UNIVERSITY OF THE CORDILLERAS ODC Form 1A

College of Nursing
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ADENOMYOSIS LEIOMYOMA UTERI S/P MYECTOMY

A Case Presented to the

College of Nursing

In Partial Fulfillment of the requirements in the Course

(Nursing Care Management 102)

Submitted by:

ARORA, Sachi Sujit E.

CAJIGAN, Ryan Jake A.
CONRAD, Lydia R.
DULNUAN, Marvin D.
MOHAMMED, Ayman Shams E.
NGAYOS, Shyrlyn Mae C.
PASKING, Regine D.
RAHHAL, Majid M.
SALTAT, Katryn Hazel L.

(Date: October 27, 2018)

Noted and Approved for Presentation:

Name of Case Presentation Adviser or Panel/s

________________________
Signature of Adviser / Date
TITLE: ADENOMYOSIS LEIOMYOMA UTERI S/P MYECTOMY
AUTHOR INFORMATION: Sachi Sujit E. Arora, Ryan Jake A. Cajigan, Lydia R. Conrad, Marvin D.
Dulnuan, Ayman Shams E. Mohammed, Shyrlyn Mae C. Ngayos, Regine D. Pasking, Majid M. Rahhal,
Katryn Hazel L. Saltat.

BACKGROUND: Adenomyosis is rarely diagnosed before hysterectomy and commonly coexist with uterine
leiomyoma. It is common, but poorly understood, condition that affects women of all age groups. It is defined
as the presence of ectopic nests of muscle hyperplasia. Adenomyosis is a common cause of dysmenorrhea,
menorrhagia, and chronic pelvic pain, but often underdiagnosed.
CASE DESCRIPTION: Adenomyosis is a benign condition of the uterus characterized by the presence of
ectopic endometrial glands and stroma below the endometrial – myometrial junction (at the depth of at least
2.5 mm below the basal layer of the endometrium). The focuses of endometrial glands and stroma in the
myometrium are typically surrounded by its hyperplastic tissue. Lymphatic and vascular channels carry out
penetration of normal myometrium. The level of endometrial invasion into a myometrium has been the issue of
heated debate. The majority of cases are observed in multiparous premenstrual women. Likelihood estimation
of diagnosis demands obligatory histological analyses, which are commonly provided after hysterectomy.
CONCLUSION: Adenomyosis is a common finding in women of reproductive age. Most women with
adenomyosis are asymptomatic. When symptomatic, adenomyosis can cause pelvic pain and abnormal uterine
bleeding. The diagnosis of adenomyosis by sonography has been well defined and has diagnostic capabilities
comparable to MRI. When a diagnostic imaging modality is required for suspected adenomyosis, sonography
should be given first consideration given its efficacy, safety and low cost.

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 TABLE OF CONTENTS

I. Introduction....................................................................................................................................................3
II. Statement of Objectives................................................................................................................................３
A. General Objectives....................................................................................................................................３
B. Specific Objectives...................................................................................................................................３
III. Patient’s Profile........................................................................................................................................４
IV. Chief Complaint........................................................................................................................................４
V. Present History of Illness..............................................................................................................................４
VI. Past History of Illness...............................................................................................................................４
VII. Family Health History..............................................................................................................................４
VIII. Developmental History.............................................................................................................................４
IX. Social and Environmental History...........................................................................................................４
X. Lifestyle and Health Practices......................................................................................................................５
XI. Health Assessment....................................................................................................................................５
A. General Survey.........................................................................................................................................５
B. Head to Toe Assessment...........................................................................................................................５
C. 13 Areas of Assessment............................................................................................................................７
XII. Diagnostics................................................................................................................................................10
XIII. Comprehensive Pathophysiology............................................................................................................15
XIV. Treatment/Management............................................................................................................................16
A. Drugs....................................................................................................................................................16
 High Blood Pressure (Hypertension)...................................................................................................19
B. IV Fluids...............................................................................................................................................26
C. Surgery..................................................................................................................................................28
XV. Nursing Care Plans...................................................................................................................................29
A. Prioritization of Problems.........................................................................................................................29
A.1. List of Problems...............................................................................................................................29
a.2. Basis for Prioritization ................................................................................................................29
B. Nursing Care Plans..................................................................................................................................30
NCP 1: Acute Pain.......................................................................................................................................30
NCP 2: Impaired Skin Integrity....................................................................................................................32
NCP 3: Sleep Deprivation............................................................................................................................34
NCP 4: Risk for Infection............................................................................................................................35
NCP 5: Risk for Bleeding............................................................................................................................36
C. Discharged Plan........................................................................................................................................39
XVI. Learning Insights......................................................................................................................................39
XVII. List of References.................................................................................................................................41
Appendix A.......................................................................................................................................................42
Appendix B.......................................................................................................................................................43

I. Introduction

Adenomyosis is a gynecological disease in which the endometrial glands and stroma are found within the
myometrium, interspersed between the smooth muscle fibers. The inner lining of the uterus breaks through
the muscle wall of uterus. Adenomyosis frequently coexist with uterine myomas or endometrial
hyperplasia. The symptoms are pelvic pain, dysmenorrhea and menorrhagia unresponsive to hormonal
therapy of uterine curettage and pregnancy termination.

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 The diagnosis of adenomyosis often occurs as an incidental finding in a uterus removed for symptoms
suggestive of myoma or hyperplasia. Up to 70% of these women have a retrospective history of painful,
heavy periods. Although in the past the diagnosis was made primarily through careful history and the
pelvic examinations findings of an enlarged boggy uterus, magnetic resonance imaging is now considered
an excellent diagnostic tool for confirming this condition.

Age-specific (15- 50) incidence of adenomyosis in the years 2011–2013. Out of the 1415 new cases
identified, 28% had a diagnosis of adenomyosis. Adenomyosis becomes more prevalent after the age of 50
years. In the Philippines the incidence of adenomyosis in the year 2017 is 18 % and endometriris has the
greatest percentage.

II. Statement of Objectives

A. General Objectives

This case analysis aims to increase the understanding and knowledge of student
nurses on how to care for patients with Adenomyosis Leiomyoma Uteri Status post
Myectomy effectively and efficiently.
B. Specific Objectives

Specifically, this case analysis aims to:

1. Define Adenomyosis Leiomyoma and its effects to the body as a
whole;
2. Illustrate the pathophysiology of Adenomyosis Leiomyoma and in relation to the
signs and symptoms specifically observed in the patient;
3. Describe and identify the common signs and symptoms of Adenomyosis Leiomyoma
4. Discuss the medical and surgical interventions for the management of Adenomyosis
Leiomyoma;
5. Formulate appropriate nursing care plans suited for the patient based on the
assessment findings;
6. Identify care measures to be given to the patient and family to
promote continuity of care and independence after discharge.
III. Patient’s Profile

Name : Patient X
Ethnic Background : Ilocano
Civil Status : Separated
Religion : Born Again
Occupation : None
Admitting Diagnosis : Adenomyosis Leiomyoma Uteri status
post Myectomy
Final/Principal Diagnosis : no final diagnosis
Date and Time Admitted : September 27, 28 and 29, 2018 at 7:00 am-
. 3:00pm

IV. Chief Complaint

Pelvic and abdominal pain and Body weakness

V. Present History of Illness

One week prior to admission she felt severe pain during her menstruation. She verbalized that she
could not tolerate the pain and was rated 9/10. The pain was not radiated to other parts of her body but she felt
weakness. Pain reliever was taken such as Advil 200 mg every time she feels severe pain but the pain is still
not tolerable.
Patient X waited until she was done menstruating for 5 days regularly. She went for checkup at
Baguio General Hospital and Medical Center and the doctor told her that she would be confined.

VI. Past History of Illness

Patient X had no history of accidents and or trauma, she had minor illnesses, such as cough, colds and
fever and was remedied with over the counter medications such as paracetamol and water therapy with rest.
She was also diagnosed with Urinary Tract Infection (UTI) at Benguet General Hospital before with antibiotic
medications . She also verbalized that she did not have known allergies for foods or medications.

VII. Family Health History

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 The patient claims to have family history of Hypertension on her mother’s family. Health problems
such as Asthma, kidney diseases, diabetes, or mental illness were verbalized to be absent. There is no present
illness is currently experienced by any member of the family.

VIII. Developmental History

The patient is the forth out of the other 5 siblings, which are composed of 3 males and 2 females. She
is a 41-year-old and is currently residing at Buyagan, La Trinidad, Benguet together with her parents and her
brothers. According to Erik Erikson’s Psychosocial theory the patient was under “Generativity and
Stagnation”, the middle – aged discover a sense of contributing to the world, usually through family and work,
or they may feel lack of purpose.

IX. Social and Environmental History

The patient doesn’t smoke and drink alcohol. No verbalized vices were identified.
She was a factory worker for 8 years at Valley Bread. The patient was separated and she was living
with her parents and her three brothers. The patient with her family visits the health center from health
problems unresolved by home remedies and rest. As a family that belongs to the middle class or class C, access
to health care facilities and interventions is not much of a problem.
The house where they stay is made up of semi-permanent and permanent materials such as wood and
cement. Privacy is maintained with the 4 separate rooms present.

X. Lifestyle and Health Practices

As a factory worker before, she used to eat unhealthy meals like processed foods such as hotdog and
canned goods. She also loves eating junk foods and drinking soft drinks. During her stay in the hospital, she
eats small frequent meals. She also verbalized that she wanted to change her food preferences from junk foods
to fruits and vegetables.

XI. Health Assessment

A. General Survey
The patient was received awake, lying on bed with a moderate high back rest elevation. Patient with
ongoing IVF’s of D5LRS I L x 30 gtts per minute.
Patient appears weak with 3/5 muscle strength, needs assistance when assuming activities of daily
living like toileting and feeding or in changing positions. She wears a neat gown, hygiene is fair. Patient is
conversant speech is well formulated, oriented to the self and others around her, able to determine the
time and date and is aware that she stays at gynecology ward.

B. Head to Toe Assessment

1. Head The head of the client is rounded, normocephalic and symmetrical.
The hair is equally distributed.
2. Eyes Eyebrows: Hair is evenly distributed. The client’s eyebrows are
symmetrically aligned and showed equal movement when asked to
raise and lower eyebrows.
Eyelashes: Eyelashes appeared to be equally distributed and curled
slightly outward.
Eyelids: There were no presence of discharges, no discoloration and
lids close symmetrically with involuntary blinks approximately 15-20
times per minute.
Eyes: The Bulbar conjunctiva appeared transparent with few
capillaries evident.
The sclera appeared white.
The palpebral conjunctiva appeared shiny, smooth and pink.
There is no edema or tearing of the lacrimal gland.
Cornea is transparent, smooth and shiny and the details of the iris are
visible.
The pupils of the eyes are black and equal in size. The iris is flat and
round. PERRLA (pupils equally round respond to light
accommodation), illuminated and non-illuminated pupils constricts.
Pupils constrict when looking at near object and dilate at far object.
Pupils converge when object is moved towards the nose.
When assessing the peripheral visual field, the client can see objects
in the periphery when looking straight ahead.
When testing for the Extraocular Muscle, both eyes of the client
coordinately moved in unison with parallel alignment.
The client was able to read the newsprint held at a distance of 14
inches.

3. Ears The Auricles are symmetrical and has the same color with her facial
skin. The auricles are aligned with the outer canthus of eye. When
palpating for the texture, the auricles are mobile, firm and not tender.

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 The pinna recoils when folded. During the assessment of Watch tick
test, the client was able to hear ticking in both ears at 2 feet distance.
4. Nose and sinuses The nose appeared symmetric, straight and uniform in color. There
was no presence of discharge or flaring. When lightly palpated, there
were no tenderness and lesions
5. Mouth The lips of the client are uniformly pink; dry, symmetric and have a
smooth texture. The client was able to purse his lips when asked to
whistle.
Teeth and Gums: There are no discoloration of the enamels, no
retraction of gums, pinkish in color of gums
The buccal mucosa of the client appeared as uniformly pink; moist,
soft, glistening and with elastic texture.
The tongue of the client is centrally positioned. It is pink in color,
moist and slightly rough. There is a presence of thin whitish coating.
The smooth palates are light pink and smooth while the hard palate
has a more irregular texture.
The uvula of the client is positioned in the midline of the soft palate.

6. Neck The neck muscles are equal in size. The client showed coordinated,
smooth head movement with no discomfort.
The lymph nodes of the client are not palpable.
The trachea is placed in the midline of the neck.
The thyroid gland is not visible on inspection and the glands ascend
during swallowing but are not visible.

7. Chest The chest wall is intact with no tenderness and masses. There’s a full
and symmetric expansion and the thumbs separate 2-3 cm during
deep inspiration when assessing for the respiratory excursion. The
client manifested quiet, rhythmic and effortless respirations.
8. Cardiac There were no visible pulsations on the aortic and pulmonic areas.
There is no presence of heaves or lifts.
9. Breast/Chest Bilateral breasts moderate in size, pendulant, and symmetric.  Breast
skin pale, pink with light brown areola.  Nipples everted bilaterally. 
Free movement of breasts with position changes of arms and hands. 
No dimpling, retraction, lesions, or inflammation noted.  Axillae free
of rashes or inflammation.
No masses or tenderness noted on palpation.  Bilateral mammary
ridge present.  No discharge noted from nipples.  Axillary ( central,
posterior, or anterior) and lateral arm lymph nodes nonpalpable.
10. Abdomen The patient’s abdomen has an incision below the navel area.
11. Genitals Patient verbalized that he had been inserted with a catheter when she
was in the OR before the operation and the day after the operation.
No complaints of dysuria or urinary retention or incontinence post
operatively.
12. Musculoskeletal Normal muscular strength of 3/5 on extremities. The muscles are not
palpable with the absence of tremors. They are normally firm and
showed smooth, coordinated movements. There are no presence of
bone deformities, tenderness and swelling.
13. Integumentary When skin is pinched it goes to previous state immediately (2
seconds); With fair complexion; With dry skin

C. 13 Areas of Assessment
1. Psychosocial and Psychological Status
Patient X is 41 year- old, female, born on December 29, 1976 and is currently residing at Buyagan, La
Trinidad, Benguet together with her parents and her brothers. According to Erik Erikson’s Psychosocial theory
the patient was under “Generativity and Stagnation”, the middle – aged discover a sense of contributing to the
world, usually through family and work, or they may feel lack of purpose.

2. Mental and Emotional Status

Patient X was received lying on the bed awake. During interview the patient is able to answer the questions
properly. According to Jean Piaget’s Cognitive Theory, she is under “Formal Operational Stage”, during this
period the patient is able to reason abstractly and think in hypothetical terms.

3. Environmental Status
Patient X is living on a two-story concrete house which is under renovation. The house was surrounded by pine

5
and bamboo trees. They have a peaceful neighborhood. During hospitalization, the patient was admitted at
Baguio General Hospital at the Gynecology ward. She sleeps in a single bed, the comfort room is accessible
and she was placed at the middle of the ward together with other patients.
4. Sensor Status
a. Visual Status
Patients eyes are assessed using penlight. Pupils are equally round reactive to light and
accommodation, the color of the iris is brown. It showed equal movement during change of facial
expression, no presence of discharge on eyelids noted.
b. Auditory
Patients ears are symmetrical and proportional to the size of her head. No deformities as observed and
no tenderness upon palpation.
c. Olfactory Status
Nose is located at the midline, symmetrical and proportional to the face. No lesions and tenderness
upon palpation noted. There is no presence of nasal flaring.
d. Gustatory Status
Lips are uniformly pink; symmetric and have a dry texture. There is no discoloration of the enamels,
pinkish in color of the gums, tongue is centrally positioned.
e. Tactile Status
Patient X can perceive dull and sharp, light and firm on right and left side.
5. Motor Status
Patient X has Normal muscular strength of 5/5 on extremities. The muscles are not palpable with the absence
of tremors. They are normally firm and showed smooth, coordinated movements. There is no presence of bone
deformities, tenderness and swelling. Confined to bed most of the time.
6. Thermoregulatory Status
Normal body temperature ranges from 36.5- 37.0 degrees Celsius. Patient X’s temperature ranges within
normal range.

Date Time Temperature

7am 36.5 °C
September 27, 2018 10am 36.7°C
2pm 36.6 °C
7am 36.6 °C
September 28, 2018 10am 37.0 °C
2pm 36.8 °C
7am 36.5 °C
September 29, 2018 10am 36.5 °C
2pm 36.9 °C

7. Respiratory Status
Her chest expansion was symmetrical with ease during respiration. Rhythm and respiration pattern are regular.
She has an effective airway clearance and effective breathing pattern which provide adequate gas exchange
and results to a good level of consciousness. Lungs were auscultated for adventitious sounds, after
auscultation, no adventitious sounds were heard. No supraclavicular or suprasternal retraction were
seen during inspiration
Date Time RR SPO2
7am 17 cpm 93 %
September 27, 2018 10am 14 cpm 95 %
2pm 16 cpm 98 %
7am 15 cpm 92 %
September 28, 2018 10am 16 cpm 93 %
2pm 14 cpm 95 %
7am 20 cpm 96 %
September 29, 2018 10am 18 cpm 95 %
2pm 17 cpm 97 %

8. Circulatory Status
Normal cardiac rate for an adult is 60-100 beats per minute. The working capacity of the heart diminishes with
aging. The heartrate of older people is slow to respond to stress and slow to return to normal after stress.
Reduced arterial elasticity results in diminished blood supply to the parts of the body especially the
extremities.
(Kozier et. al, 2004)
Date Time CR Capillary
7am 98 bpm
September 27, 2018 10am 94 bpm 1-2 seconds
2pm 95 bpm

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 7am 89 bpm
September 28, 2018 10am 88 bpm 1-2 seconds
2pm 90 bpm
7am 97 bpm
September 29, 2018 10am 97 bpm 1-2 seconds
2pm 95 bpm

9. Nutritional Status
Prior to admission, patient X only eats small frequent meals and only consumes 25 % of the food served in the
hospital. During our second rotation the patient was under NPO in preparation for her operation.
10. Elimination Status
Prior to admission, Patient X defecates 1-2 times a day. During hospitalization and during our eight (8) hour
shift, she voided 3-4 times per day.
11. Sleep, Rest and Comfort Status
Prior to hospitalization, the patient sleeps for approximately 3 to 5 hours due to excessive lighting and
roommate noise and the pain she felt in her lowed abdomen after operation. She is not comfortable in the
change of environment and the pain after surgery.
12. Fluids and Electrolytes Status
During rotation, patient X is seen drinking water only and receiving an IV medication. She consumes 1 liter of
water per day. She was also infused with IVF.

13. Integumentary Status

Patient X has brown complexion. Skin was evenly pigmented, warm to touch and has a good skin turgor. The
nails are pink, oval adhere to nail bed with160-degree angle.

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XII. Diagnostics
Diagnostic Date of
Description of the Procedure Significance/Purpose of the Procedure Findings & Implications
Procedure Procedure
Ultrasound Ultrasound is a type of It is used to see internal body structures September 26, TRANVAGINAL/TRANSABDOMINAL ULTRASOUND
imaging. It uses high- such as tendons, muscles, joints, blood 2018 Interpretation:
frequency sound waves to vessels, and internal organs. Its aim is The uterus is ant everted with smooth contour and
look at organs and structures often to find a source of a disease or to heterogeneous echo pattern measuring 3.0 x 2.52 cm with
inside the body. Health care exclude any pathology. The practice of nabothian cysts the largest of which measures 0.53 cm).
professionals use it to view examining pregnant women using
the heart, blood vessels, ultrasound is called obstetric ultrasound, The endometrium is hyperechoic measuring 0.69 cm. the sub
kidneys, liver, and other and is widely used. endometrial halo is intact.
organs. During pregnancy,
doctors use ultrasound to view Both ovaries are not visualized. At the right adnexal area is
the fetus. heterogeneous mass measuring 8.55 x 4.18 x4.36 cm with low-
level echoes and incomplete septations and normal ovarian
stroma with in. at the left adnexal is as a tubulocystic an echoic
structure measuring 4.94 x 5.84 x 2.22 cm.

Adherent to the posterofundal wall of the uterus is a cystic

structure measuring 7.20 x 6.33 x 4.48 cm with low-level echoes
within.

There is no free fluid in the posterior cul-de-sac.

Diagnostic procedure and Description of procedure Significance/ Purpose of the Significant findings Nursing Implications
date done procedure
Complete Blood Count A CBC may be ordered when a person has To determine general health status, Leukocyte (WBC) A high white blood cell count indicates that
September 27, 2018 any number of signs and symptoms that screen, diagnose, or monitor any Normal Range: the patient immune system is working to
may be related to disorders that affect one of a variety of diseases and 1.0-10.0 destroy an infection.

8
 blood cells. When an individual has an conditions that affect blood cells, Result:
infection, inflammation, bruising, or such as anemia, infection, 29.52- High
bleeding, a doctor may order a CBC to inflammation, bleeding disorder or
help diagnose the cause and/or determine cancer.
its severity.
Neutrophils A high neutrophils indicates that the patient
Normal Range: has infection.
50-70 %
Result:
94-High
Lymphocytes A high lymphocytes indicates that it helps
Normal Range: fight off diseases, so it's normal to see a
0.20-0.40 temporary rise in the number
Result: of lymphocytes after an infection.
0.4 - High
Basophils No result
Normal Range:
0.00-0.01
Result:
Not included on the test
Monocytes Within the normal range.
Normal Range:
0-10 %
Result:
2 - Normal
Platelet count Within the normal range.
Normal Range:
150- 400 x10^ 9/L
Result: 384

Urinalysis A urinalysis a test of urine It is used to detect and manage a PHYSCAL EXAMINATION
wide range of disorders such as Color: DARK YELLOW
urinary tract infections, kidney Appearance: TURBID
disease and diabetes. A urinalysis
involves checking the appearance,

9
concentration and content of urine.
Abnormal results may point to a
disease or illness.
MICROSCOPIC EXAMINTATION
Pus cells: 20-30 /hpf
Red Blood Cells: 10-15 /hpf
Yeast Cells: NONE
Bacteria: LOADED
Epithelial Cells: OCCASIONAL
Mucus Threads: MANY
Amorphous Materials: NONE
Glucose: NEGATIVE
Ketones: POSITIVE THREE
Urobillinogen: NORAMAL
Bilirubin: NEGATIVE
Erythrocyte: POSITIVE 2

CHEMICAL EXAMINATION
Specific Gravity: 1.010
pH:
Leukocyte
Nitrate: POSITIVE
Protein: NEGATIVE

CRYSTAL
Uric Acid: NONE
Calcium Oxalate: NONE
Triple Phosphate: NONE

CAST
Fine Granular: NONE
Course Granular: NONE
Hyaline: NONE

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 Waxy: NONE

Blood Chemistry Sodium Within normal the range.

September 25, 2018 Normal Range:
135-145 mmol/L
Result:
140.1 mmo/L - normal
Potassium Within normal the range.
Normal Range:
3.5- 5.5 mmol/L
Result:
3.79 mmol/L- normal
Chloride Within normal the range.
Normal Range:
98-108 mmol/L
Result:
104 mmol/L- normal
Magnesium Within normal the range.
Normal Range:
0.6- 1.6 mmol/L
Result:
0.87 mmol/L- normal

11
XIII. Comprehensive Pathophysiology

12
 Modifiable Risk Factors: Non- Modifiable Risk Factors:

 Elevated estrogen  Gender (female)

 Age (41 years old)

The TIAR system causes an

over-production of PGE2 with
an increase in local Occurs when the tissue
estrogen concentrations that normally lines the
uterus (endometrial
tissue) grows into the
muscular wall of the
uterus.
Disordered
Hyperperistalsis

Uterine
Pelvic
bleeding
pain ADENOMYOSIS LEIOMYOMA
UTERI S/P MYECTOMY

Surgery Exploratory
Post-Operative Pain Laparotomy

Risk for
Irritable and Breakdown Skin
Infection
Restless

Impaired Skin Integrity

Risk for
bleeding

Sleep Deprivation

13
XIV. Treatment/Management

A. Drugs
DRUG NAME MECHANISM OF ACTION INDICATION / ADVERSE EFFECT NURSING RESPONSIBILITIES
CONTRAINDICATION

GENERIC: Inhibits the enzyme COX-2. This INDICATIONs: CNS:

CELECOXIB enzyme is required for the  Reliefs signs and symptoms  Dizziness, headache, Dx:
BRAND: synthesis of prostaglandins. Has of osteoarthritis, rheumatoid insomnia  Monitor closely lithium levels
CELEBREX analgesic, anti- inflammatory, and arthritis, ankylosing, CV: when the two drugs are given
CLASS: anti-pyretic properties. spondylitis, and juvenile  Myocardial infarction, concurrently.
 THERAPEUTIC: Decreased pain and inflammation rheumatoid arthritis. stroke, thrombosis, edema  Monitor closely PT/INR when
Ant rheumatic, caused by arthritis or spondylitis. Management of acute pain GI: used concurrently with warfarin.
nonsteroidal anti- including primary  GI bleeding, abdominal  Monitor for fluid retention and
inflammatory agent SOURCE: dysmenorrhea. pain, diarrhea, dyspepsia, edema especially in those with a
 PHARMACOLOGIC: David’s Drug Guide for Nurses flatulence, nausea. history of hypertension or CHF.
COX-2 inhibitors 14th Edition CONTRAINDICATIONs: DERM:
www.DrugGuide.com  Hypersensitivity; cross-  Exfoliative dermatitis, Tx:
DOSAGE: sensitivity may exist with Stevens- Johnson  Teach patient toavoid aspirin
other NSAIDs, including Syndrome, Toxic andother NSAIDs (suchas
ROUTE: aspirin; History of allergic- epidermal, necrolysis, ibuprofen andnaproxen)during
ORAL type reactions to rash. therapy
sulfonamides; history of EDx:
asthma, uticaria, or allergic-  Instruct patient to take celecoxib
type reactions to aspirin or
exactly as directed. Do not take
other NSAIDs, including
the aspirin triad; advanced more than prescribed dose.
renal disease; severe hepatic Increasing doses does not appear
dysfunction; peri- operative to increase effectiveness. Use
pain from coronary artery
bypass graft (CABG) lowest effective dose for shortest
surgery. period of time.
 Use cautiously in:  Advise patient to notify health
cardiovascular disease or
care professional promptly if
risk factors for
cardiovascular disease; pre- signs or symptoms of GI toxicity

14
 existing renal disease, heart (abdominal pain, black stools), skin
failure, liver dysfunction,
concurrent diuretic, or ACE rash, unexplained weight gain,
inhibitor therapy; edema, or chest pain occurs. Patients
hypertension or fluid should discontinue celecoxib and
retention; renal
notify health care professional if
insufficiency; serious
dehydration; pre-existing signs and symptoms of hepatotoxicity
asthma. Exercise extreme (nausea, fatigue, lethargy, pruritus,
caution in history of ulcer jaundice, upper right quadrant
disease or GI bleeding.
tenderness, flu-like symptoms) occur.
DRUG TO DRUG  Advise patient to notify health
INTERACTION: care professional if pregnancy is
planned or suspected.
 Abiraterone, acetylsalicylic  Promptly report any of the
acid (ASA) and other following: unexplained weight
salicylate medications, gain, edema, skin rash.
alcohol, aliskiren,
aluminum- and magnesium-
containing antacids,
aminoglycoside antibiotics
(e.g., amikacin, gentamicin,
tobramycin), amiodarone,
angiotensin-converting
enzyme inhibitors (ACEIs;
e.g., captopril, enalapril,
ramipril), angiotensin II
receptor blockers (ARBs;
e.g., losartan, irbesartan),
aprepitant, atomoxetine,
"azole" antifungals (e.g.,
itraconazole, ketoconazole,
voriconazole), barbiturates
(e.g., butalbital,
pentobarbital,

15
 phenobarbital).

DRUG TO FOOD
INTERACTION:
 High Blood Pressure
(Hypertension)
Severe Potential Hazard, Moderate
plausibility

 NSAIDs - fluid retention

Fluid retention and edema have been

reported in association with the use
of nonsteroidal anti-inflammatory
drugs (NSAIDs). Therapy with
NSAIDs should be administered
cautiously in patients with
preexisting fluid retention,
hypertension, or a history of heart
failure. Blood pressure and
cardiovascular status should be
monitored closely during the
initiation of NSAID treatment and
throughout the course of therapy.

DRUG NAME MECHANISM INDICATION / CONTRAINDICATION ADVERSE EFFECT NURSING RESPONSIBILITIES

OF ACTION

GENERIC: Binds to an enzyme INDICATIONs: CNS: BEFORE:

OMEPRAZOLE on gastric parietal  GERD/ Maintenance of healing in erosive  Dizziness, Dx:
cells in the esophagitis. Duodenal ulcers (with or without drowsiness, fatigue,
BRAND: presence of acidic anti-infective for helicobacter pylori). Short term headache, weakness Check for allergies. This is not too common
16
 LOSEC gastric ph, treatment of active benign gastric ulcer. CV:
PriLOSEC preventing the final Pathologic hyper secretory conditions including  Chest pain with PPIs
transport of Zollinger- Ellison syndrome. Reduction of risk GI: Know what other drugs the patient is receiving
CLASS: hydrogen ions into of GI bleeding in critically ill patients.  Pseudomembranous including over the counter (OTC) and herbs.
 THERAPEUTIC: the gastric lumen. colitis, abdominal Know why the patient is receiving the drug.
Anti-Ulcer agents CONTRAINDICATIONs: pain, acid
 PHARMACOLOGIC:  Contraindicated in patients with known regurgitation, Tx:
Proton- pump inhibitors SOURCE: hypersensitivity to substituted benzimindazoles constipation, diarrhea,  Perform a thorough physical assessment to
David’s Drug or to any component of the formulation. flatulence, nausea, establish baseline data before drug therapy
DOSAGE: Guide for Nurses vomiting begins, and to evaluate for the occurrence of
14th Edition DRUG TO DRUG INTERACTION: DERM: any adverse effects associated with drug
ROUTE: www.DrugGuide.co  Concomitant use of atazanavir and nelfinavir  Itching, rash therapy.
ORAL m with proton pump inhibitors is not MS: Edx:
recommended. Co-administration of atazanavir  Bone fracture Educate patient on drug therapy to promote
with proton pump inhibitors is expected to MISC: compliance and take the drug before meals.
substantially decrease atazanavir plasma  Allergic reactions
concentrations and may result in a loss of DURING:
therapeutic effect and the development of drug Dx:
resistance. Co-administration of saquinavir with Monitor for adverse effects.
proton pump inhibitors is expected to increase Tx:
saquinavir concentrations, which may increase Establish suicide precautions for severely
toxicity and require dose reduction. depressed patients to decrease the risk of
overdose to cause harm.
DRUG TO FOOD INTERACTION: Decrease gastric acid secretion.
 Medicines can interact with certain foods. In Assist patient in taking medication.
some cases, this may be harmful and your doctor
may advise you to avoid certain foods. In the
Edx:
case of omeprazole there are no specific foods
that you must exclude from your diet when
receiving omeprazole. Don’t crush or chew. These drugs are delayed
release and long acting.
 Swallow the capsules whole; do not chew, open,
or crush them.

AFTER:
Dx:
Monitor for side effects
17
 Asses for serotonin syndromes.
Tx:
Provide comfort measures to help the patient
tolerate drug effects.
Edx:
Instruct the patient to report any changes in
urinary elimination such as pain or discomfort
associated with urination, or blood in urine.
Instruct the patient to report severe diarrhea,
drug may need to be discontinued.

DRUG NAME MECHANISM OF INDICATION / ADVERSE NURSING RESPONSIBILITIES

ACTION CONTRAINDICATION EFFECT

GENERIC: Inhibits protein synthesis INDICATIONs: CNS: BEFORE:

CLINDAMYCIN in susceptible bacteria at  Infections caused by sensitive  Dizziness, Dx:
the level of the 50s staphylococci, streptococci, headache,
BRAND: ribosome. Active against pneumococci, bacteriocides, vertigo  Check for allergies. This is not too common with PPIs
CLINDA-T, most gram positive aerobic fusibacterium, clostridium CV:  Know what other drugs the patient is receiving including over the
CLINDAGEL, cocci, including: perfringens, and other sensitive  Arrhythmias, counter (OTC) and herbs.
CLINDESSE staphylococci, anaerobic organisms. hypertension  Know why the patient is receiving the drug.
streptococcus pneumoniae,  Endocarditis prophylaxis for dental GI:
CLASS: other streptococci but not procedures in patients allergic to  Pseudomembran Tx:
THERAPEUTIC: enterococci. Has good penicillin ous colitis,  Perform a thorough physical assessment to establish baseline data
ANTI- activity against those diarrhea, bitter before drug therapy begins, and to evaluate for the occurrence of any
 Bacterial vaginosis
INFECTIVES anaerobic bacteria that taste, nausea, adverse effects associated with drug therapy.
cause bacterial vaginosis. vomiting Edx:
CONTRAINDICATIONs:
DOSAGE: DERM:  Educate patient on drug therapy to promote compliance and take the
 Contraindicated inpatients
SOURCE:  Rash drug before meals.
hypersensitive to drug or lincomycin.
ROUTE: David’s Drug Guide for  Use cautiously in patients with renal LOCAL:
ORAL Nurses 14th Edition or hepatic disease, or significant  Local irritation DURING:
www.DrugGuide.com allergies. (topical products)
Dx:
 Monitor for adverse effects.
DRUG TO DRUG INTERACTION: Tx:
18
  BCG vaccine.  Establish suicide precautions for severely depressed patients to
 erythromycin. decrease the risk of overdose to cause harm.
 mycophenolate.  Decrease gastric acid secretion.
 non-depolarizing muscle  Assist patient in taking medication.
relaxants (e.g., atracurium,
doxacurium, mivacurium, Edx:
pancuronium)
 primaquine.  Don’t crush or chew. These drugs are delayed release and long
 sodium picosulfate. acting.
 typhoid vaccine  Swallow the capsules whole; do not chew, open, or crush them.

DRUG TO FOOD INTERACTION: AFTER:

 You can take clindamycin with or Dx:
without food, but always with a full  Monitor for side effects
glass of water to help prevent it from  Asses for serotonin syndromes.
bothering your throat. It's very Tx:
important that you continuetaking the  Provide comfort measures to help the patient tolerate drug effects.
medication as prescribed until you Edx:
have finished it all, even if your  Instruct the patient to report any changes in urinary elimination such
symptoms improve and you start to as pain or discomfort associated with urination, or blood in urine.
feel better.  Instruct the patient to report severe diarrhea, drug may need to be
discontinued.

DRUG NAME MECHANISM INDICATION / CONTRAINDICATION ADVERSE NURSING RESPONSIBILITIES

OF ACTION EFFECT

GENERIC: INDICATIONs: CNS: BEFORE:

tramadol Chemical Effect:  moderate to moderately severe pain  Sedation, Dx:
hydrochloride Binds to mu-opioid dizziness
receptors. Inhibit CONTRAINDICATIONs: or vertigo,  Check for allergies. This is not too common with
BRAND: Ultram reuptake of serotonin  Pregnancy; allergy to tramadol; acute in toxicities with alcohol, opioids, headache, PPIs
and norepinephrine psychotropic drugs or other centrally acting analgesics; lactation. Use confusion,  Know what other drugs the patient is receiving
CLASS: in the CNS. cautiously with seizures, concomitant. dreaming,

19
 THERAPEUTI sweating, including over the counter (OTC) and herbs.
C: Analgesic Therapeutic effect: DRUG TO DRUG INTERACTION: anxiety, seizures  Know why the patient is receiving the drug.
 PHARMACOL Decreased pain  Blood thinners such as warfarin (Coumadin)
CV: Tx:
OGIC:  Antifungal medications, including ketoconazole(Nizoral)
SOURCE:  Hypotension,  Perform a thorough physical assessment to establish
centrally acting  Antibiotics such as erythromycin (E.E.S., E-Mycin, Erythrocin)
Tachycardia, baseline data before drug therapy begins, and to
and linezolid (Zyvox) evaluate for the occurrence of any adverse effects
www.scribd.co  Drugs used to treat bipolar disorder and schizophrenia, bradycardia
m associated with drug therapy.
DOSAGE: including lithium(Lithobid)
Dermatologic: Edx:
Tablets—50 mg  Depression medications, including monoamine oxidase (MAO)
 Sweating,  Educate patient on drug therapy to promote
inhibitors like isocarboxazid (Marplan) and phenelzine (Nardil); compliance and take the drug before meals.
ROUTE: serotonin norepinephrine reuptake inhibitors (SNRIs) such as
pruritus, rash,
ORAL pallor, urticarial
desvenlafaxine (Pristiq) and duloxetine (Cymbalta); tricyclic DURING:
antidepressants like amitriptyline; and selective serotonin
GI:  Dx:
reuptake inhibitors (SSRIs) such as citalopram (Celexa) and
 Nausea,  Monitor for adverse effects.
fluoxetine (Prozac, Sarafem)
vomiting, dry Tx:
 Heart medications, including digoxin (Lanoxin) mouth,
 Medications for anxiety, such as paroxetine (Paxil, Pexeva)  Establish suicide precautions for severely depressed
constipation, patients to decrease the risk of overdose to cause
and sertraline (Zoloft) flatulence
 Other pain medications, such as oxycodone (Roxicodone) harm.
 Decrease gastric acid secretion.
 Migraine headache medications, including almotriptan (Axert), Other:   Assist patient in taking medication.
eletriptan (Relpax), and frovatriptan (Frova)  Potential for
 Medication for seizures, such as carbamazepine abuse,
(Equetro, Tegretol) Edx:
Anaphylactic
 Muscle relaxants, including cyclobenzaprine (Flexeril)- reactions
Quinidine, Rifampin (Rifadin, Rifamate, Rimactane), St. John's  Don’t crush or chew. These drugs are delayed
wort release and long acting.
 Swallow the capsules whole; do not chew, open, or
DRUG TO FOOD INTERACTION: crush them.
 Alcohol can increase the nervous system side effects of
tramadol such as dizziness, drowsiness, and difficulty AFTER:
concentrating. Some people may also experience impairment Dx:
in thinking and judgment. You should avoid or limit the use  Monitor for side effects
of alcohol while being treated with tramadol. Do not use  Asses for serotonin syndromes.
more than the recommended dose of tramadol, and avoid Tx:
activities requiring mental alertness such as driving or  Provide comfort measures to help the patient
operating hazardous machinery until you know how the tolerate drug effects.

20
 medication affects you. Talk to your doctor or pharmacist if Edx:
you have any questions or concerns.  Instruct the patient to report any changes in urinary
elimination such as pain or discomfort associated
with urination, or blood in urine.
 Instruct the patient to report severe diarrhea, drug
may need to be discontinued.

B. IV Fluids

Name Classification Component/s Use & Effects Nursing Responsibilities

o Hypertonic Each 100 mL of Lactated Allergic reactions or anaphylactoid symptoms  Assess patient carefully for signs of hypervolemia
Nonpyrogenic Ringer's Injection, USP contains such as localized or generalized urticaria and such as bounding pulse and shortness of breath
Lactated Parenteral fluid sodium chloride 600 mg, pruritis; periorbital, facial,  Do not administer unless solution is clear and
sodium lactate, anhydrous 310 and/or laryngeal edema, coughing, sneezing,
Ringer's Electrolyte container is undamaged.
mg, potassium chloride 30 mg and/or difficulty with breathinghave been
and 5% Nutrient replenisher  Caution must be exercised in the administration
and calcium chloride, dihydrate reported during administration of Lactated
Dextrose Lactated Ringer's and 5% Ringer's and 5% Dextrose Injection, USP. The of parenteral fluids, especially those containing
Injection Dextrose Injection, USP 20 mg. May contain sodium ions to patients receiving corticosteroids
reporting frequency of these signs and symptoms
hydrochloric acid and/or sodium
has value as a source of is higher in women during pregnancy. or corticotrophin.
hydroxide for pH adjustment. A
water, electrolytes, and  Solution containing acetate should be used with
liter provides 9 calories (from
calories. It is capable of Reactions which may occur because of the caution as excess administration may result in
lactate), sodium (Na+), 130 solution or the technique of administration
inducing diuresis mEq, potassium (K+) 4 mEq, metabolic alkalosis.
include febrile response, infection at the site of
depending on the clinical calcium (Ca++) 3 mEq, chloride  Solution containing dextrose should be used with
injection,
condition of the patient. (Cl−) 109 mEq and lactate venous thrombosis or phlebitis extending from caution in patients with known subclinical or
Lactated Ringer's and 5% [CH3CH(OH) COO−] 28 mEq. the site of injection, extravasation, overt diabetes mellitus.
Dextrose Injection, USP The electrolyte content is and hypervolemia.  Discard unused portion.
produces a metabolic isotonic (273 mOsmol/liter,  In very low birth weight infants, excessive or
alkalinizing effect. Lactate calc.) in relation to the If an adverse reaction does occur, discontinue the rapid administration of dextrose injection may
ions are metabolized extracellular fluid (approx. 280 infusion, evaluate the patient, institute result in increased serum osmolality and possible
ultimately to carbon mOsmol/liter). The pH of the appropriate therapeutic countermeasures, and intracerebral hemorrhage.
solution is 6.6 (6.0 − 7.5). save the remainder of the fluid for examination if
dioxide and water, which  Properly label the IV Fluid
deemed necessary.
21
 requires the consumption  Observe aseptic technique when changing IV
of hydrogen cations. fluid.

Name Classification Component/s Use & Effects Nursing Responsibilities

o N: Isotonic Intravenous 0.9% Sodium Chloride Reactions which may occur because of the solution  A Monitor patient frequently or:
Normal Solution Injection, USP contains 9 g/L or the technique of administration a. Signs of infiltration/sluggish flow
Saline Sodium Chloride (sodium include febrile response, infection at the site of b. signs of phlebitis/infection
chloride (sodium chloride injection, venous thrombosis or phlebitis extending
c. well time of catheter and need to be replaced
injection) injection), USP from the site of injection, extravasation,
and hypervolemia. d. Condition of catheter dressing. Check the
(NaCl) with an osmolarity of level of the IVF.
308 mOsmol/L (calc). It a. Correct solution, medication and volume.
contains 154 mEq/L sodium If an adverse reaction does occur, discontinue the
infusion, evaluate the patient, institute b. Check and regulate the drop rate.
and 154 mEq/L chloride.
appropriate therapeutic countermeasures and save c. Change the IVF solution if needed.
the remainder of the fluid for examination if d. Do not connect flexible plastic
deemed necessary.

C. Surgery

Procedure Description & Indication Nursing Care/Responsibilities

An exploratory laparotomy (also known as an ex-lap) is a  The nurse should remind the patient to keep the wound from the abdomen clean and dry
Exploratory surgical operation where the abdomen is opened and the until it heals.
Laparotomy, Peritoneal abdominal organs examined for injury or disease. It is a  The patient should watch for signs of wound infection such as redness, swelling, and/or
Lavage, Drain diagnostic method used by doctors when trying to find a drainage, and be alert to symptoms indicating that the effusion recurred.
placement diagnosis for an ailment. It can be performed in both humans and
animals, but it is far more common in animals. It is used most
commonly to diagnose or locate cancer in humans.

22
XV. Nursing Care Plans

A. Prioritization of Problems

A.1. List of Problems

1. Acute Pain
2. Impaired skin Integrity
3. Sleep Deprivation
4. Risk for Infection
5. Risk for Bleeding

a.2. Basis for Prioritization .

NURSING DIAGNOSES JUSTIFICATION
1. Acute pain related to surgical This is the 1st nursing diagnosis because acute or nociceptive
Incision pain is distinct from chronic pain, the boundaries are not well
defined. Patients with acute pain usually experience resolution,
whereas patients with chronic pain are unlikely to do so.
Although acute pain has a foreseeable end its management
should be a high priority because acute pain may, when
neglected, become chronic and persistent.
2. Impaired skin integrity related This is our second priority because it is an open wound so puts
to surgical incision patient at risk for infection and could have further breakdown if
not monitored properly.
3. Sleep deprivation related to This is the 3rd nursing diagnosis because according to Maslow,
irritability and pain physiologic need should satisfy first. Sleep is one of the basic
needs of man, so that the patient should satisfy this first.
4. Risk for Infection related to The fact that the patient has incision site would make her more vulnerable in
surgical incision developing infection directly to the incision site.
5. Risk for bleeding related to This is the 5th Prioritized nursing diagnosis because according
surgical incision to the rule risk problem should prioritized least, because actual
problem should solve first.

23
 B. Nursing Care Plans

NCP 1: Acute Pain

ASSESSMENT EXPLANATION OF OBJECTIV NURSING INTERVENTIONS RATIONALE EVALUATION
THE PROBLEM ES
Subjective: Unpleasant sensory STO: Dx: STO:
and emotional
“Sumasakit yung experience arising -After4 hrs  Noted client’s age and developmental level and current  To assess etiology / precipitating (Partially Met)
kakaopera sa tyan of Nursing condition affecting ability to report pain parameters. contributory factors. -After4 hrs of
from actual or
ko, nawala na yung Interventions  Determined and document presence of possible  As this can influence the amount of Nursing
potential tissue
bisa ng anistisya” the client pathophysiological and Psychological causes of pain. Interventions the
damage or described postoperative pain experienced.
will  Noted location of surgical procedures. client verbalized
Rated Pain as 8/10 in terms of such  To help determine possibility of underlying
verbalized  Assessed for referred pain, as appropriate. decreased of on
damage (international condition or organ dysfunction requiring
Objective: decreased of the site of pain,
association for the Tx: treatment.
on the site of rated pain as
study of pain); sudden  To rule out worsening of underlying
 Ongoing IV pain. 5/10.
or swallow onset of  Obtained client’s assessment of pain to include condition or development of complications.
Fluid d5lrs x 31-
any intensity from LTO: location, characteristics, onset and duration, frequency, LTO:
32 gtts/min; quality, intensity and precipitating or aggravating
mild to severe with an
hooked at right -After 2-3 factors. Reassess each time occurs/ is reported. Note  To evaluate client’s response to pain. (Partially Met)
anticipated or
metacarpal; predicted end and a days of and investigate changes from previous reports.  To promote non pharmacological pain -After 2-3 days
infusing well. duration of less than 6 Nursing  Used pain rating scale appropriate for age and management. of Nursing
Afebrile 36.3 C months. Intervention cognition.  To distract attention and reduce tension. Intervention the
Ambulatory the patient  Provide comfort measures such as repositioning and  To rule out worsening of underlying patient
SOURCE/S: will nurse’s presence, quiet environment and calm activities verbalized
(t) abdominal condition or development of complications.
verbalized to promote non pharmacological pain management. absence of pain.
pain NANDA 12 Edition  To evaluate client’s response to pain.
absence of  Instructed in and encouraged use of relaxation
Facial grimace page 586-590 techniques such as focused breathing, imaging,
(-) sign of pain.
CDs/tapes.
infection at the  Demonstrated and monitor use of self-
site of incision administration/client’s controlled analgesia (PCA) for
site management of severe, persistent pain.
On guarding
Edx:
behavior
 Encouraged verbalization of feelings about pain.
24
Nursing Diagnosis:  Identified ways of avoiding or minimizing pain.  To enhance understanding and reduce level
 Demonstrated and monitor use of self- of anxiety and fear.
Acute Pain related administration/client’s controlled analgesia (PCA) for  To assist client to explore methods for
to Surgical Incision management of severe, persistent pain. alleviation/control of pain.
 Discussed with SO(s) ways in which they can assist  To promote wellness (teaching/ discharge
client and reduce precipitating factors that may cause considerations).
or increase pain.  To promote wellness (teaching/ discharge
 Identified specific signs/symptoms and changes in pain considerations).
characteristics requiring medical follow-up.  To promote wellness (teaching/ discharge
considerations).

NCP 2: Impaired Skin Integrity

ASSESSMENT EXPLANATIO OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION
N OF THE
PROBLEM
Subjective: Altered STO: Dx: STO:
epidermis and or  After 20-30 minutes (Partially Met)
“Nananakit yung dermis of nursing  Identified underlying condition or pathology involved  To assess causative/ contributing  After 20-30 minutes of
kakaopera sa tyan ko” intervention, the such as skin and surgical incision. factors. nursing intervention, the
SOURCE/S: patient will be able to:  Noted general debilitation, reduced in mobility,  To assess causative/ contributing patient was able to:
Objective: changes in skin and muscle mass associated with aging
1.DemonstrateProp factors. 1.DemonstrateProper way
NANDA 12 er way of wound care or chronic disease, presence of incontinence, or of wound care and
 Bloody discharges Edition page and proper dressing problems with self-care. proper dressing
coming out of the 757-762  To assess causative/ contributing
2.Understand the  Determined nutritional status and potential for delayed 2.Understand the
incision area. importance healing or tissue injury exacerbated by malnutrition. factors. importance of caring the
Fresh blood coming of caring the  Reviewed laboratory results pertinent to causative  To assess causative/ contributing incision site
out. incision site factors. factors.
Bright red discharges.  Noted skin color, texture, and turgor. Assessed areas of LTO:
25
 LTO: least pigmentation for color changes.  To assess causative/ contributing (Partially Met)
-After 2-3 days of  Determined degree and depth of injury or damage to factors. -After 2-3 days of nursing
Nursing Diagnosis: nursing intervention, integrity. intervention, the patient will
 To assess causative/ contributing
the patient will be able Tx: be able to:
Impaired Skin to: factors. 1. Maintain the wound intact.
Integrity related to 1. Maintain the  Palpated skin lesions for size, shape, consistency, 2. Shows sign of wound
surgical incision wound intact. texture, temperature, and hydration. healing (dry and intact wound
2. Shows sign of  Inspected skin on daily basis, describing wound or  To assess causative/ contributing and initial scaring).
wound healing (dry lesion characteristics and changes observed. factors. 3. No redness on the
and intact wound and  Kept the area clean and dry, carefully dress wounds, surrounding area.
 To assess extent of
initial scaring). support incision, prevent infection, manage
3. No redness on the incontinence and stimulate circulation to surrounding involvement/injury.
surrounding area. areas.  To assess extent of
 Applied appropriate dressing. involvement/injury.
 To assess extent of
involvement/injury.
Edx:
 Reviewed importance of health, intact skin, as well as
measures to maintain proper skin functioning.
 For wound healing and to best
 Discussed importance of early detection of skin meet needs of client and
changes and or complications. caregiver or care setting.
 Reviewed measures to avoid spread of communicable  The integumentary system is the
disease or reinfection.
largest multifunctional organ of
the body.
 To promote wellness.

26
NCP 3: Sleep Deprivation
ASSESSMENT EXPLANATION OF OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION
THE PROBLEM
Subjective: Sleep deprivation is STO: Dx: STO:
prolonged periods of
“Hindi po ako time without sleep.  Within 30 minutes-1 hour  Noted environment factors affecting sleep  Provides comparative baseline. (Goal Met)
maktulog, pag (NANDA) of effective nursing like excessive light and roommate  Helps identify appropriate options.
kinukuha yung VS Within 30 minutes-1 hour
interventions, the patient actions.  To document symptoms and identify
nahihirapan na po It is a general term to of effective nursing
will be able to:  Observed for physical signs of fatigue. factors that is interfering with sleep. interventions, the patient
akong matulog describe a state caused  Verbalize understanding on  Determined presence of physical and verbalized understanding
ulit” by inadequate quantity
sleep disorder. psychological stressors on sleep disorder and
or quality of sleep,
Objective:  Identify individually Identified individually
including voluntary Tx:
sleeplessness and appropriate interventions to appropriate interventions
 Observed to promote sleep.
circadian rhythm sleep promote sleep.  Suggested abstaining from day time naps
restlessness
disorders.  Recommend quiet activities such as  It may impair the ability to sleep at LTO:
LTO: night.
Nursing reading
SOURCE/S: (Goal Met)
Diagnosis:  Within 24-48 hours of  To reduce stimulation so the client can
www.betterhealth.vic. effective nursing Edx: relax.
Sleep Within 24-48 hours of
gov.au/health/conditio interventions, the client effective nursing
Deprivation  Advised to limit late afternoon or evening
nsandtreatment/sleep- will: interventions, the client
related to intake of caffeine.
deprivation  Report improvement in  These factors are known to disrupt reported improvement in
irritability and  Encouraged relaxation techniques like
pain sleep and rest pattern. sleep patterns. sleep and rest pattern.
medication and music therapy.
 Adjust lifestyle to  Advised to take warm bath and to drink  To decrease tension, prepare for rest or
accommodate Chrono warm glass of milk an hour before sleep.
biological rhythms. bedtime.  To enhance client’s ability to fall
asleep.

27
NCP 4: Risk for Infection
ASSESSMENT EXPLANATIO OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION
N OF THE
PROBLEM
Subjective: At increased risk STO: Dx: STO:
for being invaded
Objective:   by pathogenic -After 3 hrs of  Noted risk factors occurrence of risk infection such as  To assess causative contributing factors. (Goal met)
T-36.3 °C Nursing skin/tissue wounds; communities or persons sharing close  To assess causative contributing factors.
organisms. -After 3 hrs of
Weak in Interventions the quarters.
 To assess causative contributing factors. Nursing
appearance. SOURCE/S: client will  Observed for localized signs of infection at insertion sites of
Clean and intact verbalized invasive lines, sutures, surgical incisions, wounds. Interventions the
abdominal NANDA 12 understanding of  Assessed and document skin conditions around insertions of client verbalized
dressing. Edition page pins, wires, and tongs, noting inflammation and drainage.  A first-line defense against health care- understanding of
the importance of
467-471 infection control Tx: associated infections (HAIs). the importance of
 To reduce risk potential infections. infection control
Nursing  Stressed proper hand hygiene by all caregivers between
LTO:
Diagnosis: therapies and clients.  To reduce/correct existing risk factors. LTO:
-After 2-3 days  Maintained sterile technique for all invasive procedures.  To reduce/correct existing risk factors.
Risk for Infection (Goal Met)
of Nursing  Change Surgical or other wound dressing, as indicated,
related to
Intervention the using proper technique for changing/disposing of -After 2-3 days of
surgical incision contaminated materials.
client will apply Nursing
 Assist with medical procedures.  To promote wellness (Teaching/discharge
what she learned Intervention the
and demonstrate. Edx: considerations).
client applied what
 Reviewed individual nutritional needs, appropriate exercise  To promote wellness (Teaching/discharge
she learned and
program, and need for rest. considerations).
demonstrated.
 Instructed client/SO(s) in techniques to protect the integrity
of skin, care for lesions, and prevention of spread of
infection.

NCP 5: Risk for Bleeding

28
 ASSESSMENT EXPLANA OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION
TION OF
THE
PROBLEM
Subjective: STO: Dx: STO:
At risk for a
Objective:   decrease in -After 2 hrs of  Assessed client risk noting possible  This may lead to bleeding as listed in risk factors. (Goal met)
T-36.3 °C blood nursing diagnoses or disease processes.  The pattern and extent of injury may/may not be readily
Weak in appearance. interventions,  Noted type of injury (ies) present when - After 2 hrs of nursing
volume that determined such as unbroken skin can hide a significant interventions, patient
Clean and intact patient will be client presents with trauma.
abdominal dressing. may injury with internal bleeding. awareness of signs and
aware of signs  Noted client’s gender.
Bloody discharges compromise  While bleeding or clotting disorders predispose client to symptoms for bleeding
and symptoms  Evaluate client’s medication regimen.
coming out of the health. bleeding complications, necessitating specialized testing by screening the risk
for bleeding by  Assess vital signs, including blood
incision area. pressure, pulse, and respirations. Measure and/or referral to hematologist. factors of bleeding.
SOURCE/S: screening the
Fresh blood coming blood pressure lying/sitting/standing as  Use of medications such as nonsteroidal anti-inflammatory
NANDA 12 risk factors of LTO:
out. invasive hemodynamic parameters when
Edition page bleeding. drugs (NSAIDs), anticoagulants, corticosteroids, and certain
Bright red discharges. present.
Nursing Diagnosis: 467-471 herbals (gingko biloba), predispose client to bleeding. (Partially Met)
LTO:  Noted client report of pain in specific
 To document expanding bruises or hematomas.
Risk for Bleeding areas, whether pain is increasing, diffuse, -After 2-3 days of
-After 2-3 days or localized.  Can help identify bleeding into tissues, organs, or body Nursing Intervention,
related to surgical cavities.
of Nursing  Assessed skin color and moisture, urinary the patient was able to
incision
Intervention, the output, level of consciousness or  Changes in these signs may be indicated of blood loss identify individual risks
patient will be mentation. affecting systematic circulation or local organ function such and engage in
able to identify as kidneys or brain. appropriate behaviors
individual risks or lifestyle changes to
and engage in prevent bleeding.
appropriate
behaviors or Tx:
 For occult blood.
lifestyle  Hematest all secretions and excretions.  As this may contribute to bleeding.
changes to  Review laboratory data.  To prevent bleeding/ correct potential causes of excessive
prevent  Apply direct pressure and cold pack to
bleeding. blood loss.
bleeding site, insert nasal packing, or
perform fundal massage as appropriate.
 Maintained patency of vascular access.  For fluid administration or blood replacement as indicated.
 Assist with treatment of underlying
29
 conditions causing or contributing to
blood loss such as medical treatment of  To prevent bleeding/ correct potential causes of excessive
systemic infections, use of proton blood loss.
antibiotics; surgery for internal abdominal
trauma, or retained placenta.

Edx:
 Restrict activity, encouraged bedrest or
chair rest until bleeding abates.
 Instruct at risk client and family
regarding:  To prevent bleeding/ correct potential causes of excessive
Specific signs of bleeding requiring
blood loss.
healthcare provider’s notification, such as
active bright bleeding anywhere, prolonged  To prevent bleeding/ correct potential causes of excessive
epistaxis or trauma in client with known blood loss.
factor bleeding tendencies, black tarry
stools, weakness, vertigo, and syncope.
 Needs to inform health care providers
when taking aspirin and other
anticoagulant-type agents, especially
when elective surgery to other invasive
procedure is planned.
 Dietary measures.
 These agents will most likely to be held for a period of
time prior to elective procedures to reduce potential for
excessive blood loss.

 To promote blood clotting, when indicated, such as foods

rich in vitamin K.

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 C. Discharged Plan
Health Teaching
Diet/Nutrition 1. Encourage patient to increase fluid intake per day to
maintain hydration and promote proper regulation of the
body process.
2. Advised to increase consumption of food rich in fiber and
potassium to balance hormones and to keep blood sugar
levels steady.
Activity 1. Demonstrated and encouraged patients to do range of
motion exercises with patient’s capabilities to promote
good circulation.
2. Advised to get plenty of rest to maintain progress.
Medication 1. Advised to take medications in a prescribed dose. Make
sure to continue drug intake in the prescribed length of
time.
2. Instructed and encouraged significant others to monitor
patient’s ability to take medications strictly following
right dose and route.
3. Emphasized importance of compliance to treatment
regimen.
4. Instructed on dose, frequency and time of administration
of medication.
Other Follow up care:
1. Instructed to come back to the same institution for follow
up checkup as ordered.
2. Instructed the patient to immediately return to hospital if
experiencing:
 Troubled breathing
 Blue lips or finger nails
 More than normal mucous production.

XVI. Learning Insights

A. ARORA, Sachi Sujit E.

I have learned about the disease which is adenomyosis Leiomyoma. I learned about its causes,
symptoms, the percentage of women it affects, and its possible treatments.
B. CAJIGAN, Ryan Jake A.
While doing some research about this case which is Adenomyosis Leiomyoma, I found out
that Adenomyosis is a rare disease and it is poorly understood condition that affects women
of all age groups. This case study challenges the skills of clinicians and nurses and it shows
how clinicians should care for patients who is most at risk of the said disease and it expands
their scope beyond basic nursing skills and knowledge to be able to go an extra mile the
much needed supportive care thus promoting the quality of care thru improving nurses and
clinicians skills and it is important to examine the implications of these effects on the
educational needs of women of all age groups who is at risk of this disease and for us to know
the behavioral risk factors, treatment, proper inteventions to be given and to know and
understand and especially to consider all the measures and processes that are involve.

C. CONRAD, Lydia R.
While doing the drugs study I learned that Antibiotics are medicines that can fight
certain infections and can save the life of our patient when used properly before bacteria can
multiply and cause symptoms, the immune system can typically kill them. White blood cells
(WBCs) attack harmful bacteria and, even if symptoms do occur, the immune system can
usually cope and fight off the infection. There are occasions, however, when the number of
harmful bacteria is excessive, and the immune system cannot fight them all.
D. DULNUAN, Marvin D.
Handling patient X is from the drug study I learned that Tramadol is a pain reliever
that Binds to mu-opioid receptors. Inhibit reuptake of serotonin and norepinephrine in the CNS. I also helped in
handling the patient during the last rotation, it teaches me that post-operative and all types of patients should be
handled with care.

E. MOHHAMED, Ayman Shams E.

31
F. NGAYOS, Shyrlyn Mae C.
I have learned the importance of assessing the patient. Assessment is the first part of
the nursing process, and thus forms the basis of the care plan. The essential requirement of
accurate assessment is to view patients holistically and thus identify their real needs.
G. PASKING, Regine D.
While doing this particular case I was able to learn the importance of thorough
assessment to be able to understand what the case was all about, it has also given me the
opportunity to get a close encounter with a patient who was diagnosed with Adenomyosis
Leiomyoma at the same time. Not only was I enlightened by the importance of doing
everything with proper knowledge but I was also privileged to take a part in this case.

H. RAHHAL, Majid M.
I learned that in diagnostic procedures we will be able to know the problem of our
patient and by the help of diagnostic procedure they will be able to know the right medication
and the right things that we will do to our patient to be able to achieve the right path way of
recovery. Furthermore, I learned that for some diseases, it is not only important to know what
the nature of the disease is but also the degree of development.

I. SALTAT, Katryn Hazel L.

I have learned that Adenomyosis is a condition in which the inner lining of the uterus
breaks down through the muscle wall of the uterus. It can also cause menstrual cramps, lower
abdominal pressure, and bloating before menstrual periods and can result in heavy periods.

32
XVII. List of References
American College of Obstetricians and Gynecologists, American Medical Association (1994-2018)

Walker and Stewart (2005).

Shaikh and Khan, (1990) ; Vercellini et al., (1995); Parazzini et al., (1997); Vavilis et al.,
(1997); Bergholt et al., (2001); Weiss et al., (2009).

Parazzini et al., (1997, 2009); Taran et al., (2009).

David’s Drug Guide for Nurses 14th Edition www.DrugGuide.com

www.scribd.com

Dongese M.E., Moorhouse M.F., Murr A.c. NANDA (12 Ed. p 586-590)

Dongese M.E., Moorhouse M.F., Murr A.c NANDA (12 Ed. p 757-762)

Dongese M.E., Moorhouse M.F., Murr A.c NANDA (12 Ed. p 467-471)

www.betterhealth.vic.gov.au/health/conditionsandtreatment/sleep-deprivation

http://teachmeobgyn.com/gynaecology/uterine/adenomyosis/

https://www.scribd.com/doc/47323291/Ncp-Impaired-Skin-Integrity

https://www.scribd.com/doc/47805374/ACUTE-PAIN-Related-to-Post-Surgical-Incision-as-
Evidenced-by-Pain-Scale-of-10-10as-the-Highest-Facial-Grimace-and-Muscle-Guarding

https://www.scribd.com/doc/49692851/NCP-Sleep-Deprivation

https://www.scribd.com/doc/30761383/Ncp-Risk-for-Infection-Related-to-Postop-Incision

https://www.scribd.com/doc/114192544/NCP-Risk-for-Bleeding

https://healthyliving.azcentral.com/priority-nursing-diagnosis-12214289.html

Appendix A
Approval/Request Letter

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 Appendix B
Interview Guides

The patient interview is the primary way of obtaining comprehensive information about the patient in
order to provide patient-centered care.

Here are the skills and questioning techniques we used:

 Active listening
 Empathy
 Building rapport
 Open-ended questions
 Closed-ended questions
 Leading questions
 Silence
 Nonverbal communication cues

In obtaining the History and past Medical history we have asked the Patient first and the significant
other before looking over the patient chart.

We thoroughly interviewed the patient and the significant other to obtain Patient profile, Social and
Environmental History and Lifestyle and Practices. Here are the questions we have asked to the
patient.

a. Validating the information in the chart by asking the patient to say her first and last name and
spontaneously asking her profile
b. Asking the significant other for other additional information
c. Used Ilocano as the dialect in asking appropriate questions.

34