You are on page 1of 10

ESTROGEN

It is the most important hormone during puberty in female and is responsible


for secondary sexual characteristics (e.g. breast enlargement, menstruation, pelvic
enlargement, long bones). Generally secreted by the ovary specifically secreted by
the Grafian follicle.
Estrogen production
Hypothalamus

GnRH

Anterior Pituitary Gland

FSH

Graafian Follicle

Estrogen

VI. COURSE IN THE WARD


Day 1
A 48 years old female was admitted at exactly 2:16:07 p.m last August 22, 2008,
accompanied by her son, with a chief complaint of body weakness. She was
admitted under the service of Dra. Lovely Cacho and Dra. Alice Lojo and following
orders were given. Diet as tolerated, temperature, pulse rate and respiratory rate
must be recorded every shift, for chest x-ray posterior-anterior, for
electrocardiogram x 12 leads, for complete blood count blood typing and for chem.
7. It was done at the same day. The physician ordered a 5% Dextrose in Lactated
Ringers 1 liter plus 1 ampule of EC to be regulated at 20 gtts/min. The physician
ordered four units of whole blood that are properly typed and cross matched to be
run for 4-6 hours. The physician also ordered Lady L that may have full diet at 4:40
p.m. The first unit of whole blood with a serial number B-08-4660 started at 10:00
p.m.. Diphenhydramine 1 ampule intravenous 30 min. prior to blood transfusion.

Day 2
The above unit of blood finished at August 23, 2008, 2:20 a.m. There is no reaction
during and after the blood transfusion. At the same time, the second unit of whole
blood with a serial number B-08-4681 was hooked and consumed at 7:20 a.m. The
third unit of blood with a serial number B-08-4666 was started at same time. The
blood transfusion site was transferred from left to right at 11:20 a.m. At 12:30 p.m.,
the third unit of whole blood with a serial number B-08-4668 was consumed and
followed up of fourth unit of whole blood and consumed at 4:30 p.m. Intravenous
fluid number one consumed and followed the number two 5% Dextrose in Lactated
Ringers 1 liter plus one ampule of EC regulated at the same rate. By 11:10 p.m.
Lady L is under nothing per orem. Lady L informed about Total Hysterectomy
Bilateral Salphingo Oophorectomy with signed consent of her husband and her son
at the same day. Anesthesiologist on deck was informed. Cefuroxime 750 mg,
intravenous started every 8 hours after negative skin testing. At 11:40 p.m. Valium
tablet 5 mg one tablet was given as pre-operative drugs.
Day 3
August 24, 2008, at exactly 7:00 a.m. Lady L was brought to the operating room.
At 4:50 p.m. post-op orders were given. Monitor vital signs every 15 minutes until
fully stable. Nothing per orem temporarily. The patient was instructed to lie flat on
bed and low back rest for pneumonia precaution. Oxygen inhalation administered at
3 liters per minute. Suction secretion when necessary. Intake and output were
recorded hourly. 5% Dextrose Lactated Ringers 1 liter post-op to run at 15gtts/min
then to follow 5% Dextrose Lactated Ringers 1 liter at same rate. Last dose of
Cefuroxime to consumed, Metronidazole 500 mg slow intravenous push every 6
hours. Tramadol 500 mg after negative skin testing every 6 hour. Intravenous fluid
regulated at 30 gtts/min when blood transfusion finished. Repeat hemoglobin and
hematocrit.
At 5:20 p.m. the operation ended and at 6:40 p.m. patient was bought to the
intensive care unit and hooked to ventilator and Furosemide 40 mg IV was given. At
around 8:45 p.m Omeprazole 40 mg IV was given. Serum, sodium, potassium,
chloride, prothrombin time, partial prothrombin time done and result in Lady L was
nebulized if Combivent 1 neb and maintained every 8 hours potassium 30
millequivalent incorporate to her intravenous fluid and decrease it to 8 hours.
Another one unit of packed red blood cell, Calcium gluconate one ampule was given
thru slow intravenous push.
Day 4
August 25, 2008, 5a.m. patient was brought to room 206 and then nebulization
started and extubated at the time and secretion suctioned. Oxygen maintained at 4
liters per minutes via nasal canula. Diphenhydramine one ampule was given at 3:30
p.m, 30 minutes prior to blood transfusion. Blood type B with a serial # of BO8445 run at 4-6 hours. At 6:05 p.m Lady L was confirmed that she has a positive
flatulence. Measuring drained output was recorded shiftly.

Day 5
1 a.m. of August 26, 2008, to follow intravenous fluid 5% Dextrose Lactated Ringers
1 liter regulated at same rate and encouraged patient to turn side to side. Serum,
creatinine, and complete blood count done. At 9:37 a.m. the physician advised to
continue medications. At 10:00a.m. patients temperature is 38.2C and
paracetamol 200 mg one ampule was given thru intravenous. At 11:03 a.m.
nebulization was stopped. The physician suggests changing Cefuroxime to Tazocin
4.5 grams intravenous every 8 hours. Above intravenous fluid consumed and
followed up of 5% Dextrose in Lactated Ringers 1 liter regulated at same rate. At
3:15 p.m. incentive spirometer every 8 hours and two minutes oxygen inhalation
was discontinued. Patient was encouraged to ambulate. At 8:30 p.m. intravenous to
follow of 5% Dextrose Lactated Ringers 1 liter regulated at same rate. Foley
catheter was removed at 9:15 p.m. At 10:45 p.m Lady L gargled one tablespoon of
Orahex solution plus 30 cc water every 6 hours.
Day 6
Nursing care done. Vital signs are monitored and recorded. Intravenous fluid
regulated at 15 gtts/min Lady L has no further complaint. The patient is
ambulatory. Tazocin 4.5 grams intravenous every 8 hours was given. Attending
Physician did not visits the patient and no new orders were made that day.
Day 7
August 28, 2008, patient may have clear liquid then soft diet at 4 p.m., above
intravenous fluid consumed and followed up of 5% Dextrose Lactated Ringers 1 liter
regulated at the same rate. For possible discharge on the next day.
Day 8
August 29, 2008, removal of jackson-pratt drain was done and intravenous fluid was
terminated. There is no o objection for discharge. Home medications instructed and
patient may go home and start oral medication. At 8 p.m. patient was discharged
accompanied by her son via the wheelchair.

VII. LABORATORY
AUGUST 22, 2008
ULTRASOUND
Transvaginal Ultrasound

Transabdominal pelureus shows an enlarged uterus measure about 12.6x7.5x9.1 cm


(LxWxAP). There is a large hypo echoic mass in the posterior lower segment of the
uterus, measuring approximately 10.0x10.0x9.0 cm.
There is a cystic structure with internal echoes and septations in the night adnexae,
measuring about 60x4.5x4.3 cm.
There is no fluid in the posterior culde-sac.
Impression:
Enlarged uterus with large sub serous myoma wit intramural component,
posterior lower segment consider ovarian cyst at the right. Normal left ovary.
AUGUST 23, 2008
HEMATOLOGY
AUGUST 24, 2008
HEMATOLOGY

AUGUST 25, 2008


HEMATOLOGY

AUGUST 26, 2008


HEMATOLOGY
VIII.

MEDICAL MANAGEMENT

Treatment depends on various factors, including:

Age

General health

Severity of symptoms

Size of fibroids

Whether you are pregnant

If you want children in the future

Some women may just need pelvic exams or ultrasounds every once in a
while to monitor the fibroid's growth.

Treatment for fibroids may include:

Birth control pills (oral contraceptives) to help control heavy periods

Iron supplements to prevent anemia due to heavy periods

Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naprosyn


for cramps or pain with menstruation

Some women may need hormonal therapy (Depo Leuprolide injections) to


shrink the fibroids.

SURGICAL MANAGEMENT:
Hysterectomy
Hysterectomy
A hysterectomy is a surgical procedure whereby the uterus (womb) is
removed. Hysterectomy is the most common non-obstetrical procedure of women in
the United States.
Why is a hysterectomy performed?
The most common reason hysterectomy is performed is for uterine fibroids
The next most common reasons are abnormal uterine bleeding, endometriosis, and
uterine prolapse (including pelvic relaxation). Only 10% of hysterectomy is
performed for cancer of the uterus or very severe pre-cancers (called dysplasia).
Uterine fibroids (also known as uterine leiomyomata) are by far the most common
reason a hysterectomy is performed. Uterine fibroids are benign growths of the
uterus, the cause of which is unknown. Although they are benign, meaning they do
not cause or turn into cancer, uterine fibroids can cause medical problems, such as
excessive bleeding, for which hysterectomy is sometimes recommended.
What tests or treatments are performed prior to a hysterectomy?
Prior to having a hysterectomy for pelvic pain, women usually undergo more
limited (less extensive) exploratory surgery procedures (such as laparoscopy) to
rule out other causes of pain. Prior to having a hysterectomy for abnormal uterine
bleeding, women require some type of sampling of the lining of the uterus (biopsy
of the endometrium) to rule out cancer or pre-cancer of the uterus. This procedure
is called endometrial sampling. In a woman with pelvic pain or bleeding, a trial of
medication treatment is often given before a hysterectomy is considered.
How is a hysterectomy performed?
Most commonly, a hysterectomy is done by an incision (cut) through the

abdomen (abdominal hysterectomy) or through the vagina (vaginal hysterectomy).


The hospital stay generally tends to be longer with an abdominal hysterectomy than
with a vaginal hysterectomy (4 vs. 6 days on average) and hospital charges tend to
be higher. The procedures seem to take comparable lengths of time (about 2 hours),
unless the uterus is of a very large size, in which case a vaginal hysterectomy may
take longer.
What are complications of a hysterectomy?
Complications of a hysterectomy include infection, pain, and bleeding in the
surgical area. An abdominal hysterectomy has a higher rate of post-operative
infection and pain than does a vaginal hysterectomy.
Aftercare
After surgery, a woman will feel some degree of discomfort; this is generally
greatest in abdominal hysterectomies because of the incision. Hospital stays vary
from about two days (laparoscopic-assisted vaginal hysterectomy) to five or six
days (abdominal hysterectomy with bilateral salpingo-oophorectomy). During the
hospital stay, the doctor will probably order more blood tests.

Risks
Hysterectomy is a relatively safe operation, although like all major surgery it
carries risks. These include unanticipated reaction to anesthesia, internal bleeding,
blood clots, damage to other organs such as the bladder, and post-surgery
infection.
Other complications sometimes reported after a hysterectomy include changes in
sex drive, weight gain, constipation, and pelvic pain. Hot flashes and other
symptoms of menopause can occur if the ovaries are removed. Women who have
both ovaries removed and who do not take estrogen replacement therapy run an
increased risk for heart disease and osteoporosis (a condition that causes bones to
be brittle). Women with a history of psychological and emotional problems before
the hysterectomy are likely to experience psychological difficulties after the
operation.
Alternatives
Women for whom a hysterectomy is recommended should discuss possible
alternatives with their doctor and consider getting a second opinion , since this is
major surgery with life-changing implications. Whether an alternative is appropriate
for any individual woman is a decision she and her doctor should make together.
Some alternative procedures to hysterectomy include:

Embolization. During uterine artery embolization, interventional radiologists


put a catheter into the artery that leads to the uterus and inject polyvinyl
alcohol particles right where the artery leads to the blood vessels that
nourish the fibroids. By killing off those blood vessels, the fibroids have no
more blood supply, and they die off. Severe cramping and pain after the
procedure is common, but serious complications are less than 5% and the
procedure may protect fertility.
Myomectomy . A myomectomy is a surgery used to remove fibroids, thus
avoiding a hysterectomy. Hysteroscopic myomectomy, in which a surgical
hysteroscope (telescope) is inserted into the uterus through the vagina, can
be done on an outpatient basis. If there are large fibroids, however, an
abdominal incision is required. Patients typically are hospitalized for two to
three days after the procedure and require up to six weeks recovery.
Laparoscopic myomectomies are also being done more often. They only
require three small incisions in the abdomen, and have much shorter
hospitalization and recovery times. Once the fibroids have been removed, the
surgeon must repair the wall of the uterus to eliminate future bleeding or
infection.

Endometrial ablation. In this surgical procedure, recommended for women


with small fibroids, the entire lining of the uterus is removed. After
undergoing endometrial ablation, patients are no longer fertile. The uterine
cavity is filled with fluid and a hysteroscope is inserted to provide a clear view
of the uterus. Then, the lining of the uterus is destroyed using a laser beam
or electric voltage. The procedure is typically done under anesthesia,
although women can go home the same day as the surgery. Another newer
procedure involves using a balloon, which is filled with superheated liquid and
inflated until it fills the uterus. The liquid kills the lining, and after eight
minutes the balloon is removed.
Endometrial resection. The uterine lining is destroyed during this procedure
using an electrosurgical wire loop (similar to endometrial ablation).

THE PATIENT HAD UNDERGONE:


Total abdominal hysterectomy
This is the most common type of hysterectomy. During a total abdominal
hysterectomy, the doctor removes the uterus, including the cervix. The scar may be
horizontal or vertical, depending on the reason the procedure is performed, and the
size of the area being treated. Cancer of the ovary(s) and uterus, endometriosis,
and large uterine fibroids are treated with total abdominal hysterectomy. Clearly a
woman cannot bear children herself after this procedure, so it is not performed on
women of childbearing age unless there is a serious condition, such as cancer. Total

abdominal hysterectomy allows the whole abdomen and pelvis to be examined,


which is an advantage in women with cancer or investigating growths of unclear
cause.
Abdominal hysterectomies take from one to three hours. The hospital stay is
three to five days, and it takes four to eight weeks to return to normal activities.
Salpingo-Oophorectomy (Removal of the Ovaries and/or Fallopian Tubes)
Salpingo-oophorectomy is the removal of the ovary and its adjacent fallopian
tube. This procedure is performed for cancer of the ovary, removal of suspicious
ovarian tumors, or Fallopian tube cancer (which is very rare). It may also be
performed due to complications of infection, or in combination with hysterectomy
for cancer.
Application of Jackson-Pratt Drain
A Jackson-Pratt drain, JP drain, or Bulb drain, is a suction drainage device
used to pull excess fluid from the body by constant suction. The device consists of a
flexible plastic bulb -- shaped something like a hand grenade -- that connects to an
internal plastic drainage tube.

IX. DRUG STUDY

X. NURSUNG CARE PLAN


XI.

DISCHARGE PLANNING

Medication
Ciprofloxacin 500 mg 1tablet 3x a day for 1 week
Metronidazole 500 mg 1 tablet 3x a day for 1 week
Tramadol (Dolcet) 1 tablet 3x a day for pain
Environment
Instruct patients relative to provide the patient an environment
conducive for her easy recovery. Her place/room in their house must be the
most accessible area. Her environment should be free from contamination
and infection.
Treatment
The patient should follow the physicians prescription and should take his
home medication on the right time and right dose.

Health Teaching
Instruct the patient the importance of proper taking of medication on time.
Instruct the patient and her family the proper wound care to avoid contamination
and infection at surgical site.
Instruct the patient to eat nutritious foods.
Encourage ambulation for early recovery.
Good sanitation is advised.
Out Patient Department
The patient should return on the scheduled date of her follow up check-up on
September 5, 2008 in Metro Lipa Medical Center from 4:30 pm to 6:30 pm and
should continuously take her home medication as prescribed by her physician. The
patient should visit her physician whenever she feels any discomfort.
Diet
Diet as Tolerated. In order to attain proper diet, the patient should be guided
to the prescribed foods as advised by her physician. Her meals should include
Vitamin C-rich foods for wound healing.
Spiritual
Patient should enhance her spiritual relationship with God. Have faith and
trust in Gods divine power, and believed that the lord will help in her early recovery.
Keep on praying, because praying is the number one key to live a healthy life and to
be close to God.

XII. PROGNOSIS
The mortality rate in uterine myoma is low provided early diagnosis and
management are made and no complication will occur. According to the attending
physician the case of Lady L greatly improved after the management, therefore, the
prognosis is good.
XII. EVALUATION

You might also like