Transient hypertension GI: Nausea, diarrhea
Nursing considerations
• Take this drug exactly as prescribed.
• Do not use alcohol, sleep remedies, sedatives; serious sedation could occur.
•
GENERIC NAME: BISACODYL
BRAND NAME(S): Dulcolax, Fleet Bisacodyl, Magic Bullet
Classification: stimulant laxative
Action: It acts by irritating the digestive tract and stimulates intestinal
activity
Indication: . It is used to treat constipation or to clean out the intestinal tract
before bowel examinations or bowel surgery
Adverse Effects: stomach ache, cramping, weakness, sweating, irritation of
the rectal area, diarrhea, or dizziness
Contraindication: hypersensitivity to the drug
Nursing Responsibilities:
If the patient is under 6 years of age, consult child's doctor before using this
medication.

Generic Name: Ketorolac tromethamine

Brand Name: Toradol
Classification: NSAID, Nonopioid analgesic
Mode of Action: Reduces the production of prostaglandins,
chemicals that cells of the immune system make that cause
the redness, fever, and pain of inflammation and that also
are believed to be important in the production of non-inflammatory pain. It
blocks the enzymes that cells use to make prostaglandins (cyclooxygenase 1
and 2). As a result, pain as well as inflammation and its signs and symptoms
- redness, swelling, fever, and pain - are reduced.
Dosage: Ketorolac 30mg q8 IVTT
Indication: For short-term management (up to 5 days) of moderately severe
acute pain that otherwise would require narcotics. It most often is used after
surgery.
Contraindication: Hypersensitivity to ketorolac, renal Impariment, aspirin
allergy
Adverse Effects: gastric or duodenal ulcer, renal impairment, liver failure,
dysuria, bleeding, platelet inhibition, neutropenia, leukopenia, pancytopenia,
thrombocytopenia, bone marrow depression
Nursing Responsibilities:
Infuse slowly as a bolus over no less than 15 seconds.

NALBUPHINE HYDROCHLORIDE
NUBAINE
Drug Class: Narcotic agonist-antagonist analgesic
Therapeutic Actions: Nalbuphine acts as an agonist at specific opioid receptors in the CNS to
produce analgesia, sedation but also acts to cause hallucinations and is an antagonist at µ
receptors
Indications: Relief of moderate to severe pain. Preoperative analgesia, as a supplement to
surgical anesthesia, and for obstetric analgesia during labor and delivery.
Contraindications/cautions: Contraindications: hypersensitivity to nalbuphine, sulfites; lactation.
Adverse Effects:
Sedation. Clamminess, sweating headache, nervousness, restlessness, depression, crying,
confusion, faintness, hostility, unusual dreams, hallucinations, euphoria, dysphoria, unreality.
ANATOMY AND PHYSIOLOGY

Vagina: A muscular passageway that leads from the vulva (external genitalia) to
the cervix.
Cervix: A small hole at the end of the vagina through which sperm passes into the
uterus. Also serves as a protective barrier for the uterus. During childbirth, the
cervix dilates (widens) to permit the baby to descend from the uterus into the
vagina for birth.
Uterus: A hollow organ that houses the baby during pregnancy. During childbirth,
the uterine muscles contract to push out the baby. Each month, unless a fetus has
been conceived, the uterine wall sheds its lining (see The Menstrual Cycle and
Ovulation below).
Ovaries: Two organs that produce hormones and store eggs. Each ovary releases
one egg per month.
Fallopian tubes: Muscular tubes that eggs released from the ovaries must traverse
to reach the uterus.

Kinds of Fibroids/myoma depends on their orientation in the uterine wall

 PATHOPHYSIOLOGY

Predisposing Factor: Precipitating Factor:

Age of Patient: 41 y/o Hyperestrogenic state
Gender: Female Nulliparaty
Stress

Benign tumors originating in

the smooth muscular uterine
Diagnostic Test: tissue.
Ultrasound:
Impression: Stress within the myometrium
Enlarge uterus w/
intramural
myoma S/S:
CBC Simple proliferation of smooth Abdominal discomfort
muscle cells Urinary frequency
Prolonged bleeding with
Treatment: period
Development of Leiomyomas
GnRH Heavy menstrual
(Fibroid)
Analogs bleeding
Sensation of fullness

Decreased
Increased fibroid
Fibroid growth
growth
Complication
Surgical Mngt:
Myoma removed :
TAH
Infertility
Anemia
Infection
Patient recover

Blood clot
Infection
Damage to urinary tract or bladder
during surgery
Early onset of menopause
Rarely death