Table of Contents

I. Introduction

II. Patient Profile

III. Patient History/ Nursing History

IV. Gordons Level of Health Functioning

V. Physical Assessment

VI. Anatomy and Physiology

VII. Laboratory Result

VIII. Course in the Ward

IX. NCP

X. Discharge Planning

XI. Drug Study

I. Introduction

When a benign tumor grows in the muscles of the uterus, it is

known as uterine Myoma. These tumors can grow very large,
sometimes growing as large as a melon. The typical Myoma, however,
is around the size of an egg. When the Myoma penetrates the entire
wall of the uterus, it is referred to as uterus myomatosus. In certain
very rare cases the tumors can become malignant. When this happens,
it is known as sarcoma. When the Myoma pushes on the intestines or
the bladder, it can result in constipation, pain of the bladder, or a
constant need to urinate. If the tumor pushes on the nerves in the
spinal cord, it can result in pain of the back or the legs.

The causes of uterine Myoma are not fully understood. Some

research suggests that Uterine Myoma is less common in women who
have had at least two children. For at least one form of uterine Myoma,
there seems to be a genetic predisposition.

Uterine Myoma often goes undetected. Ultrasounds, CT Scans, or

MRIs may be necessary to fully diagnose uterine Myoma. If you have
symptoms of Uterine Myoma, your health care provider will help you
determine the best way to diagnose the problem.

Once it is diagnosed, Uterine Myoma can be treated through

hormonal and/or herbal treatments. Hormonal treatment typically does
not cure the Uterine Myoma. Rather, they give a temporary relief of
the symptoms of Uterine Myoma. In addition, these hormones may
have certain side effects. If these hormone treatments do not work,
surgery is typically an option. Surgical options include the surgical
removal of the Myoma tumors (known as an enucleation) or a complete
hysterectomy. Recent advances in laser surgery may make this an
option also. If this is the case, the surgery can become much less
invasive, and can be done laparoscopically.

Predisposing factors:

Age (15-35)

Gender: female

Race
 Lifestyle

Early menarche

Nulliparity

Use of oral contraceptives

High fat diet

Obesity

Family history

Anxiety

Precipitating factors:

Hormone replacement therapy (premarin)

Anovulation

Luteal insufficiency

Uterine fibroids are the most common benign tumors found in

women. They are clinically obvious in 20-25% of women of
reproductive age. Myomas have been associated with being of black
race, an increased body mass index (BMI) and non-smoker

Hormone replacement therapy (HRT) or in Britain, Hormone

therapy (HT) is a system of medical treatment for surgically
menopausal, perimenopausal and to a lesser extent postmenopausal
women. It is based on the idea that the treatment may prevent
discomfort caused by diminished circulating estrogen and
progesterone hormones. It involves the use of one or more of a group
of medications designed to artificially boost hormone levels. The main
types of hormones involved are estrogens, progesterone or progestins,
and sometimes testosterone. It often referred to as "treatment" rather
than therapy,
 HRT is available in various forms. It generally provides low
dosages of one or more estrogens, and often also provides either
progesterone or a chemical analogue, called a progestin. Testosterone
may also be included. In women who have had a hysterectomy, an
estrogen compound is usually given without any progesterone, a
therapy referred to as "unopposed estrogen therapy". HRT may be
delivered to the body via patches, tablets, creams, troches, IUDs,
vaginal rings, gels or, more rarely, by injection. Dosage is often varied
cyclically, with estrogens taken daily and progesterone or progestins
taken for about two weeks every month or two; a method called
"sequentially combined HRT" or scHRT. An alternate method, a
constant dosage with both types of hormones taken daily, is called
"continuous combined HRT" or ccHRT, and is a more recent innovation.
Sometimes an androgen, generally testosterone, is added to treat
reduced sexual desire/(libido). It may also treat reduced energy and
help reduce osteoporosis after menopause.

HRT is often given as a short-term relief (often one or two years,

usually less than five) from menopausal symptoms (hot flashes,
irregular menstruation, fat redistribution etc.). Younger women with
premature ovarian failure or surgical menopause may use hormone
replacement therapy for many years, until the age that natural
menopause would be expected to occur.

Attitudes towards HRT changed in 2002 following the

announcement by the Women's Health Initiative of the National
Institutes of Health that those receiving the treatment (Prempro) in the
main part of their study had a larger incidence of breast cancer, heart
attacks and strokes. The WHI findings were reconfirmed in a larger
national study done in the UK, known as the the Million Women Study.
As a result of these findings, the number of women taking hormone
treatment dropped by almost half. The Journal of the American Medical
Association and elsewhere based on these findings warn that women
with normal rather than surgical menopause should take prescribed
HRT treatment at the lowest feasible dose, for the shortest possible
time. For health problems associated with menopause such as
osteoporosis (a small percentage of postmenopausal women are at risk
of severe bone loss), other life-style changes and/or medications are
now recommended.

An anovulatory cycle is a cycle during which the ovaries fail to

release an oocyte. Therefore, ovulation does not take place. However,
a woman who does not ovulate at each menstrual cycle is not
necessarily going through menopause. Chronic anovulation is a
common cause of infertility.
 In addition to the alteration of menstrual periods and infertility,
chronic anovulation can cause or exacerbate other long term
problems, such as hyperandrogenism or osteopenia. It plays a central
role in the multiple imbalances and dysfunctions of polycystic ovary
syndrome.

During the first two years after menarche 50% of the menstrual
cycles could be anovulatories.

It is in fact possible to restore ovulation using appropriate

medication, and ovulation is successfully restored in approximately
90% of cases. The first step is the diagnosis of anovulation. The
identification of anovulation is not easy; contrary to what is commonly
believed, women undergoing anovulation still have (more or less)
regular periods. In general, patients only notice that there is a problem
once they have started trying to conceive.

Temperature charting is a useful way of providing early clues

about anovulation, and can help gynaecologists in their diagnosis.

Luteal insufficiency Luteal insufficiency leads to inadequate

ovarian progesterone production, which in turn results in an
incomplete secretory endometrium and ineffective ovum implantation.
Dydrogesterone almost doubles pregnancy rates compared to placebo.
II. Patient Profile

a. Ward: Medical Center Manila, 6th floor Main Building, Room 605 Bed 5

b. Date of Admission: August 31 2009

c. Patient Name: Asis, Rowena Jacavan

d. Address: 147-C Anak Bayan, Paco Manila

e. Age: 44

f. Gender: Female

g. Birthday: November 2, 1964

h. Educational Status: College Under Graduate

i. Religion: Roman Catholic

j. Nationality: Filipino

k. Civil Status: Married

l. Occupation: Vendor

m. Health Care Financing: Phil. Health

n. Informant: Roselinda Mojica

o. Reliability: In-law

p. Admission Data:

i. Chief Complaint: “Sumasakit ang aking likod at may matigas sa

akin tiyan at habang tumatagal lalong lumalaki ito” as
verbalized by the client.

ii. Initial Diagnosis: Lower back pain and abnormal mass in the
abdomen

iii. Final Diagnosis: Myoma Uteri, Intramural with subsenous

component Q4P4

III. Patient History/ Nursing History

a. History of Present Illness

 “Noong December last year, napansin kong may parang tumutubong
bukol sa tiyan ko.”, as verbalized by the client. It was observed movable,firm
and non-tender. ”Kumunsulta lang ako ng doktor nung nagsimula ng sumakit
talaga nung July 2009, pero nung August lang ako nagpacheck-up” as
verbalized by the patient. In addition, the patient complained of early satiety
and bloatedness. According to the patient, during her first consultation, she
had undergone an ultrasound procedure and was diagnosed with an enlarged
uterus with myoma. She was advised for a surgery but she refused. Then last
August 26, 2009, the patient sought consultation at MCM OPD for second
opinion. She undergone ultrasound again which diagnosed a huge myoma 32
x 37 cm. Then she was advised for a surgery hence she had her admission 5
days later, August 31, 2009.

b. Past Medical History

The patient has already bore four children with an OB Score of G4P4
(4004). Her first child was born full termed in the year 1993 through
Caesarean section procedure. The child’s weight was 2,800 g (6.39 lbs).In the
year 1995, the patient bore their second child full termed through Caesarean
Section procedure. The weight of the child was 2,700 g (6.4 lbs). Her third
child was born full termed in the year 1997 through Caesarean section
procedure with a child weight of 3,000 g (). In the year 1998, she bore their
fourth child, full termed through Caesarean Section procedure. The child’s
weight was 2,500 g (5.5 lbs).

c. Family Health History

According to the patient, her maternal side has a history of

hypertension while her paternal side has a history of pulmonary tuberculosis
and other lung diseases.

d. Personal and Social History

“Ang hanapbuhay ko talaga ay pagtitinda.”, as verbalized by the client.

During our interview, the patient denied that she’s a smoker but when we
look at patient’s chart, it revealed that the patient is a smoker for about five
years and consumes five sticks a day. According to the patient she is a non-
alcoholic beverage drinker.

”Una akong nagkaroon ng regla nung thirteen ako, regular naman

siya, mga 28-30 days bago ‘yung susunod.”, as verbalized by the patient.
According to her,, her menstruation lasts for three days and consumes 5-6
pads a day. “Hindi naman ako heavy flow talaga pag nireregla, yung tama
lang ‘di masayadong malakas, hindi naman masyadong mahina. Hindi din
sumasakit ‘yung puson ko.”, as verbalized by the patient. The patient had her
last menstruation last July 2009.
 According to the patient, she had her first sexual intercourse when at
the age of 29, which was with her husband, Reynaldo Asis. They’ve been
married for 16 years. She didn’t experience any postcoital bleeding and
dyspareunia. “Never ako gumamit ng pills or kahit anong iniinom na
contraceptives”, as verbalized by the patient. According to the patient she
had her last PAPSMEAR last August 21, 2009.

IV. Gordons Level of Health Functioning

Level Of Before During Analysis/Interference

Functioning Hospitalizati Hospitalizatio
on n
HEALTH Patient did Patient feels
PERCEPTION/HE not consult secured
ALTH a health because she
MANAGEMENT care is
PATTERN provider surrounded
upon by health
noticing a care
gradually providers
enlarging that will give
mass on her her needed
abdomen attention.
because she
perceives
that she is
healthy, due
to lack of Patient is
alarming unable to go
symptoms to work and
such as now realizes
pain, the
fatigue, importance
bleeding of health.
and even
weight loss.
She thinks
The patient that it is best
is taking her if she
health for consults
granted professional
despite health care
having providers
abdominal and not rely
mass. She on other
 still goes to people’s
work mere
regularly. experience.

Being a
mother of 4,
she is
practical
that when
she feels
something,
she asks for
other
people’s
opinion
before
consulting
medical
providers.
NUTRITIONAL Consumes She was Nutrition is a basic human need
AND METABOLIC 1500ml of ordered by that changes throughout the life
PATTERN water a day. the physician cycle and along the wellness-
to SOFT illness continuum.(Fundamentals
Consumes DIET. of Nursing 5
3-4 bottles th
of soda edition by Taylor, page 1135)
(12oz) daily. An adequate food intake consists
of balance essentials nutrients:
water, carbohydrates, fats,
3-Day Diet proteins, vitamins and minerals.
Recall Habits about eating are affected
by many factors like financial and
Sept. 1 health conditions. (Kozier et.al,
Fundamentals of Nursing 7
AM th
ed. Page 1171,1175)
1 cup of
coffee

NN

Fried
Chicken

1 cup rice

1 glass of
water
PM

Liempo

1 cup rice

1 glass
sprite

1 glass of
water

Sept. 2

AM

Gelatin

Crackers

Hardboiled
Egg

1 glass of
water

NN

Gelatin

Crackers

Hardboiled
Egg

1 cup tea

PM

La paz
batchoy

3 tbsp rice

1 glass of
water
 Sept. 3

AM

½ cup rice

1 sausage

1 glass of
water

240ml
pineapple
juice

NN

½ cup rice

Pork chop

Gelatin

1 burger

1 glass of
water

PM

Macaroni
Salad

1 glass of
water

ELIMINATION Difficulty in Folycatheteri Elimination can be affected by

PATTERN defecation. zation was a person’s developmental stage,
Fecal performed. daily patterns, the amount and
consistency/ quality of fluid or food intake, the
color: Defecates level of activity, lifestyle,
Hard/Brown once a day. emotional states, pathologic
processes, medication, and
Output: 1L – procedures such as diagnostic test
Urinates 1.5L and surgery. Most people have
200cc per individual pattern of elimination
void. 6 No excess including frequency, timing
times daily. perspiration. considerations, position and place.
For most people defecation is a
 (+) private affair experienced easily
perspiration only in the comfort of one’s own
during dry bathroom. Defecation may be
season difficult in shared hospital room
with only a curtain for privacy.
(Fundamentals of Nursing 5
th
edition by Taylor, page 1341)
The frequency of defecation is
highly individualized, varying from
several times per day to two to
three times per week. Sufficient
bulk in the diet is necessary to
provide fecal volume. Bland diets
and low-fiber diets are lacking in
the bulk and therefore create
insufficient residue of waste
products to stimulate the reflex for
defecation. Low-residue foods such
as rice, eggs and lean meats move
more slowly through the intestinal
tract. (Kozier et.al, Fundamentals
of Nursing 7
th
ed. Page 1228). Activity
stimulates peristalsis, thus
facilitating the movement of chime
along the colon. (Fundamentals of
Nursing 5
th
edition by Taylor, page 1229).
A person’s urinary habits depend
on social culture, personal habits
and physical abilities. Urine
collects in the bladder contains
between 250 to 450 ml of urine.
(Kozier et.al, Fundamentals of
Nursing 7
th
ed. Page 1256).
ACTIVITY Patient has Due to The human body was designed
EXERCISE 5+ muscle surgery, for motion, and regular exercise is
PATTERN strength in patient feels necessary for its healthy
performing weak. functioning. Individuals who
desired choose inactive lifestyles or who
activities. Movement are forced into inactivity by illness
restrictions or injury placed themselves at high
Considers due to spinal risk for serious health problems.
walking and anesthesia (Fundamentals of Nursing 5
dancing as prior to th
 her form of surgery and edition by Taylor, page 1116)
exercise. abdominal Vigorous physical activity is not
binder. always needed to achieve positive
result.(Fundamentals of Nursing 5
Physical th
Physical ADL’s edition by Taylor, page 1117)
ADL’s Bathing – 2 Lack of exercise, inactivity, or
Bathing – 0 Feeding – 0 immobility related to illness, or
Feeding – 0 Dressing – 2 injury place a person at high risk
Dressing – 0 Toiletries – 2 for serious health problems.
Toiletries – 0 Transfer – 2 Immobility can affect the major
Transfer – 0 Managing body systems. Like the benefits, a
Managing Money – 0 person receives from exercise,
Money – 0 complications resulting from
Instrumental immobility differ occurrence and
Instrumental ADL’s severity based on the patients age
ADL’s Using and overall health status. (Kozier
Using telephone – et.al, Fundamentals of Nursing 7
telephone – 0 th
0 Shopping – 2 ed. Page 1118).
Shopping – Preparing
0 Food – 4
Preparing Laundries – 4
Food – 0 Transportatio
Laundries – n–2
0 Taking Meds
Transportati –2
on – 0 Housekeepin
Taking Meds g–4
–0
Housekeepi
ng – 0
SLEEP-REST Sleeps Increase For no known reason, 8 hours of
PATTERN approximate hours of sleep a night has been the
ly 2-3 hours sleep accepted standard for adults
a day (5-6 hours) despite obvious variations seen in
without the general population. It is
naps Has sleep important however that a person
interruptions follows a pattern of rest that
Has trouble due to maintains well-being. Many factors
in falling surgery affect a person’s ability to rest.
asleep due Illnesses and various life situations
to enlarged that causes physiological stress
abdomen tends to disturb sleep. Sleep
and Sleep is her quality is also influenced by
occasional only form of certain drugs Some decreases REM
pain in the relaxation sleep (barbiturates ,amphetamines
abdomen. and antidepressants) and some
(5 days prior are seen tocause sleep problems
to (steroids, caffeine and asthma
 consultation medications) (Kozier et.al,
) Fundamentals of Nursing 7
th
Watching ed. Page 1169-117).
television,
listening to
music,
bonding
with her
children is
form of
relaxation.
ROLE- The patient Her children Relationship to another person
RELATIONSHIP lives with are the ones is a developed manner in which
PATTERN her 4 who took there is the sharing of self,
daughters. care of her showing care and putting trust. A
She is the during her healthy relationship affects an
only one hospital stay. individual’s emotional
taking care development, it will facilitate the
of them channeling of the ideas, feeling of
because his joy an others. An
husband is interpersonal relationship
an OFW in is a relatively long-term
Dubai. association between two or more
people. This association may be
based on emotions like love and
liking, regular business
interactions, or some other type of
social commitment. Interpersonal
relationships take place in a great
variety of contexts, such as family,
friends, marriage, acquaintances,
work, clubs, neighborhoods, and
churches. They may be regulated
by law, custom, or mutual
agreement, and are the basis of
social groups and society as a
whole. A relationship is normally
viewed as a connection between
two individuals, such as a romantic
or intimate relationship, or a
parent-child relationship. All
relationships involve some level of
interdependence. People in a
relationship tend to influence each
other, share their thoughts and
feelings, and engage in activities
together. Because of this
interdependence, anything that
changes or impacts one member
 of the relationship will have some
level of impact on the other
member. Psychologists have
suggested that all humans have a
basic, motivational drive to form
and maintain caring interpersonal
relationships. According to
attachment theory, relationships
can be viewed in terms of
attachment styles that develop
during early childhood. These
patterns are believed to influence
interactions throughout adulthood
by shaping the roles people adopt
in relationships.
(http://en.wikipedia.org/wiki/Intima
te_relationship)
SEXUAL AND Menarche: Patient didn’t Sexuality is defined not only by a
REPRODUCTIVE @ 13 y/o have her person’s genetalia but also by
PATTERN LMP: July 25, period while attitudes and feelings. It can also
2009 she was in be defined as learned behaviors in
the hospital. how a person reacts to his or her
Has own sexuality and by how one
dysmenorrh behaves in relationships with
ea during others. (Fundamentals of Nursing
menstruatio 5
n which th
started edition by Taylor, page 931)
since Sexuality is a crucial part of a
menarche person’s identity. Sex is central to
who we are, to our emotional well-
Period lasts being and to the quality of our
for 3-5 days lives. The world health
and uses 5- organization defined sexual health
6 pads a as the integration of the somatic,
day emotional, intellectual and social
aspect of sexual beings in ways
No problems that are positively enriching and
with her that enhances personality,
genitalia communication and love. (Kozier
et.al, Fundamentals of Nursing 7
1st Sexual th
Intercourse: ed. Pages 973)
29 y/o with During the middle adulthood both
her husband men and women experience
Does not decreased hormone production
use oral causing the climacteric, usually
contraceptiv called menopausal in women.
es These events often affect the
individuals self-concept, body
 Last image and sexual identity.
PAPSMEAR: Women through the menopausal
Aug. 21, period experiences hot flushes,
2009 vasomotor instability, sleep
(Normal) disturbances, vaginal dryness,
genital tract atrophy, mood
G4P4 changes and skin, hair changes.
The incidence of osteoporosis and
cardiovascular lipid changes also
increases. The climacteric in the
males is no as dramatic in the
females; changes are more
gradual. Sexual response love
and play involve people’s
emotional, psychologic, physical
and spiritual make up, which plays
a significant role in the
satisfaction. Sexual desires
fluctuates within each person and
varies from person to person. If
people suppresses or block out
conscous sexual desires, they may
not experience any physiological
respose. (Kozier et.al,
Fundamentals of Nursing 7
th
ed. Pages 975,980).
COPING STRESS When she is She spends Coping mechanisms which are
tired from time with her behaviors used to decrease stress
work, she kids and anxiety. Many coping
smokes behaviors are learned, based on
approximate one’s family past experiences, and
ly 5 sticks a socio-cultural influences and
day in a expectations.(Fundamentals of
regular Nursing 5
basis which th
started edition by Taylor, page 855)
since 21
years old.

She also
spends time
with her kids
to relieve
stress
VALUES-BELIEF Her family is Her fast Spiritual well-being is the
PATTERN her priority recovery and condition that exists when the
her health universal spiritual needs for
status are meaning and purpose, love and
important to belonging, and forgiveness are
 She is a her right met. O’ Briens conceptual model
Roman now. of spiritual well-being in illness
Catholic, identified three empirical referents
she goes to of spiritual well- being: personal
church faith, religious practice and
every spiritual contentment. Spiritual
Sunday Allows all beliefs are of special importance to
medical nurses because of the many ways
Has no procedures they can influence a patient’s level
restrictions of health and self-care behaviors.
on medical (Kozier et.al, Fundamentals of
procedures Nursing 7
th
ed. Pages 975,979).
COGNITIVE No hearing No hearing Cognition is greatly affected by
PERCEPTUAL difficulty difficulty education. Those who study and
PATTERN (+) Rinne’s (+) Rinne’s develop their skills have better
Test and (-) Test and (-) cognitive performances because
Weber’s Weber’s Test they have been provided with
Test different information and chances
Wears to develop their self. Perception is
Wears corrective affected by the sensory diseases.
corrective lenses Presence of any sensory
lenses Grade: abnormalities affects or halters
20/100 left perception that would affect
eye proper communication. (Black,
20/20 Medical Surgical Nursing7th
Right Eye edition, page 1880). Cognition
involves a person’s intelligence,
perceptual ability and ability to
process information. It represents
a progression of mental abilities
from illogical to logical thinking,
from simple to complex problem
solving and from concrete to
abstract ideas. (Kozier et.al,
Fundamentals of Nursing 7
th
ed. Page 359).

V. Physical Assessment:

BASELINE DATA

Vital Signs

Blood Pulse Respiratory Tempearture

Pressure Rate Rate (˚C)
Pre-Operation 120/90 mmHg 71 bpm 20 cpm 37.1
Post- 120/70 mmHg 78 bpm 17 cpm 36.6
Operation

Areas To Assess Pre- Post- Normal Interpretation

Operation Operation Findings
Findings Findings
APPEARANCE AND MENTAL STATUS

1. Body Build Slim but Slim; bulk Proportionat Sign of The

has a bulk was gone e mass mass
on her was
Height abdomen 5ft. 1 inch remove
Weight 5ft. 1 inch d
2. Posture Slightly Due to Relaxed; Due to pressure
and Gait lordotic surgery, Erect and weight the
patient has posture; posture is
restrictions coordinated altered
on her movement
movements
3. Over-all Neat, no Nurses give Neat, no No deviation
Hygiene form of her after form of bad from normal
and body odor care odor findings
Grooming
4. Signs of Distress Distress No distress Uncomfortable
Distress noted noted noted because of the
presence of
mass
5. Signs of Unhealthy Patient looks Healthy She has been
Illness appearance healthier but Appearance diagnosed with
is not yet in Myoma Uteri,
optimum Intramural with
condition Subsenous
Component
She has
undergone a
major surgery.
6. Client’s Acts Acts Acts No deviation
Mood appropriate appropriately appropriately from normal
ly on the in the given in a given findings
given situation situation
situation
7. Client’s Cooperative Cooperative Cooperative No deviation
Attitude and able to and able to and able to from normal
follow follow follow findings
instructions instructions instructions
8. Quality of Understand Understanda Understanda No deviation
Speech able; ble; ble; from normal
 moderate in moderate in moderate findings
pace; clear pace; clear pace; clear
tone tone tone
9. Organizatio Makes Makes sense Logical No deviation
n of sense of of reality sequence; from normal
Thoughts reality makes sense findings
of reality
SKIN

1. Skin Color Light brown pale Variable Pre op patient’s

skin is pale due
to blood loss;
poor circulation
2. Uniformity Generally Generally Generally No deviation
of skin uniform uniform uniform from normal
color except on except on except for findings
areas areas areas
exposed to exposed to exposed to
the sun the sun the sun
3. Assess Edema on Edema on No edema The mass puts
edema, if the lower the lower pressure on
present extremities extremities lower
extremities;
making fluids
retention
4. Skin lesions -Nevi on -Nevi on the Freckles, - Scar is due to
the face face and has birthmarks, TAHBSO
and has a a scar on the flat and
scar on the manus area raised nevi
manus area -Has scar on
-Has scar the abdomen
on the due to CS
abdomen Delivery
due to CS -Scar on
Delivery Q4P4
5. Skin Moist on Moist on skinMoist in skin No deviation
Moisture skin folds folds folds and from normal
axillae findings
6. Skin Uniform Uniform Uniform No deviation
Temperatu within within within from normal
re normal normal range normal range findings
range
7. Skin Turgor Springs Springs back Springs back No deviation
back to to previous to previous from normal
previous state state findings
state
HAIR

1. Evenness Evenly Evenly Evenly No deviation

of hair distributed distributed distributed from normal
 growth in findings
the scalp
2. Hair Thick hair Thick hair Thick hair No deviation
thickness/t from normal
hinness findings
3. Presence of No infection No infection No infection No deviation
infection from normal
findings but
there are risk
for infections
4. Amount of Has some Has some Variable No deviation
body hair hair on hair on some from normal
some parts parts of the findings
of the body body
NAILS

1. Curvature Convex @ Convex @ Convex No deviation

and Angle 160˚ angle 160˚ angle curvature from normal
of of nail plate of nail plate about 160˚ findings
Fingernail angle of nail
Plate plate
2. Fingernail Smooth Smooth Smooth No deviation
and toenail texture texture texture from normal
texture findings
3. Fingernail Not highly Not highly Highly Altered
and toenail vascularise vascularized vascular circulation
bed color d
4. Blanch Test Return to Return to Prompt Altered
for usual color usual color in return of circulation
capillary in 5 5 seconds pink/usual
refill seconds color usually
less than 4
seconds
SKULL AND FACE

1. Size, shape Round, Round, Round, No deviation

and smooth smooth smooth skull from normal
symmetry contour findings
of skull
2. Nodules, Smooth, Smooth, Smooth, No deviation
depression uniform uniform uniform from normal
in skull consistency consistency; consistency; findings
; absence absence of absence of
of nodules nodules nodules
3. Facial Symmetric Symmetric Symmetric; No deviation
Features and equal and equal palpebral from normal
features findings
equal in size
4. Signs of No edema No edema No edema No deviation
edema and from normal
 hollowness findings
of the eyes
5. Symmetry Symmetric Symmetric Symmetric No deviation
of facial facial facial facial from normal
movement movements movements movements findings
s
EYE STRUCTURE AND VISUAL ACTIVITY
1. Eyebrow Evenly Evenly Evenly No deviation
hair distributed; distributed; distributed; from normal
distribution skin intact; skin intact; skin intact; findings
, symmetrica symmetricall symmetricall
alignment, lly aligned; y aligned; y aligned;
skin quality equal equal equal
and movement movement movement
movement
2. Evenness Equally Equally Equally No deviation
of hair and distributed; distributed; distributed; from normal
direction of curled curled curled findings
eyelashes slightly slightly slightly
outward outward outward
3. Eyelid No deviation
surface from normal
characteris findings
tics: Intact Intact - skin is
• Position in No No intact; no
relation to discoloratio discoloration discoloration
cornea n ; no
Lids close discharge
Lids close symmetricall -lids close
• Ability to symmetrica y symmetricall
blink lly 17 blinks per y
17 blinks minute -15 to 20
• Frequency per minute Upper and blinks per
of blinking Upper and lower minute
• Lower lower borders -(open lids)
eyelids when borders slightly upper and
eyes are closed slightly covered lower
covered borders
slightly
covered
4. Color, Transparent Transparent; Transparent; No deviation
presence of ; evident evident evident from normal
lesions of capillaries; capillaries; capillaries; findings
the bulbar sclera is sclera is sclera is
conjunctiva white white white
5. Color, Shiny; Shiny; Shiny; No deviation
presence of smooth; red smooth; red smooth; from normal
lesions in pink/red findings
the
palpebral
 conjuctiva
6. Edema in No edema No edema No edema No deviation
the from normal
lacrimal findings
glands
7. Lacrimal No edema; No edema; No edema; No deviation
sac and no tearing no tearing No tearing from normal
nasolacrim findings
al sac
8. Clarity and Transparent Transparent; Transparent; No deviation
texture of ; shiny; shiny; shiny; from normal
the cornea smooth; smooth; smooth; findings
details of details of iris details of iris
iris are are visible are visible
visible
9. Transparen 3mm in 3mm in 3mm in No deviation
cy and depth; depth; depth; from normal
depth of transparent transparent; transparent; findings
the ; no no shadows no shadows
anterior shadows of of light in the of light in the
chamber light in the iris iris
iris
10.Color, size, Equal in Equal in size; Equal in size; No deviation
shape and size; black black in color black in color from normal
symmetry in color findings
of pupil
11.Assess No deviation
each from normal
pupil’s findings
direct and
consensual
reaction Able to Able to -should be
• Direct constrict constrict able to
response Able to Able to constrict
• Consensual constrict constrict -should be
Response able to
constrict
12.Pupil’s Constrict Constrict Constrict No deviation
reaction to when when looking when looking from normal
Accomodati looking at a at a near at a near findings
on near object object object
Dilate when Dilate when Dilate when
looking at a looking at a looking at a
far object far object far object
13.Peripheral Can see Can see Can see No deviation
Visual objects in objects in objects in from normal
Fields periphery periphery periphery findings
14.Six ocular Coordinate Coordinated Coordinated No deviation
movement d movement; movement; from normal
s for eye movement; moves in moves in findings
 alignment moves in unison unison
and unison
coordinatio
n
15.Location of Light falls Light falls Light falls No deviation
light reflex symmetrica symmetricall symmetricall from normal
lly on both y on both y on both findings
pupils pupils pupils
16.Hirschberg Uncovered Uncovered Uncovered No deviation
test/Cover eye does eye does not eye does not from normal
Test not move move move findings
17.Near Vision Able to Able to read Able to read No deviation
read newsprint newsprint from normal
newsprint findings
18.Distance 20/100 20/100 20/20 vision uses corrective
vision vision vision lenses
through
Snellen’s
Chart
EARS AND HEARING

1. Color, Color same Color same Color same No deviation

symmetry as facial as facial as facial from normal
and postion skin; skin; skin; findings
of auricles symmetrica symmetrical; symmetrical;
l; aligned aligned with aligned with
with the the outer the outer
outer canthus canthus
canthus about 10˚ about 10˚
about 10˚ from vertical from vertical
from
vertical
2. Texture, Mobile; Mobile; firm; Mobile; firm; No deviation
elasticity firm; pinna pinna recoils pinna recoils from normal
and recoils after after folded after folded findings
tenderness folded
of auricles
3. Watch-Tick Audible Audible Audible No deviation
Test from normal
findings
4. Weber’s Sound is Sound is Sound is No deviation
Test heard on heard on heard on from normal
both ears/ both ears/ both ears/ findings
localized at localized at localized at
the center the center of the center of
of the head the head the head
5. Rinne’s AC>BC AC>BC AC>BC No deviation
Test from normal
findings
 NOSE AND SINUSES

1. Deviation Symmetric; Symmetric; Symmetric; No deviation

in shape, straight; no straight; no straight; no from normal
size, color discharge discharge discharge findings
and
discharge
in the
external
nose
2. Areas of No No No No deviation
tenderness tenderness tenderness tenderness from normal
, and lesions and lesions and lesions findings
masses/dis
placements
of bone
3. Patency of Air moves Air moves Air moves No deviation
both nasal freely as freely as the freely as the from normal
cavities the client client client findings
breathes breathes breathes
through the through the through the
nares nares nares
4. Presence of Mucosa Mucosa pink; Mucosa pink; No deviation
redness, pink; clear clear watery clear watery from normal
swelling , watery discharges; discharges; findings
growths discharges; no lesions no lesions
and no lesions
discharges
5. Nasal Nasal Nasal Nasal No deviation
septum septum septum septum from normal
between intact with intact with intact with findings
nasal the midline the midline the midline
chambers
6. Maxillary Not Tender Not Tender Not Tender No deviation
and frontal from normal
sinuses findings
MOUTH AND OROPHARYNX

1. Symmetry Uniform Uniform Uniform No deviation

of contour pink; soft; pink; soft; pink; soft; from normal
color and moist; moist; moist; findings
texture of smooth; smooth; smooth;
the outer symmetric symmetric in symmetric in
lips in contour contour contour
2. Inner lips Uniform Uniform Uniform No deviation
and buccal pink; moist; pink; moist; pink; moist; from normal
mucosa smooth; smooth; soft smooth; soft findings
soft and and elastic and elastic
elastic
3. Teeth and 32 adult 32 adult 32 adult No deviation
gums teeth; teeth; teeth; from normal
smooth, smooth, smooth, findings
shiny shiny shiny
enamel; enamel; pink enamel; pink
pink gums gums gums
4. Surface of Central Central Central No deviation
Tongue position; position; position; from normal
pink; raised pink; raised pink; raised findings
papillae papillae papillae
5. Tongue Moves Moves freely; Moves freely; No deviation
Movement freely; no no no from normal
tenderness tenderness tenderness findings
6. Baseline of Smooth Smooth Smooth No deviation
the tongue tongue tongue base tongue base from normal
base with with with findings
prominent prominent prominent
veins veins veins
7. Tongue Smooth; no Smooth; no Smooth; no No deviation
and floor of palpable palpable palpable from normal
the mouth nodules nodules nodules findings
8. Hard and Soft palate Soft palate is Soft palate is Because of
Soft Palate is dark dark fading light pink smoking in the
fading pink pink and and smooth past years
and smooth smooth hard Hard palate
hard palate palate is is lighter
is slightly slightly pink and
purple purple irregular
9. Uvula Midline soft Midline soft Midline soft No deviation
Position palate palate palate from normal
findings
10.Color and Pink; Pink; smooth Pink; smooth No deviation
texture of smooth posterior posterior from normal
oropharynx posterior wall wall findings
wall
11.Inspect Pink; Pink; Pink; No deviation
tonsils smooth; no smooth; no smooth; no from normal
discharge; discharge; discharge; findings
grade 1 grade 1 grade 1
12.Gag reflex present Present present No deviation
from normal
findings
NECK

1. Neck Equal in Equal in size; Equal in size; No deviation

Muscles size; head head from normal
Head centered centered findings
centered
2. Head No deviation
Movement from normal
• Sternocleid -head -head flexes -head flexes findings
omastoid flexes @ @ @
(chin to chest) 45˚ 45˚ 45˚
• Trapezius -head hyper -head hyper
muscle extends @ extends @ -head hyper
(head to 60˚ 60˚ extends @
back) 60˚

• Sternocleid -head -head

omastoid laterally laterally -head
(side to side) flexes @ flexes @ 40˚ laterally
• Sternocleid 40˚ flexes @ 40˚
omastoid -head
(turn head -head laterally -head
from R to L) laterally rotates @ laterally
rotates @ 70˚ rotates @
70˚ 70˚
3. Muscle Equal Equal Equal No deviation
Strength strength strength strength from normal
findings
4. Palpation No deviation
of enlarged from normal
lymph nodes findings
• Occipital Not Not Palpable Not Palpable
• Postauricul Palpable
ar
• Preauricula
r
• Submandib
ular
• Submental
• Superficial
Anterior
Cervical
• Posterior
Cervical
• Inferior
Anterior
Cervical
• Supraclavic
ular
5. Palpation Central Central Central No deviation
of trachea placement placement in placement in from normal
in midline midline of midline of findings
of neck neck neck
6. Inspection Not visible Not visible Not visible No deviation
of thyroid on on inspection on inspection from normal
glands inspection findings
7. Palpation Palpable Palpable Palpable No deviation
of thyroid from normal
glands findings
THORAX AND LUNGS

1. Shape and Anteropost Anteroposter Anteroposter No deviation

symmetry erior to ior to ior to from normal
of thorax transverse transverse transverse findings
has a ratio has a ratio of has a ratio of
of 1:2 1:2 1:2
Chest Chest Chest
Symmetric Symmetric Symmetric
2. Spinal Signs of Spine Spine No deviation
Alignment Lordosis vertically vertically from normal
aligned aligned findings
3. Palpation Intact; no Intact; no Intact; no No deviation
of posterior masses masses masses from normal
thorax findings
4. Palpation Full; Full; Full; No deviation
of posterior symmetric symmetric symmetric from normal
chest for chest chest chest findings
respiratory expansion expansion expansion
excursion
5. Chest for Bilateral Bilateral Bilateral No deviation
vocal symmetry symmetry of symmetry of from normal
(tactile) of vocal vocal vocal findings
fremitus fremitus fremitus fremitus
6. Percussion Percussion Percussion Percussion No deviation
of the notes notes notes from normal
thorax resonance, resonance, resonance, findings
except over except over except over
the scapula the scapula the scapula
7. Breathing Rhythmic; Rhythmic; Quiet; No deviation
Patterns Effortless Effortless Rhythmic; from normal
effortless findings
8. Costal Costal @ Costal @ 90˚ Costal @ 90˚ No deviation
angle and 90˚ Ribs insert to Ribs insert to from normal
angle @ Ribs insert the spine @ the spine @ findings
which the to the spine 45˚ 45˚
ribs enter @ 45˚
the spine
9. Palpation Full Full Full No deviation
of anterior symmetric symmetric symmetric from normal
chest for excursion; excursion; excursion; findings
respiratory thumbs thumbs thumbs
excursion normally normally normally
separate separate separate
3-5cm or 3-5cm or 3-5cm or
(1.5—2 (1.5—2 (1.5—2
inches) inches) inches)
10.Palpate Normally Normally Normally No deviation
tactile decreased decreased decreased from normal
fremitus over the over the over the findings
heart and heart and heart and
breast breast breast
tissues tissues tissues
11.Percuss Resonance Resonance Resonance No deviation
anterior down to the down to the down to the from normal
chest 6th rib @ 6th rib @ the 6th rib @ the findings
the level of level of the level of the
the diaphragm diaphragm
diaphragm but flat over but flat over
but flat the areas of the areas of
over the heavy heavy
areas of muscle and muscle and
heavy bone; dull on bone; dull on
muscle and areas over areas over
bone; dull the heart the heart
on areas and liver; and liver;
over the tympanic tympanic
heart and over the over the
liver; underlying underlying
tympanic stomach stomach
over the
underlying
stomach
12.Auscultate Bronchial Bronchial Bronchial No deviation
the trachea and tubular and tubular and tubular from normal
breath breath breath findings
sounds are sounds are sounds are
normal normal normal
13.Auscultate Broncho- Broncho- Broncho- No deviation
the vesicular vesicular and vesicular and from normal
anterior and vesicular vesicular findings
chest vesicular breath breath
breath sounds are sounds are
sounds are normal normal
normal
HEART AND CENTRAL VESSELS

1. Inspect and No deviation

palpate from normal
precordium for findings
presence of
abnormal
pulsations
• Locate -no -no pulsation -no pulsation
angle of Louis pulsation
• Aortic Area -no pulsation -no pulsation
(right 2nd -no
intercostals pulsation
space) -no pulsation -no pulsation
• Pulmonic
Area (left 2nd -no
intercostals pulsation -no pulsation -no pulsation
space)
• Tricuspid
Area (left 5th -no -no pulsation -no pulsation
intercostals pulsation
space)
• Mitral Area
(laterally 2-3 -no
inches to the pulsation
LMCL from the
tricuspid)
2. Auscultate No deviation
the heart in the from normal
4 anatomic findings
sites: -heard in all -heard in all -heard in all
• Aortic Area sites sites (louder sites (louder
(louder in in the apical in the apical
the apical area) area)
• Pulmonic area) -heard in all -heard in all
Area -heard in all sites (louder sites (louder
sites @the base of @the base of
• Tricuspid (louder the heart) the heart)
Area @the base -heard in -heard in
of the children and children and
heart) young adults young adults
• Mitral Area -heard in -heard in -heard in
children older adults older adults
and young
adults
-heard in
older adults
3. Palpate Full Full Full No deviation
carotid pulsation; pulsation; pulsation; from normal
artery elastic elastic elastic findings
arterial wall arterial wall arterial wall
4. Auscultate No sound No sound No sound No deviation
carotid heard heard heard from normal
artery findings
5. Jugular Not visible Not visible Not visible No deviation
veins from normal
findings
BREAST AND AXILLAE

1. Breast size, Rounded Rounded Rounded No deviation

shape and shape; shape; shape; from normal
symmetry slightly slightly slightly findings
 of breast unequal; unequal; unequal;
generally generally generally
symmetric symmetric symmetric
2. Skin of the Skin is Skin is Skin is No deviation
breast uniform in uniform in uniform in from normal
color; color; color; findings
smooth smooth smooth
3. Emphasize
retraction
• Raised -retracts -retracts -retracts No deviation
arms above from normal
the head -retracts -retracts -retracts findings
• Push hands
together -retracts -retracts -retracts
• Press
hands down
to hips
4. Size, Round/oval; Round/oval; Round/oval; No deviation
shape, bilaterally bilaterally bilaterally from normal
symmetry the same; the same; the same; findings
and color light pink to light pink to light pink to
of areola dark brown dark brown dark brown
5. Size, Round; Round; Round; No deviation
shape, everted; everted; everted; from normal
symmetry equal in equal in size; equal in size; findings
and nipple size; similar similar in similar in
color in color; color; point color; point
point in the in the same in the same
same direction; no direction; no
direction; disharge disharge
no disharge
6. Palpate No No No No deviation
axillary, tenderness; tenderness; tenderness; from normal
subclavicul no masses; no masses; no masses; findings
ar, no nodules no nodules no nodules
supraclavic
ular lymph
nodes
7. Palpate No No No No deviation
breast tenderness; tenderness; tenderness; from normal
no masses; no masses; no masses; findings
no no no
discharges discharges discharges
8. Palpate No masses; No masses; No masses; No deviation
areolar no no no from normal
and nipple discharges discharges discharges findings
ABDOMEN

1. Skin (+) stretch (+) stretch Unblemished No deviation

Integrity marks marks skin from normal
 (+) scar (+) scar due findings
due to CS to CS
Delivery Delivery
2. Contour Concave in Concave in Flat/rounded; No deviation
and shape shape scaphoid; no from normal
symmetry evidence of findings
of enlargement
abdomen of the liver
or spleen
3. Abdominal No deviation
movement from normal
s Symmetric Symmetric -Symmetric findings
• Resp Movements Movements movements
iration Not visible Not visible -Visible
peristalsis on
• Peris very lean
talsis people
Not felt Not felt -felt in thin
person at the
epigastric
• Aortic areas
Pulsations
4. Vascular Not visible Not visible Not visible No deviation
Pattern from normal
findings
5. Auscultate Bowel Bowel Audible No deviation
abdomen sounds not sounds not bowel from normal
audible audible sounds; findings
absence of
Arterial Arterial arterial
bruits and bruits and bruits and
friction rubs friction rubs frictions rub
are absent are absent
6. Percuss Nothing Nothing Tympany Because ofthe
abdomen heard heard over the presence of
symmetric stomach and tumor (myoma)
ally gas-filled
bowel;
dullness over
the liver and
spleen;
resonance
over fluid-
filled bladder
7. Perform Presence of Presence of No Because of the
light tenderness; tenderness; tenderness; presence of
palpation firm and firm and relaxed tumor (myoma)
movable movable abdomen;
smooth and
consistent
 tension
8. Palpate Not Not palpable May not be No deviation
liver palpable palpable; from normal
borders feels findings
smooth
MUSCULOSKELETAL SYSTEM

1. Muscle size Equal in Equal in both Equal in both No deviation

both sides sides of the sides of the from normal
of the body body body findings
2. Muscle No tremors No tremors No tremors No deviation
tremors from normal
findings
3. Contractur No No No No deviation
es in the contracture contractures contractures from normal
muscles/te s findings
ndons
4. Palpation Smooth and Smooth and Normally No deviation
of muscles coordinated coordinated smooth; from normal
while movements movements coordinated findings
active and movements
passive
5. Palpation Firm Firm Normally No deviation
of muscles firm from normal
@ rest findings
6. Muscle Equal Equal Equal No deviation
strength strength on strength on strength on from normal
each side each side each side findings
7. Skeleton No No No No deviation
deformities deformities deformities from normal
findings
8. Edema in No edema No edema No edema; No deviation
bones no from normal
tenderness; findings
no swelling
9. Joint Joint Joint swelling No swelling No deviation
Swelling swelling from normal
findings
10.Joint range No difficulty No difficulty Varies @ No deviation
of motion in motion in motion some degree from normal
in findings
accordance
with a
person’s
genetic
make-up and
degree of
physical
activity
 VI. Anatomy and Physiology

The Female Reproductive System

Sexual characteristics are divided into two types. Primary

characteristics are directly related to reproductive and that includes the sex
organs (genitalia). Secondary sexual characteristics are attributes other than
the sex organs that generally distinguish one sex from the other but are not
essential to reproduction.

Mons Pubis/ Veneris – mountain of Venus, a pad of fatty tissue that lies
over the symphysis pubis covered by the skin and at puberty covered by
pubic hair that serves as a cushion or protection to the symphysis pubis

Labia Majora – large lips, longitudinal fold from perenium to pubis

symphysis

Labia Minora – AKA Nymphae, soft thin longitudinal fold between labia
majora

Clitoris – “key”, pea – shaped erectile tissue composed of sensitive nerve

endings; sought of sexual arousal in females

Fourchet – tapers posteriorly of the labia majora. Site of episotomy

- Sensitive to manipulation, torn during pregnancy

Vestibule – almond shaped area that contains the hymen, vaginal orifice and
batholene’s gland

Urinary Meatus – small opening of urethra/ opening for urination

Skene’s Gland – AKA Paraurethral Gland, two (2) small mucus secreting
glands for lubrication

Hymen – Membranous tissue that covers the vaginal orifice

Vaginal Orifice – external opening of the vagina

Vagina – female organ for sexual intercourse, passageway of menstruation,

¾ inches, 8 – 10 long containing rugae

Rugae - permits considerable stretching without tearing during pregnancy

Uterus – hollow muscular organ, varies in size, weight and shape; organ of
menstruation

Size: 1 x 2 x 3
 Shape: pear shaped: pregnant - ovoid

Weight: Uterine involution

Non pregnant: 50 – 60 g

Pregnant: 1000 g

4th stage of labor: 1000 g

2nd week after delivery: 500 g

3rd weeks after delivery: 300 g

5-6 weeks after delivery: 50 -60 g

Fallopian Tube – 2 – 3 inches long that serves as a passageway of the

sperm from the uterus to the ampulla or the passageway of the mature ovum
or fertilized ovum from the ampulla to the uterus.

Infundibulum – most distal part, trumphet shape, has fimbriae

Fembriae – finger like structures that collects the mature ovum from the
ovary

Ampulla – outer 3rd and 2nd half, site of fertilization, common site for ectopic
pregnancy

Isthmus – site of sterilization, site for BTL (Bi Lateral Tubal Ligation)

Interstitial – most dangerous site for ectopic pregnancy

Ovary - the ovum-producing reproductive organ, often found in pairs as part

of the vertebrate female reproductive system

6 major parts of the Ovaries

Germinal Epithelium – layers of epithelium that covers the surface of the

body

Tunica Albuginae – whitish capsule of dense connective tissue located deep

in the germinal epithelium

Stroma – region of tissue deep to the tinuca albuginea

Ovarian Follicle – the sackor bag that covers the ova during ovulation

Grafan Follicle – follicle that surrounds the ova during expulsion of the
unfertilized egg out of the ovary
 Corpus Luteum - a yellow endocrine gland found in the ovary formed when
the follicle is discharged its progesterone, estrogen and relaxin

3 Layers of Ovaries

Cortex – the outer layer of the ovary

Medulla – middle layer

Hilum – the inner layer which contains the stroma and hilar cells which
excretes hormone like progesterone, estrogen and relaxin

Oogenesis – process of maturation of ovum

30 weeks AOG – 6 million immature ovum

@ birth - 1 million immature ovum

@ puberty- 300-400 immature

@ 13 y/o – 300-400 mature oocytes

@ 23 y/o – 180-280 mature ovum

@ 33 y/o – 60-160 mature ovum

@ 26 y/o – 24-124 mature ovum

@26 y/o – 4 mature ovum

Functions of Estrogen and Progestin

Estrogen – hormone of woman

Primary Function

Responsible for the development of secondary characteristics in

female

Inhibit production of FSH

Other function

Hypertrophy of the myometrium

Spinnbarkeit and Ferning Patter (Billing Method)

Ductile structure of the breast

Osteoblastic bone activity (causes increase in height)

 Early closure of the epiphysis of the bone

Sodium retention

Increased sexual desire

Responsible for vaginal lubrication

Progesterone – Hormone of the mother

Primary Function- prepares the endometrium for implantation

making it thick and tortuous

Secondary Function – inhibit uterine contractibility

Others:

Inhibits LH (Hormone of ovulation) production

GI motility

Permeability of kidneys to lactose and dextrose causing + 1 in

urine

Mammary gland development

BBT
 VII. PathoPhysiology:

Predisposing
Factors Non-Modifiable:

Multiparity:G4P4(4004)→
↑Production of
Modifiable: ↑estrogen Estrogen during
Age:44(15-40)→↑Production of estrogen
level pregnancy
Diet: ↑cholesterol intake → during

during
reproductive age

Intramural myoma Small Fibroids

located on Diet: ↑cholesterol
anterofundal area intake →
Monoclonal
↑Mitotic Activity ↑ Estrogen
Diet: ↑cholesterol level of the
intake → ↑Cell proliferation fibroid cells

Increase Fibroid ↑ Estrogen

Growth Receptor
Size: Concentration
of fibroid
Symptomatic Enlarged fibroid 32cm x
37cm
-Severe Pelvic Pain
TAHBSO
Circulating
Estrogen
VIII. Laboratory Result

LABORATORY/DIAGN ACTUAL NORMAL ANALYSIS

OSTIC TEST VALUES VALUES

Hematology

WBC count 6,400/cu.m 5,000- Within

m 10,000/cu.m normal
m range

Hemoglobin 16.7 gms/dL 12-16 Within

gms/dL normal
range

Hematocrit 49% 37%-47% Compensatio

n for
inadequate
lung function

Segmenters 53% 50%-62% Within

normal
range

Lymphocyte 37% 25%-40% Within

s normal
range

Monocytes 3% 3%-7% Within

normal
range

Eosinophils 7% 0%-3% High level of

eosinophil
indicates
that the
patient has
ongoing
inflammation
 or asthma.

LABORATORY/DIAGN ACTUAL NORMAL ANALYSIS

OSTIC TEST VALUES VALUES

Urinalysis

Color Yellow Light yellow No deviation

to amber from normal

Transparenc Slightly Clear-slightly No deviation

y cloudy hazy from normal

Glucose Negative Negative No deviation

from normal

Protein Negative Negative No deviation

from normal

pH 6.0 4.5-8.0 No deviation

from normal

Specific 1.025 1.015-1.025 No deviation

Gravity from normal

WBC 1-3/HPF Negative or Signifies a

rare urinary tract
infection.

RBC 0-1/HPF Negative or May be

rare caused by
excessive
red cell
destruction,
urinary tract
infection,
malignancy,
or urinary
tract injury.

Epithelial Few Few No deviation

cells from normal

Bacteria Few Few No deviation

from normal

Cast/s None seen None No deviation

from normal

DIAGNOSTIC ACTUAL NORMAL ANALYSIS

TEST FINDINGS FINDINGS

Ultrasonography

ULTRASOUN The uterus All pelvic It shows that

D occupies the organs like the patient
mid anterior bladder, has enlarged
abdomen. It uterus, mass on her
is vagina and abdomen
asymmetrica cervix are in (myometriu
lly enlarged proper m). Her left
to 32 x 37 place, size ovary cannot
cm. with and shape. be visualized
heterogenou No problems due to the
s echo like cyts, large mass
texture. tumors, and covering it.
There is a fibroid are
huge present. No
conglomerati stones or
on of abdominal
posterior growths are
subserous present in
myometrial uterus.
masses Bladder
measuring empties
29.2 x 34.2 completely if
cm (cervix checked
measures before and
1.6 x 1.8 x after
1.3 cm.) urination.
 The
endometriu
m is
hyperechoic
and smooth,
measuring .7
cm. the
subendomet
rial halo is
intact. The
right ovary
measures
3.4 x 2.0 x
2.4 cm with
few follicles,
the largest
measuring
1.2 cm.

The left
ovary is not
visualized.
The left
adnexa and
posterior sul-
de-sac are
obliterated
by the huge
mass.

There is no
free fluid in
the lines of
pelvic cavity.

IX. Course in the Ward

The patient was admitted on August 1, 2009 and diagnosed with

Myoma Uterine and was operated by the procedure of Total Abdominal
Hysterectomy with Bilateral Salphingo- Oophorectomy on the following day
(September 1, 2009).

On September 2, 2009, 6:15 am, her vital signs were normal with a
blood pressure of 120/70, her heart rate is 78 bpm, has a respiratory rate of
17 cpm, and her temperature is 36.6 ˚C.

By 7:52 am on the same day, the patient has adequate and clear urine
output, has normoactive bowel sound and has a minimal vaginal bleeding. As
the doctor ordered, the IVF of the patient should be consumed, may have
general liquid diet which consist of soft boiled egg, crackers and gelatin for
lunch. Her catheter can be removed once IVF is consumed. The patient may
sit up in bed. The doctor added that once the IVF is consumed, it should be
shifted to oral medication.

1. Co-Amoxyclav (Natravol) 628 mg capsule every 2 hours

2. Mefenamic Acid (Istan) 500 mg capsule every 6 hours PRN for

pain

3. Insert Dulcolax 1 rectal suppository STAT

By 6:30 pm of the same day, the patient may have a full diet.

September 3, 2009, her vital signs were still stable with a blood
pressure of 120/80, has a pulse rate of 71 bpm, her respiratory rate is 21 cpm
and her temperature is 36.8˚C. By 6:38 am, the patient voids freely with
flatus and has bowel movements. Her abdomen was soft, non-tender and no
vaginal bleeding. The patient is now comfortable and has no complaint. The
doctor ordered to increase oral fluid intake and also prepare her PhilHealth
requirements.

Exactly by 8:00 am, the wound dressing was done, the wound was well
copulated. No discharge found, stable vital signs and has a positive bowel
movement. Still has no vaginal bleeding. By this time, the patient may go
home but still needs to take medication.

The patient is needed for a follow check up on September 11, 2009

10:00 at OBOAD.

By 6:05 pm, her vital signs were still stable. Her blood pressure is
110/70, has a pulse rate of 76 bpm, has a respiratory rate of 20 cpm and her
temperature is 36.2˚C. Still has no vaginal bleeding with flatus, has bowel
movements and voids freely.
 September 4, vital signs of the patient were still normal with a blood
pressure of 120/70, has a pulse rate of 74 bpm, her respiratory rate was 18
cpm and her temperature was 36.6˚C. By 6:45 am, upon checking her
condition, her abdomen is soft and non- distended. The patient voids freely,
has positive flatus and positive bowel movements. And finally, by 7:05 am,
the doctor ordered to cancel the previously saved blood.
X. NCP
 XI. Discharge Planning

Home Medication

1. Co- Amoxyclav (Natravol) 628 mg BID for more days

2. Mefenamic Acid 500 mg TID for pain

3. Vitamin C

4. Multivitamins

Exercise

Do deep breathing exercise in a side lying position

Treatment

No lifting of heavy objects

Health Teachings

Diet

Diet as tolerated

The patient can eat without any restriction

XII. Drug Study

DRUG Actions Indications Side Effect/Adverse Nursing

Effect Considerations
Drug Name: Amoxicillin CNS: agitation, - Monitor
Co-Amoxiclav inhibits dizziness, fatigue, patient
transpeptidase, (DAPAT PRE- hyperactivity carefully for
Brand Name: preventing OP signs and
Natravol cross-linking of PROPHYLAXIS) GI: nausea, symptoms of
bacterial cell vomiting, diarrhea, hypersensitivity
Drug wall and leading Contraindicati abdominal pain reaction.
Classification: to cell death. ons: - Monitor for
Anti-infective Addition of Hematologic: seizures when
clavulanate (a giving high
-
Dosage/Route: beta-lactam) doses.
625mg capsule increases drug's Hypersensitivit eosinophilia - Check
1 cap q8 resistance to y to drug or patient's
beta-lactamase any penicillin temperature
(an enzyme - and watch for
produced by Phenylketonuri other signs and
bacteria that a (some symptoms of
may inactivate products) superinfection,
amoxicillin). - History of especially oral
cholestatic or rectal
jaundice or candidiasis.
hepatic - Instruct
dysfunction patient to
associated immediately
with this drug report signs or
symptoms of
hypersensitivity
reaction, such
as rash, fever,
or chills.
- Tell patient he
may take drug
with or without
food.
- Inform patient
that drug
lowers
resistance to
some types of
infections.
Instruct him to
report new
signs or
symptoms of
infection
(especially of
mouth or
rectum).
- Advise patient
to minimize GI
upset by eating
small, frequent
servings of food
and drinking
plenty of fluids.
- Tell patient
taking
hormonal
contraceptives
that drug may
reduce
contraceptive
efficacy.
Suggest she
use alternative
 birth control
method.
- Inform
parents that
they may give
liquid form of
drug directly to
child or may
mix it with
foods or
beverages.
- As
appropriate,
review all other
significant and
life-threatening
adverse
reactions and
interactions,
especially
those related to
the drugs,
foods, and
herbs
mentioned
above.
Drug Name: Inhibits - This - Hypersensitivity - If patient have
Mefenamic Acid prostaglandin medication to NSAIDs including had a stomach
synthesis by relieves pain aspirin or any ulcer or
Brand Name: decreasing the and reduces component of the bleeding, tell
Istan activity of the inflammation. formulation healthcare
enzyme, - Short-term - CNS: Headache, provider.
Drug cyclooxygenase, relief of mild nervousness, - Instruct
Classification: which results in to moderate dizziness patient to avoid
Analgesic decreased pain - Integumentary: alcohol
formation of Itching, rash (includes wine,
Dosage/Route: prostaglandin Contraindicati - Endocrine: Fluid beer, and
500mg capsule precursors ons: retention liquor) when
tid for pain - - GI: Abdominal taking this
Hypersensitivit cramps, heartburn, medicine since
y to aspirin indigestion, it can cause
(acetylsalicylic nausea,vomiting, increases in
acid) or other diarrhea, stomach
non-steroidal constipation, irritation.
anti- abdominal - Use caution if
inflammatory distress/cramping/p the patient has
agents. ain, dyspepsia, a weakened
- Inflammatory flatulence, gastric heart. It may
intestinal or duodenal ulcer cause
diseases. with bleeding or increased
- Active peptic perforation, shortness of
ulcers gastritis breath or
- Renal Failure - Hematologic: weight gain.
Bleeding Then
- Otic: Tinnitus recommend
 talking with
healthcare
provider or his
own physician.
- Avoid aspirin,
aspirin-
containing
products, other
pain medicines,
other blood
thinners
(warfarin,
ticlopidine,
clopidogrel),
garlic, ginseng,
ginkgo, and
vitamin E while
taking. Talk
with healthcare
provider.
- If patient is
allergic to any
medicine,
especially
aspirin, or have
asthma. Make
sure to tell
about the
allergy and how
it affected the
patient by
consulting its
attending
physician.
Drug Name: The only Indications: Transient mild Diabetics,
Vitamin C functional role of - soreness may occur patients prone
the vitamin to be recommended at the site of to recurrent
Brand Name: categorically for the intramuscular or renal calculi,
Poten-Cee established is its prevention subcutaneous those
ability to prevent and treatment injection. Too-rapid undergoing
Drug and or cure of scurvy intravenous stool occult
Classification: scurvy. In this - Its parenteral administration of blood tests,
Vitamins role, however, it administration the solution may and those on
must affect in is desirable for cause temporary sodium-
Dosage/Route: some degree patients with faintness or restricted diets
1 tablet a every bodily an acute dizziness. or
day function because deficiency or anticoagulant
the vitamin is for those therapy should
needed literally whose not take
to hold the absorption of excessive
body’s cell orally ingested doses of
together. Normal ascorbic acid vitamin C over
development of is uncertain. an extended
cartilage, bone, period of time.
and dentine is Contraindicati Vitamin C
 dependent upon ons: should be given
an adequate -have with care to
supply of diabetes, patients with
vitamin C. -have kidney hyperoxaluria.
disease or an Tolerance may
increased risk be induced with
of kidney prolonged use
stone of large doses.
formation,
-have a
tartrazine
sensitivity
-have a sulfite
sensitivity
-are on a
sodium
restricted diet
-are
undergoing
testing of the
stool for blood
-are taking
warfarin
(Coumadin).

Drug Name: Multivitamin Indications: -Vitamin A: Known

Multivitamins supplement In vitamin Absorbtion of hypersensitivity
where a poor deficiencies. vitamin A from the to any of the
Brand Name: dietary intake of gastro-intestinal vitamins in this
Cernevit the relevant Contraindicati tract may be product or a
vitamins exists. ons: reduced by the pre-existing
Drug Hypersensitivit presence of hypervitaminos
Classification:Vi y to any of the neomycin, is.
tamins ingredients. cholestyramine, or
Pantothenol is liquid paraffin;
Dosage/Route: contra- absorption may
1 tab OD indicated in also be impaired in
haemophiliacs cholestatic jaundice
and in patients and fat-
with ileus due malabsorption
to mechanical conditions.
obstruction.
-Vitamin B6:
Reduces the effects
of levodopa.

-Vitamin C: Large
doses may cause
diarrhoea and other
gastro-intestinal
disturbances and
are associated with
the formation of
renal calcium
oxalate calculi.
APPENDIX:

I. Definition of terms

Myoma uteri - a benign tumor of the smooth muscle fibers of the uterus

salpingo-oophorectomy - is the surgical removal of a fallopian tube and an ovary

adhesiolysis - Surgery The surgical lysis of adhesions, usually by laparoscopy

Abdominal bloating - Abdominal bloating is a condition in which the

abdomen (belly) feels full and tight.

Tinnitus - is a ringing, swishing, or other type of noise that seems to

originate in the ear or head

Vertigo - It is the sensation of spinning or swaying while the body is actually

stationary with respect to the surroundings

Epistaxis – (nose bleed) is the relatively common occurrence of hemorrhage

from the nose, usually noticed when the blood drains out through the nostrils

Dysphagia - is the medical term for the symptom of difficulty in swallowing

Orthopnea - The inability to breathe easily unless one is sitting up straight

or standing erect.

Paroxysmal nocturnal dyspnea - A form of dyspnea characterized by the

patient's waking from sleep unable to breathe.

Engorged Neck Veins - Increased pressure and filling of the veins in the
neck, making them appear engorged and stand out

Cervical lymphadenopathy - The enlargement of the cervical lymph nodes.

Cyanosis - is a blue coloration of the skin and mucous membranes due to

the presence of > 5g/dl deoxygenated hemoglobin in blood vessels near the
skin surface.

heredofamilial disease - tending to occur in more than one member of a family

and suspected of having a genetic basis

cephalopelvic disporoportion - implies disproportion between the head of

the baby ('cephalus') and the mother's pelvis.

Abdominal hysterectomy - is a surgical procedure that removes your

uterus through an incision in your lower abdomen
 Bilateral salpingo-oophorectomy - is a surgery in which both a woman's
ovaries are removed, along with the fallopian tubes

infundibulopelvic ligament – or suspensory ligament of ovary, a band of peritoneum that

extends upward from the upper pole of the ovary; it contains the ovarian vessels and ovarian
plexus of nerves.

vesicouterine ligament - a ligament that extends from the anterior aspect

of the uterus to the bladder.

uterosacral - pertaining to the uterus and sacrum.

Cardinal ligament - part of a thickening of the visceral pelvic fascia beside

the cervix and vagina, passing laterally to merge with the upper fascia of the
pelvic diaphragm.

Transfixion suture - A crisscross stitch placed so as to control bleeding

from a tissue surface or small vessel when it is tied.

Laparotomy - Surgical incision into the abdominal cavity through the loin or
flank.

Endometrium - is the inner membrane of the mammalian uterus

Hyperechoic - producing increased amplitude of waves returned in

ultrasonography; characteristic of bone and dense tumor tissue.

Poikilocytosis - the presence of poikilocytes in the blood

Poikilocytes - are erythrocytes with abnormal shapes

Round ligament of uterus - A fibromuscular band attached to the uterus

on either side in front of and below the opening of the fallopian tube and
passing through the inguinal canal to the labia majora.

Broad ligament of the uterus - is the wide fold of peritoneum that

connects the sides of the uterus to the walls and floor of the pelvis.