I.

INTRODUCTION

A. Overview of the case Endometrial hyperplasia is a condition of excessive proliferation of the cells of the endometrium, or inner lining of the uterus. Most cases of endometrial hyperplasia result from high levels of estrogens, combined with insufficient levels of the progesterone-like hormones which ordinarily counteract estrogen's proliferative effects on this tissue. This may occur in a number of settings, including polycystic ovary syndrome, estrogen producing tumours (e.g. granulosa cell tumour) and certain formulations of estrogen replacement therapy. Endometrial hyperplasia is a significant risk factor for the development of endometrial cancer so careful monitoring and treatment of women with this disorder is essential. Like other hyperplastic disorders, endometrial hyperplasia initially represents a physiological response of endometrial tissue to the growth-promoting actions of estrogen. However, the gland-forming cells of a hyperplastic endometrium may also undergo changes over time which predispose them to cancerous transformation. Several histopathology subtypes of endometrial hyperplasia are recognisable to the pathologist, with different therapeutic and prognostic implications. Endometrial hyperplasia (simple or complex) - Irregularity and cystic expansion

of glands (simple) or crowding and budding of glands (complex) without worrisome changes in the appearance of individual gland cells. In one study, 1.6% of patients diagnosed with these abnormalities eventually developed endometrial cancer. Atypical endometrial hyperplasia (simple or complex) - Simple or complex

architectural changes, with worrisome (atypical) changes in gland cells, including cell stratification, tufting, loss of nuclear polarity, enlarged nuclei, and an increase in mitotic activity. These changes are similar to those seen in true cancer cells, but atypical hyperplasia does not show invasion into the connective tissues, the defining characteristic of cancer. The previously mentioned study found that 22% of patients with atypical hyperplasia eventually developed cancer. This is a case study of a 45 year old Medical Ward female patient named patient A, who was admitted last February 29, 2012 at the ER of Bukidnon Provincial Medical Center. Days prior to admission, client was already complaining of abnormal vaginal bleeding which prompted her admission. The student chose the case of Patient X as subject for case study for it was the most interesting case amongst the many cases I encountered during the clinical exposure.

B. Objective of the study

This study aims to investigate the condition of the client and further understand the extent of the case. Specifically the student nurse sought to: Perform physical assessment, data base and history taking that solidifies the diagnosis of the client. Identify signs and symptoms associated with the disorder. Identify priority nursing problem that will serve as the basis for the care plan. Develop plan of care and implement nursing interventions relevant and suitable for the case. Evaluate the effectiveness of the interventions and detect any progress or regression of the clients condition.

C. Scope and Limitation The scope of the study covers one client from the Station 1 Gyne 2 of Bukidnon Provincial Medical Center. The informant, the client herself was interviewed during the course of the assessment to gather relevant and valuable data. The period of time the study was conducted was limited and constrained to a span of three days. The initial assessment was conducted on February 29, 2012 and the follow up assessment and care was during the time of the exposure on March 1 and 2, 2012. The encounter with the patient was maximized in gathering relevant and important data.

II. HEALTH HISTORY A. Patients Profile CLIENT: AGE: SEX: ADDRESS: BIRTHDATE: HEIGHT: WEIGHT: CIVIL STATUS: EDUCATIONAL BACKGROUND: RELIGION: CITIZENSHIP: OCCUPATION: INCOME: Patient A 45 years old Female Purok-4 Merangerang, Quezon, Bukidnon October 23, 1966 50 62 kg Married High school level Roman Catholic Filipino Housekeeper P 2000/month

DATE ADMITTED: TIME: DIAGNOSIS: INFORMANT: ADMITTING PHYSICIAN:

2/29/2012 11:00 AM AUB T/C endometrial hyperplasia Patient A/husband/mother Dr. Nectarina Chavez

B. Family and personal history

PAST HEALTH HISTORY: According to patient A., she had her first menstruation when she was 13 years old. According to her mother, she was brought to the hospital since she was still 1month old every month due to asthma. She was also brought to the hospital last 2 years due to allergy. She had measles, mumps and chickenpox when she was young. Patients mother added that the patient was fully immunized. FAMILY HEALTH HISTORY: According to patient A, her paternal side has a history of hypertension and lung disease and her maternal side has a history of heart disease. GENOGRAM: Paternal Side Maternal Side

Legend: - male - lung cancer - hypertension

- female - heart disease - nervous breakdown - endometrial hyperplasia

-bone disease - hyperglycemia - asthma

- gout - convulsion -deceased

C. Chief complaint and history of present illness

Patient A is a 45 year old woman, married, residing at P-4, Quezon, Bukidnon. She was born on October 23, 1966. She is a Filipino citizen and a Roman Catholic. She is a housewife. She was admitted on February 29, 2012 at 11 am for complaints of vaginal bleeding. According to patient A it was 7 days before admission that patient A experienced bleeding. Two days prior to admission, patient experienced headache, fever and chills. On the morning of February 29, 2012, she experienced heavy bleeding that prompted her admission to BPMC. She was diagnosed with endometrial hyperplasia by Dr. Chavez. 3

III. DEVELOPMENT DATA Sigmund Freuds Psychosexual Theory GENITAL stage begins at puberty involves the development of the genitals, and libido begins to be used in its sexual role. However, those feelings for the opposite sex are a source of anxiety, because they are reminders of the feelings for the parents and the trauma that resulted from all that. Patient A is under the genital stage wherein she finds pleasure with his sexuality and functions accordingly with his gender role. However, according to Freud, attraction to the opposite sex is unusual and only a source of anxiety that resulted from past experiences. Jean Piagets Cognitive Development Theory The client belongs to the formal operational stage of Piagets theory. In this stage, individuals move beyond concrete experiences and begin to think abstractly, reason logically and draw conclusions from the information available, as well as apply all these processes to hypothetical situations. The abstract quality of the adolescent's thought at the formal operational level is evident in the adolescent's verbal problem solving ability. The logical quality of the adolescent's thought is when children are more likely to solve problems in a trial-and-error fashion. Adolescents begin to think more as a scientist thinks, devising plans to solve problems and systematically testing solutions. They use hypotheticaldeductive reasoning, which means that they develop hypotheses or best guesses, and systematically deduce, or conclude, which is the best path to follow in solving the problem. During this stage the adolescent is able to understand such things as love, "shades of gray", logical proofs and values. During this stage the young person begins to entertain possibilities for the future and is fascinated with what they can be. Adolescents are changing cognitively also by the way that they think about social matters. Adolescent Egocentrism governs the way that adolescents think about social matters and is the heightened selfconsciousness in them as they are which is reflected in their sense of personal uniqueness and invincibility. Adolescent egocentrism can be dissected into two types of social thinking, imaginary audience that involves attention getting behaviour, and personal fable which involves an adolescent's sense of personal uniqueness and invincibility.

IV. Medical Management A. Doctors Order DATE 2-29-12 ORDER -Pls. admit at gyne ward -DAT, NPO midnight for FBS in AM -Secure consent -Labs: CBC, Serum Crea, UA, CXray ECG 12 leads, UTZ, TUS, FBS, Serum Na+K+ -Start PLR 1 L @ 30 gtts/min -Schedule for D and C once cleared -IVFTF D5LR 1L @ 30 gtts/min -Refer to IM for clearance -Refer accordingly -Meds 1. Ampicillin 250 mg IVT q 6 RATIONALE -For medical care -For legal purpose -For monitoring -To confirm diagnosis

-For medication line

-To eliminate causative agent 2. Mefenamic acid 500 mg tab -NSAID, relief of mild or q6 acute pain 3. Cephalexin 500 mg cap q 8 -To inhibit cell wall synthesis

4. Paracetamol 500 mg q 4 -To lower temperature PRN for fever 5. FeSO4 Durule -Iron supplement

V. Lab Results

Laboratory Exam Hematology

Normal Results * Leukocyte # cone : 4.5 - 11.0 x 109 / L * Hemoglobin Mass cone : 139 - 163 g / L * Different Counts Segmenters : 0.31 - 0.76% Lymphocytes : 0.14 - 0.44% Eosinophils : 0 - 0.04% * Erythrocyte vol. fraction : 0.40 0.50

Patients Results * Leukocyte # cone : 15.1x109/L * Hemoglobin Mass cone : 78g/L * Different Counts Segmenters : 0.74% Lymphocytes : 0.26% Eosinophils : 0.25 * Erythrocyte vol. fraction : 0.48

Indication Increased Normal Normal Normal Normal Normal

Laboratory Exam Urinalysis

Normal *Color: amber to yellow *Character: clear *Reaction(ph): adults &children(4.6-8.0) newborn(5.0-7.0) *Specific gravity: 1.010-1.025 *Albumin: negative *Sugar: negative

Patients Result *Color: yellow *Character: turbid *Reaction(ph): adults: 8.0 *Specific gravity: 1.008 *Albumin: negative *Sugar: negative

Indication *normal * *normal

*decreased *normal *normal

Laboratory Exam Blood chemistry

Normal

Total cholesterol :up to 6.17 mmol /L Creatinine : 88-176.88 mmol/L 10-20mg s% Fasting blood glucose: 75-115 mg s / d/ 4.2-6.4 mmol Triglycerides :up to 1.71 mmol /L Uric acid : M=3.4-7 mg s /dL F=2.4 - 5.7 mgs/dL

Patients Result Total cholesterol : 2.94

Indication

88.4 86 0.46 6.52

Decreased : low fat diet, malabsorption, anemia, liver disorders, carbohydrate sensitivity. Increased : kidney damage Increased : diabetes, liver disease, obesity, pancreatitis, stress Increased : too much carbohydrate intake and hyperlipidism
Normal

XRAY There is no evidence of active parenchymal infiltrates. Cardiomediastinal silhouette does not appear enlarged. Aorta, trachea, diaphragm and sinuses are unremarkable. The included osseous structures are intact.

Impression: No radiograph abnormalities in the chest.

UTZ The uterus is normal in size and measures 6.0 cm x 5.6 cm x 5.0 cm with normal myometrial echopattern. The endometrial stripe is echogenic and thickened and measures 1.2 cm. The R ovary measures 2.6 cm x 3.2 cm. the L ovary is obscured by overlapping bowel gas. Cervix is unremarkable. No fluid seen in the posterior sac.

Impression: Thickened endometrium Obscured left ovary Sonographically normal R ovary, cervix and adrexae

B. Drug study

Name of Drug Ampicillin

Date ordered 2-29-12

Classification Anti-infectives

Dose/Route/Freq uency 250 mg IVT q 6

Mechanism of Action Interfere with the bacterial cell wall synthesis during active multiplication causing cell wall death and resultant bactericidal activity against susceptible bacteria.

Specific Contraindication Indication Treatment of Contraindicated with susceptible allergy to bacterial cephalosporin and infections. penicillin, lidocaine or any other local anaesthetic product of amide.

Side Effects . Diarrhea, rash, vomiting, oral candidiasis, severe abdominal pain, encephalophath y, seizures, lymphathic leukemia.

Nursing Precaution Assess: -I&O ratio; report hematuria, oliguria, since penicillin in high doses is nephrotoxic. -Culture sensitivity before drug theraphy; drug may be taken as soon as culture is taken. - Bowel pattern before, during treatment. -Skin eruptions after administration of penicillin to 1 wk after discontinuing drug.

Name of Drug Cephalexin

Date ordered 2-29-12

Classification Anti-bacterial

Dose/Route/Fre quency 500 mg cap q 8

Mechanism of Action Binds to P site of 50S bacterial ribosomal subunits thereby inhibiting protein synthesis; bactericidal or bacteriostatic.

Specific Indication Treatment of community acquired pneumonia.

Contraindication

Nursing Precaution Contraindicated Palpitations, chest Serious with pain, dizziness, cardiovascul hypersensitivity to fatigue, rash, ar problems. azithromycin, dyspepsia, nausea, erythromycin or any vomiting and macrolide vertigo. antibiotic.

Side Effects

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Name of Drug Mefenamic acid

Date ordered 2-29-12

Classification NSAID

Dose/Route/Fre quency 500 mg cap TID

Mechanism of Action Inhibits prostaglandin synthesis by decreasing the activity of the enzyme, cyclooxygenase, which results in decreases formation of prostaglandin precursors.

Specific Indication Short term relief of mild to moderate pain including primary dismenorrhea.

Contraindication Contraindicated with hypersensitivity.

Side Effects Skin rash, dizziness, abdominal cramps, heartburn, indigestion nausea, itching, ringing in ears, fluid retention, headache.

Nursing Precaution Take with food, milk or with antacids; extended release capsules must be swallowed intact.

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Name of Drug Paracetamol

Date ordered 2-10-12

Classification Antipyretic

Dose/Route/Fre quency 500 mg tab PO q 4 PRN

Mechanism of Action Decreases fever by inhibiting the effects of pyrogens on the hypothalamic heat regulating centers and by a hypothalamic action leading to sweating and vasodilation.

Specific Contraindication Indication Treatment of Hypersensitivity; fever. intolerance to tartrazine, alcohol, table sugar and saccharin.

Side Effects

Nursing Precaution Stimulation, Use drowsiness, cautiously nausea, vomiting, with abdominal pain, impaired hepatotoxicity kidney or rash and urticaria. liver function. Patients with alcohol dependence.

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Name of Drug Paracetamol

Date ordered 2-10-12

Classification Antipyretic

Dose/Route/Fre quency 500 mg tab PO q 4 PRN

Mechanism of Action Decreases fever by inhibiting the effects of pyrogens on the hypothalamic heat regulating centers and by a hypothalamic action leading to sweating and vasodilation.

Specific Contraindication Indication Treatment of Hypersensitivity; fever. intolerance to tartrazine, alcohol, table sugar and saccharin.

Side Effects

Nursing Precaution Stimulation, Use drowsiness, cautiously nausea, vomiting, with abdominal pain, impaired hepatotoxicity kidney or rash and urticaria. liver function. Patients with alcohol dependence.

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V. Pathophysiology ANATOMY AND PHYSIOLOGY Uterus The uterus (Latin word for womb) is a major female hormone-responsive reproductive sex organ of most mammals, including humans. It is within the uterus that the fetus develops during gestation. The uterus is located inside the pelvis immediately dorsal (and usually somewhat rostral) to the urinary bladder and ventral to the rectum. The human uterus is pear-shaped and about 3 in. (7.6 cm) long. A females uterus can be divided anatomically into four segments: The fundus, corpus, cervix and the internal os. Regions From outside to inside, the path to the uterus is as follows:

Vulva Vagina Cervix uteri - "neck of uterus" o External orifice of the uterus o Canal of the cervix o Internal orifice of the uterus corpus uteri - "Body of uterus" o Cavity of the body of the uterus o Fundus (uterus)

Layers The layers, from innermost to outermost, are as follows: Endometrium The lining of the uterine cavity is called the "endometrium". It consists of the functional endometrium and the basal endometrium from which the former arises. Damage to the basal endometrium results in adhesion formation and/or fibrosis (Asherman's syndrome). In most mammals, including humans, the endometrium builds a lining periodically which is shed or reabsorbed if no pregnancy occurs. Shedding of the functional endometrial lining in humans is responsible for menstrual bleeding (known colloquially as a woman's "period") throughout the fertile years of a female and for some time beyond. In other mammals there may be cycles set as widely apart as six months or as frequently as a few days. Myometrium The uterus mostly consists of smooth muscle, known as "myometrium." The innermost layer of myometrium is known as the junctional zone, which becomes thickened in adenomyosis. Perimetrium The loose surrounding tissue is called the "perimetrium." Peritoneum The uterus is surrounded by "peritoneum." The uterus provides structural integrity and support to the bladder, bowel, pelvic bones and organs. The uterus helps separate and keep the bladder in its natural position above the pubic bone and the bowel in its natural configuration behind the uterus. The uterus is continuous with the cervix, which is continuous with the vagina, much in the way that the head is continuous with the neck, which is continuous with the shoulders. It is attached to bundles of nerves, and networks of arteries and veins, and broad bands of ligaments such as round ligaments, cardinal ligaments, broad ligaments, and uterosacral ligaments .

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The uterus is essential in sexual response by directing blood flow to the pelvis and to the external genitalia, including the ovaries, vagina, labia, and clitoris. The uterus is needed for uterine orgasm to occur. The reproductive function of the uterus is to accept a fertilized ovum which passes through the utero-tubal junction from the fallopian tube. It then becomes implanted into the endometrium, and derives nourishment from blood vessels which develop exclusively for this purpose. The fertilized ovum becomes an embryo, develops into a fetus and gestates until childbirth. Due to anatomical barriers such as the pelvis, the uterus is pushed partially into the abdomen due to its expansion during pregnancy. Even during pregnancy the mass of a human uterus amounts to only about a kilogram (2.2 pounds).

Pathophysiology Diagram

Definition
Endometrial hyperplasia is a condition of excessive proliferation of the cells of the endometrium, or inner lining of the uterus. Predisposing Factors:

obesity early menstruation ovarian diseases, such as polycystic ovaries, that may cause a woman to have higherthan-normal estrogen levels and lower-than-normal progesterone levels

Precipitating Factors: too much food intake sedentary lifestyle increased weight

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Pre menopausal stage (45 years old)

Increased estrogen

Proliferation of endometrial cells

Thickening of endometrial lining

Periods of anovulation

Absence of progesterone to counteract estrogen activity

Continuous proliferation of endometrial cells

Endometrium thickens further and becomes highly vascularized

Blood vessels rupture due to further thickening and increased pressure

Prolonged and profuse vaginal bleeding

Low platelet count and hemoglobin

Anemia

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VI. Nursing Assessment

Nursing Assessment (System Review & Nursing Assessment II)

Name: Patient X Date: Feb. 17, 2012 Temp: 3.5 C HR: 75 bpm BP: 110/70 mmHg Height: 54 Weight: 56 kg RR: 30 cpm INSTRUCTIONS: Place an [X] in the area of abnormality. Comment at the space provided. Indicate the location of the problem in the figure using [X]. EENT: Impaired visionblind pain reddened drainage gums hard of hearing deaf burning edema lesion teeth Asses eyes, ears, nose Throat for abnormality no problem RESPIRATION asymmetric tachypnea apnea rales cough barrel chest bradypnea shallow rhonchi sputum diminished dyspnea orthopnea labored wheezing pain cyanotic Asses resp. rate, rhythm, depth, pattern breath sounds, comfort no problem CARDIO VASCULAR arrhythmia tachycardia numbness diminished pulses edema fatigue irregular bradycardia murmur tingling absent pulses pain Assess heart sounds, rate, rhythm, pulse, blood pressure, etc., fluid retention, comfort no problem GASTRO INTESTINAL TRACT obese distention mass dysphagia rigidity pain Assess abdomen, bowel habits, swallowing, bowel sounds, comfort no problem GENITO-URINARY and GYNE pain urine color vaginal bleeding hematuria discharge nocturia Assess urine freq., control, color, odor, comfort/ Gene-bleeding, discharge no problem NEURO paralysis stuporous unsteady seizures lethargic comatose vertigo tremors confused vision grip Assess motor function, sensation, LOC, strength, grip, gait, coordination, orientation, speech. no problem MUSCULOSKELETAL and SKIN appliance stiffness itching petechiae hot drainage prosthesis swelling lesion poor turgor cool deformity wound rash skin color flushed atrophy pain ecchymosis diaphoretic moist Assess mobility, motion, gait, alignment, joint function /skin color, texture, turgor, integrity no problem O2 via nasal cannula 2-4 L/min

Hearing problem

Tachypnea

Non-productive Cough Irregular pulse/weak pulsation

Wheezing

Diaphoretic

PNSS 1L @ 20 gtts/min

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SUBJECTIVE COMMUNICATION: [X] hearing difficulty [ ] visual changes [ ] denied

OBJECTIVE

Comments: Di kaau gyud ko kadungog sir sa akong wala na dalunggan

[ ] glasses [ ] languages [ ] contact lenses [x] hearing difficulties due to age [ ] speech difficulties Pupil size:R:3 mm L:3mm PERRLA

OXYGENATION: [ ] dyspnea [X] smoking history [X] cough [ ] sputum [ ] denied CIRCULATION: [ ] chest pain [ ] leg pain [ ] numbness of extremities [x] denied

Comments: Ga hanguson ko sir mao galisod kog ginhawa

Resp. [ ] regular [X] irregular Describe: Lung expansion is symmetrical to both left and right. Presence of wheezing upon auscultation

Comments: No complaints made

Heart Rhythm [ ] regular [x ] irregular Ankle Edema: No ankle edema present on both extremities Pulse Car Rad. DP Fem* R + + + NO _ L + + + NO _ Comments: Pulsation is weak but palpable

NUTRITION: Diet: Soft diet Character [ x ] recent change in weight [ ] swallowing Difficulty [ ] denied ELIMINATION: Usual bowel pattern 1 a day [ ] constipation remedy _ _ Date of last BM Feb 17, 2012

Comments: Loss of appetite

[X ]dentures Complete Upper Lower [ ] [ ]

[ ]none Incomplete [X] [X]

[ x] urinary frequency 4-6 times/day

Comments: Urine output per shift averages 200 cc

[ ] urgency [ ] dysuria [ ] hematuria [ ] incontinence [ ] polyuria [ ] diarrhea [ ] foley in place _ [ ] denied MGT. OF HEALTH & ILLNESS: [X] alcohol [ ] denied (amount & frequency) 375 ml/day [ ] SBE: N/A Last Pap Smear: N/A

Bowel sounds: normoactive Abdominal Distention Present [ ] yes [X] no Urine* (color, consistency, odor) Yellow in color. *if they are in place

Briefly describe the patients ability to follow treatments (diet, meds, etc.) for chronic health problems (if present): . Patient is very religious in following medication regimen. He understands the importance of his medication in his recovery.

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SUBJECTIVE SKIN INTEGRITY: [ ] dry [ ] other [X] denied

OBJECTIVE

Comments: No complaints made

[ ] dry [ ] cold [ ] pale [ ] flushed [X] warm [ ] moist [ ] cyanotic *rashes, ulcers, decubitus (describe size, location) Presence of rashes in posterior extremity Comments: Client is diaphoretic

ACTIVITY/ SAFETY: [ ] convulsion [ ] dizziness [ ] limited motion of Joints Limitation in Ability to [ ] ambulate [X] bathe self [ ] other [ ] denied COMFORT/ SLEEP/ AWAKE: [ ] pain (location) Frequency Remedies [ ] nocturia [X]sleep difficulties [ ] denied

Comments: Luya kaayo akong lawas sir di ko ganhan mag lihoklihok

[x] LOC and orientation: Awake and coherent. Oriented to time, date and place. Gait: [X] walker [ ] cane [ ] other [ ] steady [X] unsteady__weak____ [ ] sensory and motor losses in face or Extremities:_________________________ [ ] ROM limitations: _________________

Comments: Makamata ko ushay anang gabie kay gapanington kog ayo

[ ] facial grimaces [ ] guarding [ ] other signs of pain :

none

COPING: Occupation: None Members of household: 7 members of household Most supportive person: Wife _ SPECIAL PATIENT INFORMATION Not ordered _Daily weight _Every 2 hours___BP ____N/A____ Neuro vs ____N/A__ CVP/SG Reading __N/A___

Observed non-verbal behavior: The patient is very hesitant and shy. Phone number that can be reached anytime: Refused ____N/A___ PT/OT __ N/A __ ____N/A___ Irradiation __ done _Urine test ___________ __No Order__24 hour Urine Collection

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VII. Nursing Management A. Ideal Nursing Management 1. Ineffective airway clearance Intervention 1. Position head midline with flexion. 2. Suction PRN. 3. Elevate head of bed. 4. Encourage deep breathing exercise. 5. Administer bronchodilators. Rationale 1. To open or maintain airway. 2. To clear secretions. 3. To promote drainage of secretions. 4. To maximize effort. 5. To help liquefy secretions.

2. Imbalanced Nutrition Less Than Body Requirements Intervention 1. Determine ability to chew, swallow or taste Rationale 1.To identify factors digestion of nutrients. that affect

2. Assess weight, age and activity/rest level. 3. Use flavoring agents. 4. Promote pleasant, relaxing environment. 5. Provide oral care before and after meals.

2. Provides comparative baseline. 3. To stimulate appetite. 4. To enhance intake. 5. To stimulate salivation.

3. Hyperthermia Intervention 1. Monitor core temperature 2. Instruct client to use comfortable clothing. 3. Promote cool environment. Proper ventilation. 4. Do tepid sponge bath. 5. Administer antipyretics. Rationale 1. Provide baseline basis. 2. To promote surface cooling. 3. Promote heat loss by convection. 4. Promote heat loss by evaporation. 5. To decrease body temperature.

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B. Actual Nursing Management

Galisod kog ginhawa sir 1. Tachypnea 2. RR = 36 cpm; rapid shallow breathing; irregular 3. With oxygen via nasal cannula regulated at 2-4 L/min. Ineffective airway clearance related increase bronchial secretions Short term: At the end of 8 hours, patient will have improved ventilation and adequate oxygenation. Long Term: At the end of 1 day, patient will maintain adequate ventilation and oxygenation by regular respiration rate. 1. 2. Raised head of bed and position the patient comfortably to maintain open airway. Instructed to do deep breathing exercise to promote effective lung expansion and drainage of secretions. Placed on high back rest Back kept dry. Administered bronchodilators as ordered.

I 3. 4. 5.

Goals not met. Patient demonstrated no improvement of disease condition. Clients RR still tachypneic.

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Init akong paminaw sir unya sige kog panington 1. Temperature 38.5 C

2. Skin warm to touch. 3. Diaphoretic.

Hyperthermia related to disease process Short term: At the end of 30 minutes, patients temperature will lower down to 38 C

Long Term: At the end of 1 day, patient will maintain normal temperature.

1. Instructed client to wear cool clothing. I 2. Promoted cool environment. 3. Performed tepid sponge bath. 4. Administered antipyretic q 4 as ordered. E Goals met. Patients body temperature was able to lower down to 38 C.

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S O

Dili ko ganahan mo kaon mao ng nag niwang ko 1. Weight loss from 62 kg to 56 kg. 2. Loss of appetite. Imbalanced nutrition less than body requirements related to disease process Short term: At the end of 8 hours, patient will have improved appetite.

Long Term: At the end of 1 day, patient will maintain adequate food intake manifested by weight gain.

1. Instructed client to do mouth care before and after meals. I 2. Promoted relaxing environment. 3. Allowed client to choose food preference. 4. Instructed client to eat frequent small feedings. Goals partially met. Patient demonstrated an improved appetite by consuming share of meals. However, weight gain was not monitored due to time constraints.

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VIII. Referral and follow-up

MEDICATIONS

Review with client about the information of medications to be taken at home, including name, dosage, frequency, and possible side effects, stressing the importance of continuing to take medications even after signs and symptoms have decreased or subsided are provided. Significant others was also instructed to avoid intake of certain medications without doctors prescription, and take medications religiously. Breathing and coughing exercises was taught and demonstrated to the client to promote maximum ling expansion and promote drainage of secretions. Instructed client and significant other to monitor for recurrence of any sign and symptoms of the disease like persistent cough, fever, hemoptysis, night sweats and anorexia or loss of appetite. Avoid intake of certain medications and food that exacerbate symptoms like crab meat, shrimps, dried fish, chocolates and egg. They were counseled to let the patient eat meals at regular times and in a relaxed setting and to promote small frequent feeding. Emphasized on intake of highly nutritious foods like fruits and vegetables to promote proper nutrition and increase the immune system.

EXERCISE

TREATMENT DIET

OUTPATIENT

Instructed client to comply referral with their rural health unit for prompt DOTS treatment at Valencia City. Strict compliance to NTPs program is emphasized.

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IX. Evaluation and Implication

At the end of our rotation at BPMC, I was able to apply the nursing process appropriately. I was able to identify needs and problems of the client. Nursing interventions were rendered depending on the need of the client. Rapport was also established. The client and his significant other were also cooperative and trying to take appropriate action for problems identified. Unfortunately, time constraint was an obstacle for some of the implementation of the nursing care plan. However, I was able to maximize the given time in providing efficient and effective nursing interventions. At the end of my nursing care to my client, I have observed that there were a lot of changes in his perception and outlook towards his condition: there were of course

understanding of the disease condition and prevention of transmitting to viable family members. Overall, the intervention that was implemented to the client made a difference on his perception towards promoting health, curing the disease and preventing illness. As a practicing health care giver, the experience that I had gain during the rotation had uplifted my understanding about elective nursing, not only that I have implemented interventions but the feeling of being accepted as a health care provider and touch others lives is the essence of all. For me, the concept of Elective Nursing is not all about fulfilling the requirements to pass or just intervening the problems identified, Its how the health care giver touches others lives and be one of them in attaining the solution of the problem, its all about empathy and lots of perseverance, and motivation towards one self and others to perform such task pertaining to promoting health, preventing disease, curative nursing process as well. This exposure has really inculcated in me valuable opportunities of learning and values which would eventually help me to become an effective and a competent health provider in the future.

X. REFERENCE

Medical Surgical Nursing by Joyce Black 7th edition, 2009 Anatomy and Physiology by Sheila Marieb 2nd edition, 2008 Textbook of Medical-Surgical Nursing by Joyce Young Johnson 11th edition, 2008 Manual of Nursing Practice Handbook by Lippincott 3rd Edition, 2008 PPDs Nursing Drug Guide, 2008

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