A Case Presentation

In Partial Fulfillment of the Requirements

in
NCM 104 Curative and Rehabilitative Nursing (RLE)
EAC BSN IV Section 27 Group C

Magat, Federico Jr.

Magtira, Anna Riza F.
Marquez, Shanelle Erika M.
Mercado, Jenilyn
Moncayo, Michelle
Navarro, Lovely
Nomil, Julius
Nomos, Jesse
Paglicawan, Mc Richard V.
Paler, Carmela Ruah C.

January 08, 2009

 Submitted to

Anthony E. Estolas R.N.

 I. INTRODUCTION
 
 
We, the fourth year nursing students of Emilio
Aguinaldo College, Manila - Section 27 have prepared
a clinical study utilizing the NURSING PROCESS.

This is a case of NAD, a 44 year old woman. She

chose not to establish her private life for public
consumption. She belongs to a very simple and
extended type of family
 
She and her family believe in the assumption of
proper roles, and for them, the family to function
normally, they see to it that:
 
1. They shared different ideas and ways of child
rearing responsibilities.
2. Their family communicates openly with the other
members of the family.
3. Their family members are satisfied with their roles,
and how the decisions are made.
She was admitted at the Metro Lemery Medical Center on
the 9th of December 2008 due to vaginal bleeding.
 

Upon admission, the patient was diagnosed with:

 
 
Hydatiditum Mole (H-Mole), (+)
palpable mass @ CAR
 
 
 
She went through different laboratory procedures such
as CBC, Hematology, Compatibility Testing and Blood Cross
Matching. After getting the results of the laboratory exams
she was advised for TAHBSO the following day.
II. PATIENT’S DATA
 III. NURSING HEALTH HISTORY
 
 
A. History of Present Illness
 
One month prior to admission, the patient
experienced vaginal bleeding and went to the faith
healer for they believe that it could help them to stop
the bleeding. The Faith Healer advised them to use his
prescribed herbal medicines. Those herbal medicines
just worked for a moment and occurred again on the
first week of December that’s why they went to
Mercado Hospital in Tanawan, Batanggas for a check-
up and found out that she has H-Mole through
ultrasound. They went to Metro Lemery Medical Center
and admitted at the Emergency Room. They were
advised to have the laboratory exams and scheduled
the patient for a surgery on December 11, 2008. The
patient underwent Total Abdominal Hysterectomy and
Bilateral Salpingo Oophorectomy last December 11,
2008 by Dr. Roberto Saunar.
B. Past Medical History
 
The patient has no other hospitalizations except the time she had
her pregnancy labor at Mercado Hospital.
 
 
C. Medical History

The patient upon admission was diagnosed of having a Hydatiditum

Mole.

 
D. Family Medical History
 
The patient has a history of hypertension on the mother’s side. 3 of
her 8 siblings are suffering from hypertension and 1 has Diabetes
Mellitus.
 
 
E. Social and Personal History
 
The patient is a full time housewife spending her time of the day
only in the house. She has 6 children and most of them have their own
families. She is the one responsible preparing the foods for her family
and cleaning the house. Her family is an example of a Roman Catholic
not active of attending the weekly church or any activities in the
community.
F. Occupational History
 
She stays home all day to do her daily household
chores and prepare for breakfast, lunch and dinner of the
family. Her husband is the one responsible for supplying for
food allowance of the family. Any other needs of the family
were given by her other children.

 
G. Developmental History
 
Cooking the food and cleaning the house is her daily
chores. Washing the dishes and the clothes was the
responsibility of her daughter in law. After finishing the
household chores, the patient enjoys playing mahjong and
tong-its with their neighborhood.
 
H. Psychosocial History
 
The patient is not an active member in the community
or any groups. She only finished 3rdyear high school and
was married to her husband. She only expresses her
 IV. PHYSICAL ASSESMENT
 
 A. General Appearance 
The patient is conscious and coherent during our interview.
 
B. General Survey
 - Pink palpebral conjuctiva, moist lips, moist oral mucosa
No crackles, no wheezes
Regular rate and rhythm of the pulse and the respiratory rate
Cold and clammy
  
C. Measurement / Vital Signs
  Height
Not taken.
  Weight
Not taken.
  Temperature
36.4ºC
  Pulse Rate
68 bpm
  Respiratory Rate
18 cpm
  Blood Pressure
90/60 mmHg
  Plan:
 
Diet : DAT
IVF : D5LR
V. PHYSICAL ASSESSMENT
VI. PATTERNS OF
FUNCTIONING
VII. LABORATORY RESULTS
Specimen from the patient
 VIII. ANATOMY AND PHYSIOLOGY
 
The Female Reproductive System
 
Sexual characteristics are divided into two types. Primary
characteristics are directly related to reproductive and included the
sex organs (genitalia). Secondary sexual characteristics are
attributes other than the sex organs that generally distinguish one
sex from the other but are not essential to reproduction.
 
The Female Sexual Anatomy and Physiology
 
The Female External Reproductive Organs
Mons pubis/ veneris – mountain of Venus, a pad of fatty
tissues that lies over the symphysis pubis covered by skin
and at puberty covered by pubic hair that serves as a
cushion or protection to the symphysis pubis
Labia Majora – large lips, longitudinal fold from perenium
to pubis symphysis
Labia Minora – AKA Nymphae, soft and thin longitudinal
fold created between labia majora
Clitoris – “key”, pea – shaped erectile tissue composed
of sensitive nerve endings; sight of sexual arousal in
females
Fourchet – tapers posteriorly of the labia majora. Site
for episotomy
- Sensitive to manipulation, torn during
pregnancy
Vestibule – almond shaped area that contains the hymen,
vaginal orifice and batholene’s gland
Urinary Meatus – small opening of urethra/ opening
for urination
Skene’s Gland – aka Paraurethral Gland, 2 small
mucus secreting glands for lubrication
Hymen – membranous tissue that covers the vaginal
orifice
Vaginal Orifice – external opening of the vagina
 Bartholene’s Gland – paravaginal gland, secretes
alkaline substance, neutralizes acidity of the vagina
Doderleins Bacillus – responsible for vaginal acidity
Parumculae Mystiformes – healing of a hymen
Perenium – muscular structure in between lower vagina
and anus
 
 
The Female Internal Reproductive Organs
 Vagina – female organ for sexual intercourse,
passageway of menstruation, ¾ inches 8 – 10 cm long
containing rugae
Rugae – permits considerable stretching without tearing
during delivery
Uterus – hollow muscular organ, varies in size, weight
and shape, organ of menstruation

Size : 1 x 2 x 3
Shape : pear shaped, pregnant – ovoid
Weight : Uterine involution
Non pregnant : 50 – 60 g
Pregnant : 1000 g
th
4 stage of Labor : 1000 g
2nd week after of Delivery : 500 g
3rd weeks after delivery : 300 g
5 – 6 Weeks after delivery: 50 – 60 g
Parts of the Uterus
 
Fundus – upper cylindrical layer
Corpus/ Body – upper triangular layer
Cervix – lower cylindrical layer
Isthmus – lower uterine segment during pregnancy
 
Muscular Composition: 3 main Muscles making
possible expansion in all direction
Endometrium - muscle layer for menses
Myometrium
Power of labor
Smooth muscles is considered to be Living Ligature
(muscles of delivery, capable of closing) of the body
Largest portion of the uterus
Peremetrium
Protects the entire uterus
 
Ovaries
2 female sex gland
almond shape
Fxn: Ovulation,production of 2 hormones( estrogen and
progesterone)
 Fallopian Tube
2 – 3 inches long that serves as a passageway of the sperm from the uterus
to the ampulla or the passageway of the mature ovum or fertilized ovum from
the ampulla to the uterus
5 significant segments
Infundibulum – most distal part, trumpet shape, has fimbriae
Fimbriae – finger like structures that collects the mature ovum from the
ovary
Ampulla– outer 3rd or 2nd half, site of fertilization, common site for
ectopic preg.
Isthmus – site for sterilization, site for BTL
Interstitial – most dangerous site for ectopic pregnancy
6 Major Parts of the Ovaries
 
Germinal Epithelium – layers of
epithelium that covers the surface of the
body
Tunica Albuginea – whitish capsule of
dense connective tissue located deep in
the germinal epithelium
Stroma – region of tissue deep to the
tinuca albuginea
Ovarian Follicle – the sack or bag that
covers the ova during ovulation
Grafan Follicle – follicle that surrounds
the ova during expulsion of the
unfertilized egg out of the ovary
Corpus Luteum – a yellow endocrine
gland found in the ovary formed when
the follicle is discharged its secondary
oocyte which secretes progesterone,
estrogen, and relaxin.
3 Layers of Ovaries
Cortex – the outer layer of the ovary
Medulla – middle layer
Hilum – the inner layer which contains the stroma and
hilar cells which excretes steroids hormones like
progesterone, estrogen, and relaxin
OOGENESIS – process of maturation of ovum
30 weeks AOG – 6 million immature ovum
@ birth – 1 million immature oocytes
@ puberty – 300 – 400 immature oocytes
@ 13 y/o – 300 – 400 mature oocytes
@ 23 y/o – 180 – 280 mature ovum
@ 33 y/o – 60 – 160 mature ovum
@ 36 y/o – 24 – 124 mature ovum
@46 y/o – 4 mature ovum
 
 
Functions of Estrogen and Progestin
ESTROGEN – hormone of woman
Primary function
Responsible for the development of secondary characteristics in
females
inhibit production of FSH
Other function
Hypertrophy of the myometrium
Spinnbarkeit and Ferning Pattern (Billings Method)
Ductile structure of the breast
Osteoblastic bone activity (causes increased in height)
Early closure of the epiphysis of the bone
Sodium retention
Increased sexual desire
Responsible for vaginal lubrication
PROGESTERONE – Hormone of the mother
Primary function – prepares the endometrium
for implantation making it thick and tortous
Secondary Function – inhibit uterine
contractibility
Others
Inhibit LH (hormone of ovulation)
production
 GI motility
 Permeability of kidneys to lactose and
dextrose causing + 1 sugar in urine
Mammary gland development
 BBT
Mood swings
The Ovarian Cycle
 
The follicles are then ready to complete their maturation as
part of the ovarian cycle, a 28 day cycle that includes follicle
maturation, ovulation and the subsequent release of hormones
by the remaining follicle cells. Each of these phases lasts
approximately 14 days and the changes in follicle structure
that occur as part of the ovarian cycle.
 
Until this time, the primary oocyte has been suspended in
prophase of meiosis I. as the development of the tertiary
follicle ends, rising LH levels prompt the primary oocyte to
compkete meiosis I. The completion of the first meiotic division
produces a secondary oocyte. The secondary oocyte begins
meiosis II but stops short of dividing. Meiosis II will not be
completedunless fertilization occurs.
 
Generally, on day of 14 of a 28-day ovarian cycle, the
secondary oocyte and its surrounding follicular cells lose their
connections with the follicular wall and float within the antrum.
The follicular cells surrounding the oocyte are now known as
the corona radiata.
 
The Follicular Phase
 
At the start of each ovarian cyclean ovary contains only few secondary
follicles destibned for further development; by day 5 of the cycle, there is
usually only one. Stimulated by FSH, that follicle forms a tertiary follicle or
mature Graafian Follicle, roughly 15-20mm in diameter. The tertiary
follicle is formed by days 10-14 of the ovarian cycle. Its large size creates
a prominent bulge in the surface of the ovary. The Oocyte and its covering
of follicular cells projects into the expanded central chamber of the
follicle, the antrum.
 
 
Ovulation
 
At ovulation, the tertiary follicle releases the secondary oocyte. The
distended follicular wall then ruptures, releasing the follicular contents,
including the secondary oocyte, into the pelvic cavity. The sticky follicular
fluid keeps the corona radiata attached to the surface of the ovary near
the ruptured wall of the follicle. Contact with projections of the uterine
tube or with fluid currebnts established by its ciliated epithelium then
sweeps the secondary oocyte into the uterine tube.
 
The Luteal Phase
 
The 14 day luteal phase of the ovarian cycle begins at ovulation. The
empty follicle collapses, an the remaining follicular cells invade the
resulting cavity and multiply to create an endocrine structure known as
corpus luteum. Unless fertilization occurs, the corpus luteum begings to
degenerate roughly 12 days after ovulation. The disintegration of the
corpus luteum marks the end of an ovarian cycle. A new ovarian cycle
begings with the selection of another secondary follicle and its formation
IX. PATHOPHYSIOLOGY
LI PR
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