NURSING CARE PLAN

NURSING CARE PLAN
History
Present
Patient is regularly menstruating monthly lasting 3-4 days consuming 3-4 pads/ day with dysmenorrhea prior to onset of menses.
Condition started 2 years PTA, patient experienced profuse vaginal bleeding lasting 3-5 days consuming 5 moderate fully soaked pads and 1 kiddie diaper/day with passage of blood clots. This was accompanied by abdominal enlargement described as tightening of pants. There were no other associated signs and symptoms noted such as ” hypogastric pain, hypogastric mass or change in bladder/bowel habits. Patient sought consult w/ previous AP were TVS done revealed ” MYOMA UTERIN”, exact result unrecalled. She was advised for operation however was non-compliant. No medication were prescribed. Said vaginal bleeding spontaneously resolved. Said abdominal enlargement persiated.
1 year PTA, apparently asymptomatic patient sought consult with present AP for regular gynaecologic check-up. Transvaginal ultrasound done revealed “MYOMA UTERIN” , exact result unrecalled. Patient was advised for operation however was deffered due to medical problems.
1 month PTA, apparently asymptomatic patient again sought consult with present AP. TVS done revealed an enlarge anteverted uterus measure 13.3 x 8.7 x 8.8 cm with heterogeneous nodular parenchynal echopattern. Indistinct endometrial stripe, both ovaries not dilated, no fluid in the culdesac. She was then advised for operation hence admission.

Past
It says in the chart of the patient that she is (+) bronchial asthma, non smoker, non alcoholic drinker, no food and known allergies. And in his family history it shows that they are
(+) High B.P, (+) Diabetes.

Menstrual History
Menarche 14 years old duration 3-4 days dysmenorrhea to menses
Interval Monthly amount 3-4 pads/ day

LMP=> August 26-29, 2011
PMP=> July, 2011
PPMP=> June, 2011

Obstetric History
G4P2
G1 = 1997, NSD, FT, Male, BW- 7lbs => Isabela Hospital
G2= 1999,spontaneous abortion, completion curettage
G3=2002, NSD, FT, Female, BW-6lbs, Isabela Hospital
G4=2003, blighted ovum S/p completion curettage

Gynecologic History
( -) Dyspareunia
(-) Postcostal Bleeding
(-) Vaginal Discharge
(-) Vaginal Menitus
Last Papsmear- 2006- Findings – Normal

Laboratory’s
1. Blood Chemistry
Test
Result
Blood Urea Nitrogen
60
Sodium
3.72

2. Hematology
Test
Result
Protime Control
14 seconds
Protime-Patient
20 seconds
Protime- % activity
70 %
Protime – Air
1.46
Hemoglobin
123
Hematocrit
37.7
WBC
7.0
Neutrophil
0.78
Lymphocytes
0.19
Monocytes
0.03
Stab Cell
4.34
Platelets
Adequate

3. X- Ray- Chest
Findings: Both lungs fields are clear.
Heart is normal in size and configuration
Hemidiaphragms, costophrenic sinuses and bony structures are intact.
Impressions: Normal Chest

4. Platelets
Platelet Count 297
5.
Tests
SI Result
Reference Values
Total Protein
75 g
63.82
Albumin
45 g
35.50
Globulin
30 g
25.35
a/g Ratio
1.5
1.5-3.5

6. Ultrasound Report-Transvaginal
Findings:
LMP: July 2, 2011
The uterus is anteverted and enlarged with heterogeneous nodular parenchymal echopatern. It measures 133(L) x 87 ( T) x 89 (W) mm. The endometrial stripe is indistinct. The uterine outline is irregular. Both ovaries are not delineated. No fluid is seen in the posterior cul-de-sac.

Impression:
Consider diffuse uterine myoma with indistinct endometrial stripe.
Non Delineated Ovaries

PATHOPHYSIOLOGY

Pregnancy Early Menarche
(14 years old)

Increase Estrogen production Increase the lifetime exposure
To estrogen

Stimulates the growth of fibroid

Grows in the anterior wall of the uterus

Pelvic Pain

Deform Uterine Cavity

Menorrhagia

Myoma

Drug
Action
Indication
Contra indication
Adverse Reaction
Nursing Consideration
generic name: Keterolac Tromethamine
Brand Name: Toradol

Generic name: Ranitidine
Brand name:
Zantac

Generic name:

Brand name:

Anti-inflammatory and analgesic activity, inhibits prostaglandins and leukotriene synthesis.

Competitively inhibits the action of histamine at the H2 receptors of the parietal cells of the stomach, inhibiting basal body gastric acid secretion and gastric acid stimulated by food, insulin, histamine, cholinergic agonist, gastrin and pentagastrin.
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.

Post surgery antacid to prevent ulcer formation.
Hypersensitivity to ketorolac, renal Impariment, aspirin
allergy.

Hypersensitivity to ranitidine, lactation.
gastric or duodenal ulcer, renal impairment, liver failure,
dysuria, bleeding, platelet inhibition, neutropenia, leukopenia, pancytopenia,
thrombocytopenia, bone marrow depression.
Malaise, insomnia , urticaria, tachycardia, bradycardia, thrombocytopenia, gynecomastia.

History- renal impairment, impaired hearing, allergies, hepatic, CV, and GI conditions, lactation and pregnancy.
Physical-
Skin color and lesion, orientation, reflexes, peripheral sensation.

Intervention:
-be aware that patient may be at increased risk for CV events, GI bleeding, renal toxicity, monitor accordingly.

History- allergy to ranitidine, impaired renal or hepatic function, lactation, pregnancy.
Physical-
Skin lesions, orientation, affect; pulse, baseline ECG;liver evaluation, abdominal examination, normal output.

Intervention: -decrease doses in renal and liver failure
-provide concurrent antacid therapy to relieve pain
-arrange for regular follow up, including blood test, to evaluate effects.

Introduction
Uterine myoma is the most common tumors of the female genitalia tract. Myoma commonly called “Fibroid”. It is benign tumor of the smooth muscle in the wall of the uterus. Hysterectomy has been a common therapy in patients who have completed reproduction. Total hysterectomy plus unilateral salphingo oophorectomy TAHBSO- this procedure removes the uterus, cervix, one ovary, and one fallopian tube, while one ovary and one fallopian tube are left.
Fibroids can be present and be apparent. However they are clinically apparent in up to 25% of the women. Although myoma is generally consider to be slow growing tumor in 20-40% of women at the age of 35 and more have uterine fibroids of significant sizes with severe clinical symptoms. Moreover myoma can be relapse in 7-28% of patient after surgical treatment and in certain case it may even turn to malignant tumor, this could causes significant morbidity including prolonged or heavy menstrual bleeding, pelvic pleasure and pain in the rare cases reproductive dysfunction.

Discharge Planning
– instruct the patient to have an adequate bed rest and calm environment.

– Encourage to increase fluid intake and eat nutritious food.

– Emphasize the importance of follow check up

– Emphasize the importance of taking medications as prescribed by the physician.

– Emphasize the importance of daily diet upon discharge.

Cues
Nursing diagnosis
Rationale
Planning
Rationale
Evaluation
Subjective:
” di ako makagalaw” as verbalized by the patient.

Objective:
-restlessness
-facial grimace
-appears weak
-with verbal reports of discomforts.

Activity intolerance related to generalized weakness as manifested by facial grimace, restlessness, and verbal discomforts.