President Diosdado Macapagal Boulevard, Metropolitan Park, Pasay City

For Related Learning Experience

NURSING PROCESS
Diagnosis:
Ovarian Cyst
OR Department
at St. Clare’s Medical Center

Submitted to:

Submitted by:
Group CB-15
Camino, Sheena D.
Cebrero, Rinalyn B.
Davantes, Yna Geeniel D.
Torres, Ranier Mark V.

Submitted on:
August 13, 2010
 CONTENTS

I. ASSESSMENT

A. General Data

B. Chief Complaint(s)

C. History of present illness

D. Past History

E. Systems Review

F. Family Assessment

G. Heredo-Family illness

H. Developmental History

I. Physical Examination

II. PERSONAL/SOCIAL HISTORY

III. ENVIRONMENTAL HISTORY

IV. OB/GYNE HISTORY

V. PEDIATRIC HISTORY

VI. PATOPHYSIOLOGY

VII. LABORATORY RESULT AND FINDINGS

VIII. DRUG STUDY

IX. LIST OF PRIORITY PROBLEM

X. NURSING CARE PLAN

XI. ON-GOING APPRAISAL

XII. DISCHARGE PLAN

INTRODUCTION

Ovarian cysts are small fluid-filled sacs that develop in a woman's ovaries. Most cysts are
harmless, but some may cause problems such as rupturing, bleeding, or pain; and surgery may be
required to remove the cyst(s). It is important to understand how these cysts may form. Women
normally have two ovaries that store and release eggs. Each ovary is about the size of a walnut,
and one ovary is located on each side of the uterus. One ovary produces one egg each month, and
this process starts a woman's monthly menstrual cycle. The egg is enclosed in a sac called a
follicle. An egg grows inside the ovary until estrogen (a hormone), signals the uterus to prepare
itself for the egg. In turn, the uterus begins to thicken itself and prepare for pregnancy. This cycle
occurs each month and usually ends when the egg is not fertilized. All contents of the uterus are
then expelled if the egg is not fertilized. This is called a menstrual period. In an ultrasound
image, ovarian cysts resemble bubbles. The cyst contains only fluid and is surrounded by a very
thin wall. This kind of cyst is also called a functional cyst, or simple cyst. If a follicle fails to
rupture and release the egg, the fluid remains and can form a cyst in the ovary. This usually
affects one of the ovaries. Small cysts (smaller than one-half inch) may be present in a normal
ovary while follicles are being formed. Ovarian cysts affect women of all ages. The vast
majority of ovarian cysts are considered functional (or physiologic). In other words, they have
nothing to do with disease. Most ovarian cysts are benign, meaning they are not cancerous, and
many disappear on their own in a matter of weeks without treatment. Cysts occur most often
during a woman's childbearing years. Ovarian cysts can be categorized as noncancerous or
cancerous growths. While cysts may be found in ovarian cancer, ovarian cysts typically represent
a normal process or harmless (benign) condition.

Ovarian Cysts Causes

Oral contraceptive/birth control pill use decreases the risk of developing ovarian cysts
because they prevent the ovaries from producing eggs during ovulation. The following are
possible risk factors for developing ovarian cysts:
•History of previous ovarian cysts
•Irregular menstrual cycles
•Increased upper body fat distribution
•Early menstruation (11 years or younger)
•Infertility
•Hypothyroidism or hormonal imbalance
•Tamoxifen therapy for breast cancer

Ovarian Cysts Symptoms

Usually ovarian cysts do not produce symptoms and are found during a routine physical
exam or are seen by chance on an ultrasound performed for other reasons.
However, the following symptoms may be present:
•Lower abdominal or pelvic pain, which may start and stop and may be severe, sudden, and
sharp.
•Irregular menstrual periods
•Feeling of lower abdominal or pelvic pressure or fullness
•Long-term pelvic pain during menstrual period that may also be felt in the lower back
•Pelvic pain after strenuous exercise or sexual intercourse
•Pain or pressure with urination or bowel movements
•Nausea and vomiting
•Vaginal pain or spots of blood from vagina
•Infertility
 Manila Doctors College
Pres. Diosdado Macapagal Blvd., Metropolitan Park, Pasay City

NURSING PROCESS

I. ASSESSMENT

A. General Data

Patient’s initial: R. N. G Sex: Female

Address: Baguio City Civil status: Married
Age: 39 years old Place of birth: Mindoro
# of days in the hospital: 2 days Order of admission: Ambulatory
Date of birth: February 16, 1971
Date of admission: August 5, 2010
Informant: Sena Catapano (sister)
Date of history taking: August 6, 2010

B. Chief Complaints

“Magpapaopera ako ng ovarian cyst,” as verbalized by the patient.

C. History of Present Illness

• June 1997, she undergoes bilateral tubal ligation after giving birth to her 2 nd child in Saint
Louis University Hospital of Sacred Heart, Baguio.

• August 2006, in San Juan de Dios Hospital she was tested for ultrasound of her urinary
bladder because she experience excess urination, the doctor noted that she has a cyst on
her left ovary.

• July 2007, during a routine check up the patient underwent on ultrasound of the whole
abdomen and was incidentally found to have a large ovarian cyst on her left ovary and
Cholecystectomy. She was advised to see her OB-GYNE.

• April 2008, she undergoes surgery of open Cholecystectomy at San Juan de Dios Hospital

• This July 28, 2010, at Saint Claire Medical Center, a week before her oophorectomy
operation, she was tested for her liver then at the same time the doctor noted that she has
 myoma on her left ovary after that she was told to consult to her OB-GYNE for surgery
of her myoma.

• August 5, 2010, the patient undergoes oophorectomy at Saint Claire Medical Center

D. Past History
1. Childhood Illness/es: mumps, measles, chicken pox
2. Adult Illness/es: DM type II
3. Immunization/s: NONE
4. Previous Hospitalization/s:1997 Saint Louis University Hospital for BTL
2008 San Juan de Dios Hospital for open Cholecystectomy
August 5, 2010 Saint Claire Medical Center for oophorectomy
5. Operation/s: 1997- Bilateral Tubal Ligation, 2008- Open Cholecystectomy
6. Injury/-ies: NONE
7. Medication/s: Celebrex for pain, Januvia for DM
8. Allergy/-ies: Seafoods

E. Systems Review - Gordon's Eleven Functional Areas

Interview date: August 5, 2010 (Post Operation)

• Health Perception -Health Management Pattern

Before confinement, the client said “ok lang naman ako, kumakain ako ng
marami tsaka nagpapahinga ako cminsan pag nakakaramdam ako ng pagod. Hindi
naman ako umiinom ng alak, di ako naninigarilyo, madalas naglilinis lang ako ng
bahay.” The client hadn’t experienced any accidents, just previous hospitalizations
because of her fatty liver, ovarian cyst and tubal ligation.

Preoperatively, the client stated “medyo kinakabahan nga ako eh pero pang
ilang operasyon na ‘to kaya nabawasan na din ang takot ko at naniniwala naman
akong magaling ang mga surgeon dito.”

Postoperatively, the client stated “medyo ok naman na ako, pero di ako

masyadong makagalaw ngayon kasi minsan kumikirot yung tahi ko. Kahit ganito
ang kalagayan ko, nakakakain pa rin naman ako ng marami.” She feels that she’s
recovering well.

• Nutritional-Metabolic Pattern

Before confinement, the client eats 5 times a day with good appetite. She
was restricted to eat beef and pork because of her fatty liver so she eats chicken
and vegetables most of the time. She also eats sandwiches in between meals. Her
typical fluid intake is 8-10 glasses of water. She drinks juice sometimes. She also
said that she drinks Gouji juice as her herbal medicine. She has allergy on
seafoods.
 Preoperatively, she lost her appetite because of the low abdominal pain
she’s experiencing. Six hours before the surgery, she was instructed NPO.

Postoperatively, she regained his lost appetite. She was advised clear liquid
diet. After that, full liquid diet then soft diet.

• Elimination Pattern

Before confinement, preoperatively and postoperatively, the client said she

doesn’t feel discomfort when urinating and defecating. She defecates twice a day,
brownish in color, soft and formed. She urinates with the amount of 80-105cc
every urge for 6-8 times a day. “Lagi akong ihi ng ihi at marami ang ihi ko,” as
verbalized by the patient. She describes her urine as amber in color and aromatic.

• Activity-Exercise Pattern

Before confinement, the client walks every morning with her husband
while going to the place where they work. She said that cleaning their house and
going out with her family every Sunday was her exercise.

Preoperatively and postoperatively, she can’t do her usual activities or

exercise because of intermittent low abdominal pain.

• Sleep-Rest Pattern

Before confinement, the client sleeps for 8-9 hours. She feels comfortably
after sleeping and does not have difficulty in sleeping. The client also takes nap
whenever she feels tired.

Preoperatively, she stated, “di ako masyadong nakatulog dahil iniisip ko

yung operasyon na gagawin sa akin.”

• Cognitive-Perception Pattern

Before confinement, preoperatively and postoperatively, the client has no

visual and hearing difficulties. She can speak well. She said that she has difficulty
in remembering things.

• Self-Perception - Self-Concept Pattern

The client feels satisfied of herself. She is happy with her family and she is
ready to do anything for the sake of her family. She said that she loves her family.
 Preoperatively, she sees herself weak and useless because she can’t do her
usual activities.

Postoperatively, she was relieved and felt blessed because the operation
was successful and her family showed their full support for her.

• Role-Relationship Pattern

The client has a nuclear family. She stated that as a mother, it is her
responsibility to take care of her family. Her children are very close to her. She
also said that when her children are sick, she’s the one taking them to the hospital
or to a doctor. Whenever there is problem in their house, she and her husband
handles the problem.

• Sexuality-Reproductive Pattern

The client and her husband are in good relationship. She said that her
husband is sweet and caring, most of the time helping her with responsibilities in
their house. She decided to have family planning by the means of undergoing
bilateral tubal ligation. She has irregular menstruation and experiences
dysmenorrhea and flank pain.

• Coping-Stress Tolerance Pattern

The client said that her usual stressor is their customers in their cell phone
repair shop. Whenever she feels stress, she takes a rest or sometimes goes out with
her family just to send away her stress. She copes well with her family and with
her neighbors.

 Values-Beliefs Pattern

The client is Roman Catholic. She prays every night and attends mass
every Sunday. Praying is important and divine for them. She said that her religion
really helps when difficulties arise. “Mas naging malapit ako kay God dahil sa
kondisyon ko ngayon,” as verbalized by the client.

F. Family Assessment

NAME RELATION AGE SEX OCCUPATION EDUCATIONAL

ATTAINMENT
M.G. Husband 42 M Self-employed High school graduate
R.G. Daughter 14 F Student 3rd yr. high school
C.G. Son 12 M Student Gr. 6

G. Heredo

Maternal: DM and Hypertension

Paternal: DM

H. Developmental History

THEORIST AGE TASK PATIENT DESCRIPTION

Erik Erikson 39 Intimacy vs. The patient has an intimate relationship with
 Isolation her husband. She works hard for the sake of
his family.
Sigmund Freud 39 Genital The patient is so much comfortable with his
sexuality and has a healthy relationship with
his husband.
Jean Piaget 39 Formal The patient knows that he had done his very
Operational best to be a good wife and mother. She solves
Stage problems independently or with the help of his
husband.
Lawrence 39 Universal The patient’s decisions and behaviors are
Kohlberg Ethical based on conscience rather than social laws.
Principle
James Fowler 39 Stage 6: The patient as a catholic is devoted with God.
Conjunctive She has kept her faith stronger especially that
Faith she is encountering a lot of trials. She
considers God as the center of his life.

I. Physical Examination

Time: 7:00pm Date: August 6, 2010 Post Operation

Height: 5'2'' Actual weight: 62 kg

Skin
I:
• No signs of edema
• absence of discoloration
P:
• skin moist and warm to touch
• good skin turgor

Nail
I:
• absence of clubbing
• absence of cyanosis
P:
• good capillary refill
• capillary refill is 2 sec

Head and Face

I:
• Normocephalic
• absence of lesions
P:
• absence of tender areas, masses and deformities

Eyes
I:
• eyes are parallel to each other
• pink conjunctiva
 • pupils (3-4 mm)
• eyebrows are symmetrical
• sclera is white
• PERRLA
• good eye convergence
• can read a newspaper

Ears
I:
• presence of cerumen
• symmetrical to the face
• same color as face
• no deviations
• able to hear whispered words
P:
• absence of lesions

Nose
I:
• symmetric and same color as the face
• patent bilaterally
• absence of exudates
• absence of nasal flaring
• can distinguish different kind of smell

Mouth & Pharynx

I:
• lips is pinkish
• absence of exudates
• absence of lesions
• buccal mucosa is pinkish
• absence of swelling in the gums and teeth
• no dentures
• tongue and uvula is in midline

Neck
I:
• absence of lesions
• full range of motion
• trachea is in midline
P:
• absence of tenderness

Thorax & Lungs

I:
• chest contour is symmetrical
P:
• no presence of lumps or masses
• no retractions
• chest excursion is symmetrical

Heart
 P:
• full & equal pulses
• PR: 78 bpm

Breast
• not performed

Abdomen
I:
• with dressing, dry and intact
• absence of redness and swelling in the surgical site
• with pain scale of 9/10

Extremities
I:
• absence of lesions or scars
• no cyanosis
• no edema
P:
• absence of numbness on lower extremities

Genitals
• not performed

Rectum & Anus

• not performed

Neurologic exam
• not performed

II. PERSONAL/ SOCIAL HISTORY

Habits: watching t.v. and doing household chores

Vices: none
Lifestyle: active
Social Affiliation: none
Rank/Order in the Family: mother
Travel: none
Educational Attainment: high school graduate
Client’s Usual Day Like:
The client usually wakes up at around 6 am and do some chores. She eats breakfast at 8
am, works in their and lunch at around 12 nn. Then eats dinner at 7 pm. The client usually goes
to sleep at 9 or 10 pm.

III. ENVIRONMENTAL HISTORY

The client’s place is a residential house with enough ventilation and the climate is cold.
Their garbage is collected regularly every Monday, Wednesday and Friday in the morning. They
have
IV. OB/GYNE HISTORY

Menarche (age): 11
When: every 3-4 months (irregular)
Amount and Characteristics:
The patient uses 4-5 pads per day and her menstruation flow is heavy, usually dark red and form
clots.
Duration: 3-4 days
Associated symptoms: Dysmenorrhea, flank pain
Deliveries: G-2 P-2 Operations-NSD
OB Score: T-2 P-0 A-0 L-2

V. PEDIATRIC HISTORY

N/A

VI. PATHOPHYSIOLOGY

THEORETICAL BASED

NON-MODIFIABLE: MODIFIABLE:

Gender Infertility
Age (commonly 30-60 yrs.) Lifestyle
History of previous ovarian cysts Irregular menstrual cycle
Early menstruation (11yrs. or younger) Hormonal imbalance

Hormonal imbalance

Irregular Follicles failed to ovulate/ released and ruptured an egg

menstruation

An egg may increase growth. Fluid remains

and can form a cyst in the ovary
Lower abdominal pain

Cyst may grow in size up to 15 cm in diameter Increase abdominal girth

Increase pelvic pressure/pain

Hemorrhage & acute Rupture of the cyst
pain
Fatigue & feeling of
Infection heaviness in the pelvis Urinary frequency &
painful defecation

Sepsis
 CLIENT BASED

NON-MODIFIABLE: MODIFIABLE:

Gender Infertility (bilateral tubal ligation)

Age (39 yrs.) Lifestyle
Early menstruation (11 yrs.) Irregular menstrual cycle
Hormonal imbalance
 Hormonal imbalance

Irregular Follicles failed to ovulate/ released and ruptured an egg

menstruation

An egg may increase growth. Fluid remains

and can form a cyst in the ovary
Lower abdominal pain

Cyst grow in size about 6 cm in diameter

Increase abdominal girth

Increase pelvic pressure/pain

Fatigue & feeling of Urinary frequency

heaviness in the pelvis

OOPHORECTOMY

VII. LABORATORY RESULT AND FINDINGS

SPECIMEN: URINE
• August 5, 2010

PHYSICAL EXAMINATION
Color: Yellow
Transparency: Clear
CHEMICAL ANALYSIS
pH: 5.0
Specific gravity: 1.020
Albumin: Negative
Glucose: Negative
MICROSCOPIC
RBC 0
WBC 0-1/HPF
Epithelial cell Few
Mucus Threads Few

Why Get Tested?

Urinalysis is to screen for metabolic and kidney disorders and urinary tract infections. It is
ordered widely and routinely to detect any abnormalities that require follow up. Often,
substances such as protein or glucose will begin to appear in the urine before patients are aware
that they may have a problem. It is used to detect urinary tract infections (UTI) and other
disorders of the urinary tract.
SPECIMEN: BLOOD

• August 5, 2010

LABORATORY NORMAL VALUE RESULT INTERPRETATIONS/

SIGNIFICANCE
HEMOGLOBIN (Male)140 – 175 g/L 132.0 NORMAL
(Female)120-150 g/L (Increased: dehydration
Decreased: anemia)
HEMATOCRIT (Male)0.41 – 0.51 0.40 LOW – may cause
(Female)0.37-0.47 hypervolemia
RBC COUNT (Male) 4.61 NORMAL
4.6 – 5.6X10^2/L (Decreased: anemia;
(Female) Increased: when too
4 – 5.6X10^2/L many made and with
fluid loss due to
diarrhea, dehydration,
burns)

WBC COUNT 4.5 – 11X10^9/L 7.8 NORMAL

(Increased: infections,
inflammation, cancer,
leukemia
Decreased: bone marrow
failure, and congenital
marrow aplasia (marrow
doesn't develop
normally)

When is it ordered?

The CBC is a very common test. Many patients will have baseline CBC tests to help determine
their general health status. If they are healthy and they have cell populations that are within
normal limits, then they may not require another CBC until their health status changes or until
their doctor feels that it is necessary.

If a patient is having symptoms such as fatigue or weakness or has an infection, inflammation,

bruising, or bleeding, then the doctor may order a CBC to help diagnose the cause. Significant
increases in WBCs may help confirm that an infection is present and suggest the need for further
testing to identify its cause. Decreases in the number of RBCs (anemia) can be further evaluated
by changes in size or shape of the RBCs to help determine if the cause might be decreased
production, increased loss, or increased destruction of RBCs. A platelet count that is low or
extremely high may confirm the cause of excessive bleeding or clotting and can also be
associated with diseases of the bone marrow such as leukemia.

XI. ONGOING APPRAISAL

N/A

XIII. DISCHARGE PLAN

N/A