I.

INTRODUCTION
In the field of nursing, one encounters a wide-array of various
diseases and conditions. In order to give adequate and holistic
care to individuals, it is necessary that nurses be equipped
with the proper knowledge and skills for dealing with diff erent
health states. It is only through continuous learning that nurses
acquire the necessary skill. A case study is a means of continuing
such learning. In doing a case study, the nurses delve into the
question, what is this disease condition?
Myoma is a condition where there is a benign growth or tumor of
smooth muscle in the wall of the uterus. The said growth is made up
of fibrous tissue; hence it is often called a fibroid tumor. Uterine
fibroids can be present and be in apparent. Fibroids vary in size and
number, and are most often slow-growing and usually cause no
symptoms. It may grow as a single nodule or in clusters, and may
range in size from 1 mm to more than 20 cm in diameter. Myomas
are the most frequently diagnosed tumor of the female pelvis,
and the most common reason for hysterectomy. Although they are
often referred to as tumors, they are not cancerous. Most myomas
develop in women during their reproductive years. Myomas do not
develop before the body begins producing estrogens. Myomas tend
to grow very quickly during pregnancy when the body is producing
extra estrogen. Once menopause as begun, the myoma generally
stops growing and may begin to shrink due to the loss of estrogen.
Fibroids may be removed if they cause discomforts or if they are
associated with uterine bleeding. Approximately 25% of myomas
will cause symptoms and need medical treatment.
Statistics
Approximately 25 % of the myomas will cause symptoms and need
medical treatment. Myomas that that do not produce symptoms, do
not need to be treated. The said 25 % of women cause significant
morbidity, including prolonged or heavy menstrual bleeding, pelvic
pressure or pain, and in rare cases, reproductive dysfunction. In the
Philippines, the estimated number of women is 86,241,697 squared,
and the 4,312,084 had been affected of Myoma.
Rationale:
Nurses learn actively and will be able to handle patients and
experience what it means to care for a patient with that particular
condition. They learn from continuous interaction with the patients
along side with inquires into books and informative journals of the
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disease process, it symptoms, and corresponding treatments.

Myomas are one of the conditions which nurses encounter during
their exposure to the clinical setting. The disease comprises of
complexities of the anatomical concepts that surveys a
thorough description to understand its manifestations and formulate
interventions. It is interesting on my part to learn its definition,
causes, and proper management. I had chosen the case to be
able to have an insight about the condition for my continuous
learning for my patients also for myself as a woman on how to
prevent this condition also to educate other misconception on this
disease.
THEORETICAL BACKGROUND
The study is anchored in two theories of nursing which is related to
patients condition.
First the Lydia Hall theory which contains the three independent
but interconnected circles of the core, care and cure. This
explains how the patient should be managed during the disease
process which I may say Ive followed for the betterment of my
patient.
Halls theory define Nursing as the participation in care, core and
cure aspects of patient care, where CARE is the sole function of
nurses, whereas the CORE and CURE are shared with other
members of the health team. The major purpose of care is to
achieve an interpersonal relationship with the individual that will
facilitate the development of the core.
As Hall says; To look at and listen to self is often too difficult
without the help of a significant figure (nurturer) who has learned
how to hold up a mirror and sounding board to invite the behaver to
look and listen to himself. If he accepts the invitation, he will
explore the concerns in his acts and as he listens to his exploration
through the reflection of the nurse, he may uncover in sequence his
difficulties, the problem area, his problem, and eventually the
threat which is dictating his out-of-control behavior.
The Care Circle
According to the theory, nurses are focused on performing the noble
task of nurturing patients. This circle solely represents the role of
nurses, and is focused on performing the task of nurturing patients.
Nurturing involves using the factors that make up the concept of
mothering (care and comfort of the person) and provide for
teaching-learning activities.
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The care circle defines the primary role of a professional nurse such
as providing bodily care for the patient and helping the patient
complete such basic daily biological functions as eating, bathing,
elimination, and dressing. When providing this care, the nurses goal
is the comfort of the patient.
Moreover, the role of the nurse also includes educating patients,
and helping a patient meet any needs he or she is unable to meet
alone. This presents the nurse and patient with an opportunity for
closeness. As closeness develops, the patient can share and explore
feelings with the nurse.
The Core Circle
The core, according to Halls theory, is the patient receiving nursing
care. The core has goals set by him or herself rather than by any
other person, and behaves according to his or her feelings and
values. This involves the therapeutic use of self, and is shared with
other members of the health team.
This area emphasizes the social, emotional, spiritual, and
intellectual needs of the patient in relation to family, institution,
community and the world. This is able to help the patient verbally
express feelings regarding the disease process and its effects by the
use of reflective technique. Through such expression, the patient is
able to gain self-identity and further develop maturity.
Reflective technique is used by the professional nurse in a way
the he or she acts as a mirror to the patient to help the latter
explore his or her own feelings regarding his or her current health
status and related potential changes in lifestyle.
Motivations are discovered through the process of bringing into
awareness the feelings being experienced. With this awareness, the
patient is now able to make conscious decisions based on
understood and accepted feelings and motivation.
The Cure Circle
The cure as explained in this theory is the aspect of nursing which
involves the administration of medications and treatments. Hall
explains in the model that the cure circle is shared by the nurse with
other health professionals, such as physicians or physical therapists.
In short, these are the interventions or actions geared toward
treating the patient for whatever illness or disease he or she is
suffering from. During this aspect of nursing care, the nurse is an
active advocate of the patient.

As seen in the figure above, the three interlocking circles may change in size
and overlap in relation to the patients phase in the disease process. A nurse
functions in all three circles but to different degrees.
For example, in the care phase, the nurse gives hands-on bodily care to the
patient in relation in relation to the activities of daily living such as toileting
and bathing. In the cure phase, the nurse applies medical knowledge to
treatment of the person, and in the core phase, the nurse addresses the
social and emotional needs of the patient for effective communication and a
comfortable environment.
Hall used her knowledge of psychiatry and nursing experiences in the Loeb
Center as a framework for formulating the Care, Core and Cure Theory. Her
model contains three independent but interconnected circles. The three
circles are: the core, the care, and the cure.
Second the theory of Faye G. Abdellah which should be applied during the
patients interaction in order to recognized, prioritized and give proper
management for my patient who had a heavy bleeding, undergone an
operation and adaptation to the changes after the operation.
According to Abdellahs theory, Nursing is based on an art and science that
moulds the attitudes, intellectual competencies, and technical skills of the
individual nurse into the desire and ability to help people, sick or well, cope
with their health needs.

The patient-centered approach to nursing was developed from Abdellahs

practice, and the theory is considered a human needs theory. It was
formulated to be an instrument for nursing education, so it most suitable and
useful in that field. The nursing model is intended to guide care in hospital
institutions, but can also be applied to community health nursing, as well.
The 21 nursing problems fall into three categories: physical, sociological, and
emotional needs of patients; types of interpersonal relationships between
the patient and nurse; and common elements of patient care. She used
Hendersons 14 basic human needs and nursing research to establish the
classification of nursing problems. Abdellahs 21 Nursing Problems are the
following:
1.

To maintain good hygiene and physical comfort

2.

To promote optimal activity: exercise, rest, sleep

3.

To promote safety through prevention of accident, injury, or other

trauma and through prevention of the spread of infection

4.

To maintain good body mechanics and prevent and correct deformity

5.

To facilitate the maintenance of a supply of oxygen to all body cells

6.

To facilitate the maintenance of nutrition for all body cells

7.

To facilitate the maintenance of elimination

8.

To facilitate the maintenance of fluid and electrolyte balance

9.

To recognize the physiologic responses of the body to disease

conditionspathologic, physiologic, and compensatory

10.

To facilitate the maintenance of regulatory mechanisms and functions

11.

To facilitate the maintenance of sensory function

12.
To identify and accept positive and negative expressions, feelings, and
reactions
13.

To identify and accept interrelatedness of emotions and organic illness

14.
To facilitate the maintenance of effective verbal and nonverbal
communication
15.

To promote the development of productive interpersonal relationships

16.

To facilitate progress toward achievement and personal spiritual goals

17.

To create or maintain a therapeutic environment

18.
To facilitate awareness of self as an individual with varying physical,
emotional, and developmental needs
19.
To accept the optimum possible goals in the light of limitations,
physical and emotional
20.
To use community resources as an aid in resolving problems that arise
from illness
21.
To understand the role of social problems as influencing factors in the
cause of illness
Moreover, the needs of patients are further divided into four
categories: basic to all patients, sustenal care needs, remedial care needs,
and restorative care needs

Abdellah s typology of 21 nursing problems is a conceptual model mainly

concerned with patients needs and the role of nurses in problem
identification using a problem analysis approach.
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According to the model, patients are described as having physical,

emotional, and sociological needs. People are also the only justification for
the existence of nursing. That is, without people, nursing would not be a
profession since they are the recipients of nursing.
As a whole, the theory is intended to guide care not just in the hospital
setting, but can also be applied to community nursing, as well. The model
has interrelated concepts of health and nursing problems, as well as
problem-solving, which is an activity inherently logical in nature.
CONCEPTUAL FRAMEWORK

F a
y e
A b
d e l
l a h

U t e
r i n
e
LMy y
d i a
m l l ' s
Ho a
C aa r e , C
o P r ae t, iC u
e nr et

The Uterine Myoma patient undergone the disease process which needs a
total patient care that co relate with Lydia Halls 3Cs Care, Core, Cure and
also the Faye G. Abdellah 21 Nursing problem which should be applied during
the patients interaction in order to recognized, prioritized and give proper
management for my patient who had a heavy bleeding, undergone an
operation and adaptation to the changes after the operation.

In Lydia Halls theory the core is the patient, the cure refers to the medical
and nursing interventions and the care is the nurturing provided by nurses.
7

Nursing functions in all three of the circles but shares them to different
degrees with other disciplines.
Even though Hall confined her concepts for patients with the age of 16 years
and above, the concepts of care, core and cure can still be applied to every
age group but again, none was specified.
This theory puts emphasis on the importance of the total patient rather than
looking at one part or aspect. There is also emphasis put on all three aspects
of the theory, the three Cs, functioning together.
And for a nurse to successfully apply Halls theory, the individual must pass
an acute stage of illness. In this theory, no nursing contact with healthy
individuals, families, or communities, contradicts the concept of health
maintenance and disease prevention.
In Faye Abdellahs 21 nursing this gives emphasis on the problem solving
approach in caring for the patient. Patient-centered approaches to nursing
health are described as a state mutually exclusive of illness. Abdellah does
not provide a definition of health, but speaks to total health needs and a
healthy state of mind and body in her description of nursing.
However, Abdellah rather conceptualized nurses actions in nursing care
which is contrary to her aim of formulating a clear categorization of patients
problems as health needs. Nurses roles were defined to alleviate the
problems assessed through the proposed problem-solving approach.

STATEMENT OF THE PROBLEM

The main purpose of this case study is to gain knowledge, skills in
assessment and attitude in caring of patient with Uterine Myoma.
Also to answer these specific queries:
Specifically it aims to find out the following:
1.) What is Uterine Myoma (Leiomyoma)?
2.) What is the precipitating/predisposing factor that causes Uterine
Myoma?
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3.) How to assess signs and symptoms of Uterine Myoma?

4.) How is the disease occur or disease process?
5.) What are the medical and surgical management of Uterine
Myoma?
6.) Nursing interventions/management in caring for patient with
Uterine Myoma and post TAH.
7.) What are the possible complications of Uterine Myoma?
8.) Prevention and Treatment of Uterine Myoma.
SIGNIFICANCE OF THE STUDY
This study will be of great benefit to the following:
The patient this will help her to gain more knowledge about
the disease condition and make prompt action if ever another
fibroid may grow. This may also motivate her to maintain a healthy
lifestyle.
The husband and family/significant others - this would give
them insights about what is the disease which will make them
broaden their mind in understanding and caring for the patient. By
this they can be a great help for the patient to be the primary
health care providers and support system.
The healthcare professionals - this study will make them more
knowledgeable about the disease condition. The knowledge of
which can help them encourage the patient to the compliance to
the prescribed treatment and be the primary health educator as to
the prevention of the risk/predisposing factor, by this also this can
help in modifying their nursing care plan in caring for patients with
Uterine Myoma.
The community this will widen the perspective of the
community people on having a productive and healthy lifestyle. By
this they will be encourage to do prevention more than cure.
RESEARCH METHODOLOGY

A Case Study Approach

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 Design
- This study utilized the case study approach. Herein
the researcher will have a depth analysis of a Uterine
Myoma patients condition and will try to focus on
the different reaction and responses of the patient
with her current status.
Environment
-

The study was conducted in a hospital setting

specifically in Medical Mission Group Hospitals and
Health Services Cooperative Philippines (Bohol
Cooperative Hospital) Private Room 222 in Binayran
Road, Dampas District, Tagbilaran City, Bohol, where
the patient was admitted and managed for her
current condition.

Study subjects
- The study was focused on a certain OB or
Maternal patient. The researcher conducted a
thorough physical assessment of the patient and
performed a nursing measures to resolve health
problems seen and recognized by the patient and
the researcher.
Instrument
- Physical examination/assessment
- Interview with the patient herself and significant
others using the therapeutic communication
technique
- Reviewing the chart and taking notes for further
assessment
SITUATIONAL ANALYSIS

PATIENTS PROFILE
Name: L. E.C
Age: 42 years old
Address: La Paz, Carmen, Bohol
Sex: Female
Status: Married
Citizenship: Filipino
Religion: Roman Catholic
Date of Birth: November 6, 1971
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Birth Place: Carmen, Bohol

Occupation: Nurse at HNU- MCFI
Attending Physician: Dr. Marjorie Aventurado
Date Admitted: August 4, 2014 (3:19 P.M.)
Date Discharged: August 8, 2014 (2:18 P.M.)
Final Diagnosis: Abnormal Uterine Bleeding Intramural Myoma
Surgical Procedure: Elective Total Abdominal Hysterectomy
SOURCE OF INFORMATION
Primary source: The patient herself
Secondary source: The chart ,patients husband and patients
significant others
CHIEF COMPLAINT
Abdominal Pain on Hypogastric Area with Enlargement and
Heavy Menstrual Flow
HISTORY
Present Illness:
Few days prior to admission on/off abdominal pain on
hypogastric area persist. Ultrasound done and Myoma was
confirmed heavy menstrual bleeding.
July 16, 2014 Diagnosed with Myoma
Obstetrical history:

G2 P2 ( 2-0-0-2)
Menarche starts at between ages 9- 10 years old
First sexual intercourse at age 17 years old
Get married and pregnant at the age of 29 years old
Delivered NSVD 2x with a gap of 5 years
Reported did not undergone any OB diagnostic examination for
regular basis before.

Past Illness:
Asthma in High School
Delivered Normal Spontaneous Vaginal Delivery ( 1998 and 2003)
Familial Illness:
Father side: (+) Asthma, Diabetes Mellitus and Hypertensive, (+)
Alcolohic and has known history of colon cancer
Mother side: (+) Hypertensive, no known history of cancer of any
kind but has (+) of Alzheimers and Schizophrenia
Environment:
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 In Carmen, Bohol: The house is located along the Provincial High

Way with a minimal distance to the rice fields, surrounded by
plants and trees.
Currently residing in Tagbilaran City, in an Apartment in Dampas
District near in the hospital where she works

ANATOMY AND PHYSIOLOGY OF THE ORGAN INVOLVED

The female reproductive system consists of the ovaries, uterine tubes

(or fallopian tubes), uterus, vagina, external genitalia, and mammary
glands. The internal reproductive organs of the female are located
within the pelvis, between the urinary bladder and the rectum. The
uterus and the vagina are in the midline , with an ovary to each side of
the organ. The internal reproductive organs are held in place within the
pelvis with ligaments. The most conspicuous is the brad ligament,
which spreads out on both sides of the uterus and to which the ovaries
and the uterine tubes attach.

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Ovaries
The two ovaries are small organs suspended in the pelvic cavity by
ligaments. The s upe rio r li game nts exte nd from each ovary to the
lateral body wall, and the ovarian ligament attaches the ovary to the
superior margin of the uterus. In addition, the ovaries are attached to
the posterior surface of the broad ligament by folds of the peritoneum
called the mesovarium. The ovarian arteries, veins, and nerves
transverse the suspensor ligament and enter the ovary through the
mesovarium.
A layer of visceral peritoneum covers the surface of the ovary. The
outer part of the ovary is made up of dense connective tissue and
contains the ovarian follicles. Each of the ovarian follicles contains an
oocyte, the female sex cell. Loose connective tissue makes up
the inner part of the ovary, where blood vessels, lymphatic vessels,
and nerves are located.
Uterine Tubes
A uterine tube, fallopian tube, or oviduct (named after the Italian
anatomist, Gabriele Fallopio) is associated with each ovary. The
uterine tubes extend from the area of the ovaries to the uterus. The
open directly into the peritoneal cavity near each ovary and receive an
oocyte. The opening of each uterine tube is surrounded by long, thin
processes called fimbriae. The fimbriae nearly surround the surface of
the ovary. As a result, as soon as the oocyte is ovulated, it comes into
contact with the surface of the fimbriae. Cilia on the fimbriae surface
sweep the oocyte into the uterine tube. Fertilization usually occurs in
the part of the uterine tube near the ovary known as the ampulla.
Uterus
The uterus is as big as the size of a medium-sized pear. It is oriented
in the pelvic cavity with the larger, rounded portion directed superiorly.
The part of the uterus superior to the entrance of the fallopian tubes is
called the fundus. The main part of the uterus is called the body, and
the narrower part is termed the cervix and is directed inferiorly.
Internally, the uterine cavity in the fundus and uterine body continues
through the cervix as the cervical canal, which opens into the vagina.
The cervical canal is lined by mucous glands.
The Uterine wall is composed of three layers: a serous layer or
perimetrium of the uterus, consists of smooth muscle is quite thick and
accounts for the bulk of the uterine wall. The inner most layer of the
uterus is called the endometrium. The endometrium consists of simple
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columnar epithelium tissues with an underlying connective tissue layer.

Simple tubular glands, called endometrial glands, are formed by folds
of the endometrium. The superficial part of the endometrium is
sloughed off during menstruation. The uterus is supported by the
broad ligament and the round ligament. In addition to these ligaments
that support the uterus, much support is provided inferiorly to the
uterus by skeletal muscles of the pelvic floor. If ligaments that support
the uterus or the muscles of the pelvic floor are weakened such as in
childbirth, the uterus can extend inferiorly into the vagina, a condition
termed as a prolapsed uterus. Severe cases require surgical correction.
Vagina
The vagina is the female organ of copulation and functions to receive
the penis during intercourse. It also allows menstrual flow and
childbirth. The vagina extends from the uterus to outside the body. The
superior portion of the vagina is attached to the sides of the cervix so
that a part of the cervix extends into the vagina. The wall of the
vagina consists of an outer muscular layer and an inner mucous layer.
The muscular layer is smooth muscle and contains many elastic fibers.
Thus the vagina can increase in size to accommodate the penis during
intercourse, and it can stretch greatly during childbirth. The mucous
membrane is moist stratified squamous epitheliam that forms a
protective surface layer. Lubricating fluid passes through the vaginal
epithelium into the vagina.
In young females, the vaginal opening is covered by a thin mucous
membrane known as the hymen. The hymen can completely close the
vaginal oriface in which case it must be removed to allow menstrual
flow. More commonly, the hymen is perforated by one or several holes.
The openings of the hymen are usually greatly enlarged during the first
sexual intercourse. The hymen can also be perforated during a variety
of activities including strenuous exercise. The condition of the hymen is
therefore not a reliable indicator of virginity.
The External Genitalia
The external female genitalia, also called the vulva, or pudendum,
consists of the vestibule and its surrounding structures. The vestibule
is the space into which the vagina and urethra open. The urethra opens
just anterior to the vagina. The vestibule is bordered by a pair of thin,
longitudinal skin folds called the labia minora. A small erectile structure
called the clitoris is located in the anterior margin of the vestibule. The
two labia minora unite over the clitoris to form a fold of skin known as
the prepuce. The clitoris consists of a shaft and a distal glans. Like the
glans penis, the clitoris is well supplied with sensory receptors, and it is
14

made up of erectile tissue. An additional erectile tissue is located on

either side of the vaginal opening.On each side of the vestibule,
between the vaginal opening and the labia minora, are openings of the
greater vestibular glands. These glands produce a lubricating fluid that
helps maintain the moistness of the vestibule. Lateral to the labia
minor are two prominent rounded folds of skin called the labia majora.
The two labia majora unite anteriorly at the elevation of tissue over the
pubic symphys are called the mons pubis. The lateral surfaces of the
labia majora and the surface of the mons pubis are covered with
coarse hair. The medial surfaces of the labia minora are covered with
numerous sebaceous and sweat glands. The space between the labia
minor is called the pudendal cleft. Most of the time, the labia minora
are in contact with each other across the midline , closing the pudendal
cleft and covering the deeper structures within the vestibule. The
region between the vagina and the anus is the clinical perineum. The
skin and muscle of this region can tear during childbirth. To prevent
such tearing, an incision called an episiotomy is sometimes made in
the clinical perineum. Traditionally, this clean, straight incision is
thought to result in less injury and less trouble in healing, and less
pain. However, many studies indicate that there is less injury and pain
when no episiotomy is performed.
Mammary Glands
Mammary glands are located inside the breasts of sexually mature
female body. They are in actuality modified sweat glands which are in
fact comprised of secretory mammary alveoli and the appropriate
ducts. Mammary glands are considered to be part of the
integuementary system rather than the reproductive system. The
glands are associated with the female reproductive system in part due
to their assistance in attracting a mate as well as their role in
nourishing a baby. Size and shape of the female breast are different for
every human body and factors such as race, age, body fat, and
pregnancy can make a large difference in these variations. The release
of estrogens during puberty releases hormones that stimulate the
growth of the breasts and the functions of the mammary
glands. Pregnant women as well as nursing women experience
hypotrophy of the breasts while it is not uncommon for atrophy of the
breasts to occur after menopause.
Breasts are situated over ribs 2 through 6 and overlap the pectoral
muscle as well as some portions of the oblique muscles. The lateral
margin of the sternum creates an unintentional margin for the edge of
each breast. Each breast also follows the anterior margin of
the respective axilla. Coming within very close proximity to the Axillary
vessels, the breasts upward and laterally toward the axilla, which
15

contributes to the high incidence of breast cancer due to the axillary

process lymphatic drainage.15 to 20 lobes compose the mammary
gland, and each lobe is equipped with its own duct to the outside of
the body. Adipose tissue in varying amounts segregates each lobe.
While this tissue controls the size and shape that the breast takes,
there is no determination by this tissue when it comes to the womans
ability to suckle her young. Lobules are subdivisions of each
lobe. These subdivisions contain mammary alveoli. The milk of a
lactating female are produced within the mammary alveoli. Suspensor
ligaments support the breasts which are attached between the lobules
and run deep into the fascia which overlap the pectoral muscles.
Breast milk is secreted into a network of mammary ducts which receive
the milk from the clusters of mammary alveoli. These mammary ducts
converge to form lactiferous ducts. Near the nipple, each lactiferous
duct expands into the lumen to allow for outward flow of milk. The
lactiferous sinuses store the milk before the suckling action, or
additional pressure, releases it from the body. The milk leaves the body
from the tip of the nipple. The nipple contains some erectile tissue that
protrudes into a cylindrical projection. The circular area around the
nipple that contrasts in colour is the areola. Sebaceous areola glands
create a bumpy surface around the areola which resides just under the
surface of the areolas skin. These glands secrete fluids during
lactation as well as when a woman is not lactating, which keep the
nipple supple. The complexion of the areola is based on the
complexion of the skin that covers the rest of the body, varying in
pigments and tints. During gestation most areola surfaces darken. It
also becomes larger in most cases. This is thought to be more obvious
for a nursing infant to find. Branches of the internal thoracic artery are
responsible for supplying blood flow to the nipple as well as the rest of
the breast and mammary glands. Between the second, third, and forth
intercostals spaces these branches of the thoracic artery enter the
mammary glands. These spaces are positioned laterally to the sternum
and offer entry to the mammary artery, which only supplies supportive
blood. The return veins run alongside the initial arteries which supply
the blood. During pregnancy and lactation, and sometimes during
other periods, a superficial venous plexus can be seen through the
surface of the skin. The fourth, fifth, and sixth thoracic nerves
innervate the breast principally through sensory somatic neurons.
These neurons are derivative of the anterior and lateral branches
of the thoracic nerves. The release of milk is dependent upon the
sensory innervations as stimulus is the only natural release an infant
can provide to be nourished.
Menstrual Cycle

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Menstruation is the shedding of the lining of the uterus (endometrium)

accompanied by bleeding. It occurs in approximately monthly cycles
throughout a woman's reproductive life, except during pregnancy.
Menstruation starts during puberty (at menarche) and stops
permanently at menopause. By definition, the menstrual cycle begins
with the first day of bleeding, which is counted as day1. The cycle ends
just before the next menstrual period. Menstrual cycles normally range
from about 25 to 36 days. Only 10 to 15% of women have cycles that
are exactly 28 days. Usually, the cycles vary the most and the intervals
between periods are longest in the years immediately after menarche
and before menopause. Menstrual bleeding lasts 3 to 7 days,
averaging 5 days. Blood loss during a cycle usually ranges from to
2 ounces. A sanitary pad or tampon, depending on the type, can hold
up to an ounce of blood. Menstrual blood, unlike blood resulting from
an injury, usually does not clot unless the bleeding is very heavy. The
menstrual cycle is regulated by hormones. Luteinizing hormone and
follicle-stimulating hormone, which are produced by the pituitary
gland, promote ovulation and stimulate the ovaries to produce
estrogens and progesterone stimulate the uterus and breasts to
prepare for possible fertilization. The cycle has three phases: follicular
(before release of the egg), ovulatory (egg release), and luteal (after
egg release).
Menopause
When a woman is 40-50 years old, the menstrual cycles become less
regular and ovulation does not consistently occur during each cycle.
Eventually, the cycles stop completely. The cessation of menstrual
cycles is called menopause, and the whole time period from the onset
of irregular cycles to their complete cessation is called the female
climacteric. The major cause of menopause is age-related changes in
the ovaries. The number of follicles remaining in the ovaries of
menopausal women is small. In addition to this, the follicles that
remain become less sensitive to the stimulation of FSH and LH. As the
ovaries become less responsive to stimulation by FSH and LH, fewer
mature follicles and copora lutea are produced.
Gradual changes occur in women in response to the reduced amount of
estrogen and progesterone produced by ovaries. During the
climacteric, some women experience hot flashes, irritability, fatigue,
anxiety, temporary decrease in libido, and occasionally severe
emotional disturbances. Many of these symptoms can be treated
successfully with hormone replacement therapy, which usually consists
of small amounts of estrogen or progesterone. A potential side effect of
HRT is a slightly increased possibility of the development of breast
cancer, uterine cancer, heart attacks, strokes, and blood clots. HRT
17

does slow the decrease in bone density that can become sever in some
women after menopause, and decreases the risk of
developing colorectal cancer.
HORMONES AND FEMALE CYCLES

The ovarian cycle is hormonally regulated in two phases. The follicle secretes
estrogen before the ovulation; the corpus luteum secretes both estrogen
and progesterone after ovulation. Hormones from the hypothalamus and
anterior pituitary control the ovarian cycle. The ovarian cycle covers events
in the ovary; the menstrual cycle occurs in the uterus.
Menstrual cycles vary from between 15 and 31 days. The first day of the
cycle is the first day of blood flow (day 0) known as menstruation. During
menstruation, the uterine lining is broken down and shed as menstrual flow.
FSH and LH are secreted on day 0, beginning both the menstrual cycle and
the ovarian cycle. Both FSH and LH stimulate the maturation of a single
follicle in one of the ovaries and the secretion of estrogen. Rising levels of
estrogen in the bloodtrigger secretion of LH, which stimulates follicle
maturation and ovulation (day 14, or midcycle). LH stimulates the remaining
follicle cells to form the corpus luteum, which produces both estrogen and
progesterone. Estrogen and progesterone stimulate the development of the
endometrium and preparation of the uterine lining for implantation of
a zygote. If pregnancy does not occur, the drop in FSH and LH causes
the corpus luteum to disintegrate. The drop in hormones also causes the
sloughing off of the inner lining of the uterus by a series of muscle
contractions of the uterus.

18

PATHOPHYSIOLOGY
UTERINE (INTRAMURAL) LEIOMYOMA

Etiology
Predisposing/Precipitating Factors
Unknown
Age(30-45 years old)

- Heredity/Genetics
- Early Menarche
- High Fat Intake
Myoma is a condition where

Anxiety/Stress
there is a benign growth or tumor

Oral Contraceptives or
in the wall of the uterus. The said

Hormonal Replacement
growth is made up of fibrous
therapy
tissue; hence it is often
- Caffeine Intake
called a fibroid tumor.

Luteal Insufficiency
Smoking
- Multiparity/Nulliparity
- Menopause
Organ Involved:
Uterus

Sudden increase in
estrogen production

Proliferation of cells
in the uterus

19

Overgrowth of the
endometrial lining

Myoma: Development of
Uterine Fibroid

Uterine cavity begins

to stretch or increase in size

Interference in the
vascular supply

Degeneration of the
inferior part of fibroid

Signs and Symptoms:

-

Abdominal fullness, gas

Bleeding between periods or very prolonged bleeding with
periods
Increase in urinary frequency
Heavy menstrual bleeding (menorrhagia), sometimes with the
passage of blood clots
Pelvic cramping or pain with periods
Sensation of fullness or pressure in lower abdomen
Sudden, severe pain due to a pedunculated fibroid

20

Medical Treatment/
Nursing Interventions
Management
- Monitor Vital signs for
- Oral Contraceptives
baseline data
- Iron supplements
Monitor active fluid
- Hormonal Therapy
loss
- NSAIDs
Encouraged to drink
- IVF Therapy
only the prescribed

Diagnosis
Medical Diagnosis:
Uterine (Intramural)
Myoma

Nursing Diagnosis:
- Deficient fluid volume related

to blood loss

- Risk for infection related to

amount of fluids
Surgical Management
exposure of the surgical wound
Monitor serum
- Hysterectomy
to the environment
electrolytes and urine - Open Surgery
- Ineffective tissue
perfusion
osmolality
- Laparoscopy
related to hypovolemia
- Assess nutritional
- Hysteroscopy
- Pain related to uterine fibroids
status including
- Oophorectomy
or post surgical wound
weight, history of
- Myomectomy
- Impaired bowel or urinary
weight loss and
elimination related to post
serum albumin
operation
- Encourage intake of
protein and calorie
rich foods
-

Educate patient and

significant others the

21

importance of proper
hand washing
Inspect dressings and perineal
pads,
noting color, amount, and odor of noting color,
amount, and odor of drainage.
Weigh pads and compare with
dry weight if patient
is bleeding heavily.
- Turn patient and encourage
frequent
coughing and
deepbreathing exercises.
- Assessed characteristics of
pain including the non
verbal cues
- Encouraged gradual ambulation
when tolerated
- Avoid high-Fowlers position and
pressure under the
knees
or crossing of legs.
- Assist with/instruct in foot and
leg
exercises and ambulate as
soon as able.
-

COMPLICATIONS
o Large fibroids may cause infertility by:
- Impairing the uterine lining, blocking the fallopian tubes, Distorting
the shape of theuterine cavity, Altering the position of the cervix and
preventing sperm from reaching theuterus
o Pregnancy complications and delivery risks:
- Cesarean section delivery, Breech presentation, Preterm birth,
Placenta previa, Postpartumhemorrhage
o Anemia
o Pressure on the ureters may cause urinary obstruction and kidney
damage.
o Pain can also develop if the blood supply is cut off from the fibroid
tissue. In such cases,the cells blacken and die (a process called
necrosis) from lack of oxygen.
22

- A very large fibroid outgrows its own blood supply; a pedunculated

fibroid (one that growson a stem from the uterine wall) becomes
twisted, thus cutting off its blood supply, Pregnancyoccurs in which the
risk for fibroid cell degeneration and necrosis increases
o Fibroid breaks away from the uterus and develops in other locations.
They are typicallyone of the following:- Benign Metastasizing
Leiomyoma, or BML (which usually spreads to thelung)
- Disseminated Peritoneal Leiomyomatosis (which spreads to the
abdominal wall
o Uterine Cancer
- Fibroids are nearly always noncancerous, even if they have abnormal
cell shapes. Cancer of the uterus nearly always develops in the lining
of the uterus (endometrial cancer).
WRITE UPS ABOUT THE DISEASE
UTERINE MYOMA (LEIOMYOMA)
Among 20% to 50% women may have myoma uterine. This could not be
alarming since it is a noncancerous type of tumor growing in the uterus. This
mutation of cells in the uterus is benign in nature which means it could not
affect the function of the uterus. There are some medical literatures that
describe this benign tumor as fibroid or leiomyomata.
Although it is benign in nature, this is the most common indication for
women to undergo a surgical procedure called hysterectomy. The larger the
body mass of a woman, the higher her tendency to develop such tumors.
According to the survey, black American women are more common to have
this compared to Asian women. The symptoms usually appear between the
age of 30 to 40 years old. When it comes to its etiology, the origin of tumor
growth cannot be pointed out yet. Usually, women may have this growing in
their uterus during pregnancy. When menopause ensues, it shrink its size,
however there are cases that it may cause pain as it degenerates.

23

Classification of Myoma Uterine:

1.
Intramural This is the most common(70%) myoma uteri. It can be
located in the uterine wall.
2.
Subserosal Almost 20% of women may have this. It can be located in
the serosa
3.
Submucosal It is located beneath the endometrium. Only 10% of
women were found to have this case.
Signs and Symptoms:
1.
Asymptomatic in most cases
2.
Fullness sensation in the lower abdomen
3.
Frequent urination
4.
Vaginal bleeding between periods
5.
Dyspareunia
6.
Lower back pain
7.
Abdominal pain or cramps
8.
Change in bowel movement
9.
Infertility
10. Recurrent miscarriage
Clinical Examination:
1.
Evident abdominal mass
2.
Tender and large size abdomen
3.
Signs of anemia due to menorrhagia
Diagnostic Examination:
1.
A pregnancy test must be done so that pregnancy can be ruled out.

24

2.

Complete blood count must be taken in order to check for the

haemoglobin levels especially for women who experience excessive
bleeding.
3.
An accurate examination is through transvaginal ultrasound.
4.
In cases that the myoma cannot be completely diagnosed with
transvaginal ultrasound, a magnetic resonance imaging is used in order to
help in assessing the depth of the tumor.
5.
Biopsy can be done during hysterectomy in order to study the tissue
involved in the mutation.

TREATMENT AND MANAGEMENT

Medical Management:
1. Non-steroidal Anti-inflammatory Drugs (NSAIDS) are prescribed in order
to reduce the pain sensation as well as minimize the blood loss.
2. Tranexamic acid is given for patients suffering from excessive blood
loss.
Surgical Management:
1. Oophorectomy is done when ovaries are also included in the damage.
Surgical management is indicated when the uterine size is much
enlarged. The abnormal bleeding is also another indication for surgical
removal since continuous blood loss can result to anemia.
2. Myomectomy are intended for patients that are included in the
reproductive age. Women who wanted to conceive can opt for this
after a complete assessment.
3. Laparoscope-assisted vaginal hysterectomy is the newest method of
surgery wherein only a small incision is done in order to minimize
bleeding.

25

II. PROBLEM ANALYSIS

DATE
OF
DUTY
August
05,
2014
(AM
shift)
Day 1

NURSING
DIAGNOSI
S
1. Pain
related to
post
surgical
operation(
Total
Abdominal
Hysterecto
my)
Data:
> Patient
reported of
pain with a
pain scale
of 9/10
> grimaced
face and
guarded
movement
observed
1hour after
transport
from the OR
> weakness
noted

EXPECTED
OUTCOME
After my 8
hours of
nursing
care and
interventio
n patient
will report a
decrease in
pain
sensation.

PLAN OF
INTERVENTION
Monitored vital
signs

Perform a
comprehensive
assessment of
pain to include
location,
characteristics,
onset, duration,
frequency,
quality, intensity
or
severity, and
precipitating
factors of pain
Encouraged
verbalization of
feelings

Encourage
turning to sides,
coughing, deep
breathing and
relaxation
technique also
some distraction
activities

SCIENTIFIC
BASIS WITH
RATIONALE
- for baseline data
( post operatively
and on regular
basis)
- Pain is a
subjective
experience and
must be described
by the patient in
order to plan
effective
treatment.

- to assess the
level of
consciousness and
to monitor the
wearing off of
anaesthesia

- the use of non

invasive pain relief
can increase the
release of
endorphins and
enhances the
therapeutic effect
26

of pain relief
medications

Orient to time,
date and place

Provide
adequate rest
periods and a
conducive
environment to
sleep to ease
feeling after the
operation

2.
Impaired
urinary
eliminatio
n related
to post
operative
trauma to
the
bladder
Data:
> With
Foley Bag
catheter
drained to
Urobag
> No urine
output after

After my
8 hours of
nursing
care and
interventio
n patient
will be able
to empty
bladder
regularly
and
completely.

Collaborative
Management:
Administer
prescribed pain
relief medications

- to assess the
level of
consciousness and
for patients
comfort
- to give time for
the patient to rest
due to traumatic
exposure

- for relief of pain

Note voiding
pattern and
monitor urinary
output.

Palpate bladder.
Investigate
reports of
discomfort,
fullness, inability
to void

Provide routine

- May indicate
urinary retention if
voiding frequently
in
small/insufficient
amounts
- Perception of
bladder fullness,
distension of
bladder above
symphysis pubis
27

8 hours
post
operation
> Slightly
distended
bladder
noted

voiding
measures, e.g.,
privacy, normal
position, running
water in sink,
pouring warm
water over
perineum.

Provide/encourag
e good perianeal
cleansing and
catheter care.
Assess urine
characteristics,
noting color,
clarity, odor.

Maintain
patency of
indwelling
catheter; keep
drainage tubing
free of kinks
Check residual
urine volume
after voiding as
indicated.

Collaborative
Management:
DLR 1Liter fast

indicates urinary
retention.
- Promotes
relaxation of
perineal muscles
and may facilitate
voiding efforts

- Promotes
cleanliness,
reducing risk of
ascending urinary
tract infection
(UTI).
- Urinary
retention, vaginal
drainage, and
possible presence
of
intermittent/indwe
lling catheter
increase risk of
infection,
especially if
patient has
perineal sutures.
- Promotes free
drainage of urine,
reducing risk of
urinary
stasis/retention
and infection.
- May not be
emptying bladder
completely;
retention of urine
increases
possibility for
28

drip of 500 cc as
ordered

August
06,
2014
(AM
shift)
Day
2

1.
Impaired
physical
mobility
related to
pain/disco
mfort

2. Risk for
infection
related to
surgical
wound
exposure

After my 8
hours of
nursing
care and
interventio
n patient
will be able
to:
a.)
Verbalize
understandi
ng
of situation
and
individual
treatment
regimen
and safety
measures.
b.)
Demonstrat
e
techniques
that enable
resumption
of activities
such as
splinting,
early
ambulation
and
engaging in
self-care
activities.

Instruct patient
to splint the
wound with a
pillow if patient
attempts to
move.
Assist with
self care
activities.

Provide
assistance with
mobility

Monitor BP with
resumption
of activity. Note
reports
of dizziness.
Collaborative
Management:
Administer
prescribed pain
relief medications
Assess
nutritional status,

infection and is
uncomfortable/pai
nful.
- to flush urine
output
- Splinting
supports the
wound and
minimizes the
discomfort and
pain felt.
- Improves muscle
strength and
circulation,
enhances patient
control in the
situation and
promotes
self directed
wellness.
- Early mobility
reduces
complications
of bed rest.
Promotes
healing and
normalization of
organ function.
- Postural
hypotension is
common to
patients on bed
rest and may
require
interventions like
elevation of bed.
- for relief of pain

29

to the
environme
nt
Data:
> surgical
wound at
hypogastric
area of the
abdomen

After my 8
hours of
nursing
care and
interventio
n patient
will be free
from
infection as
evidenced
by normal
vital signs
and
absence
of purulent
drainage
from
wounds,
incisions,
and tubes

including weight,
history of weight
loss, and serum
albumin.

Encourage
intake of proteinand calorie-rich
foods.
Educate patient
of importance of
frequent hand
washing and
teach
other caregivers
to wash
hands before
contact with
patient
and between
procedures
with patient.
Collaborative
Management:
Administer
prescribed
Antibiotics

August
07,
2014
(AM
shift)
Day
3

1.Constipa
tion
related to
anatomica
l
obstructio
n of the
rectum

After my 8
hours of
nursing
care and
interventio
n patient
will be able
to:

Determine
patients fluid
intake
Note color,
odor. consistency,
amount, and
frequency of
stool

- Patients with
poor nutritional
status may be
anergic, or unable
to muster a
cellular immune
response to
pathogens and are
therefore more
susceptible to
infection.
- This maintains
optimal nutritional
status.
- Friction and
running
water effectively
remove
microorganisms
from hands.
Washing between
procedures
reduces the risk of
transmitting patho
gens from one
area of the body
to another.
- to prevent from
infection
- To evaluate
patients hydration
status.
- Provides a
baseline
for comparison,
promotes
recognition
30

and
inadequat
e intake of
fluids and
bulk
Data:
> reported
(+) flatus
last August
06,2014 but
no stool
> reported
no bowel
movement
for 4 days

2.
Impaired
skin
integrity
related to
surgical
incision in
the

a.)
Verbalize
understandi
ng
of etiology
and
appropriate
interventio
ns
for individu
al situation.
b.)
Verbalize
the need to
participate
in a bowel
program as
indicated.
c.)
Verbalize
the need to
increase
consumptio
n of high
fiber foods
such as
fruits and
vegetables
and the
need to
increase
intake
of fluids to
8-10
glasses per
day.
After my 8
hours of
nursing

Instruct on a
diet of balanced
fiber and bulk
and
fiber supplements
.
Promote
adequate fluid
intake, including
high-fiber
fruit juices;
suggest drinking
warm stimulating
fluids.
Encourage
activity/exercise
within limits
of individuals
ability.

Inspect skin on
a daily basis,
describing wound
characteristics
and changes

of changes.
- To improve
consistency
of stool and
facilitate passage
through colon.
- To promote
passage of soft
stool

-To stimulate
contractions
of intestines.

- To
monitor progress
of wound healing.

- To assist bodys
31

hypogastri
c region of
the
abdomen
Data:
> surgical
wound/incis
ion at the
hypogastric
area of the
abdomen

care and
interventio
n patient
will be able
to:
a.)
verbalize
and
demonstrat
e
appropriate
wound
dressing
procedure
b.)
demonstrat
e the use
splinting
and
support to
protect the
wound
c.)
verbalize
the need to
increase
intake of
protein and
carbohydra
tes
for faster
wound
healing.

observed.
Instruct the
patient and
significant others
to keep the area
clean and dry.
Teach patient
of proper wound
dressing
techniques

natural process of
repair.
- This involves the
patient in her care
and promotes
empowerment
over her condition.
This also prevents
infection.
-To provide
support over the
incision area.

Instruct patient
to apply splint
using a pillow
when patient
coughs or moves.

Position patient
for comfort and
minimal pressure
on bony
prominences.
Turn to sides at
least every 2
hours.
Encourage
continuous
gradual
ambulation
or mobilization.

Provide
optimum
nutrition, and
increased protein

-These measures
promote
circulation, reduce
pressure and
avoid skin
breakdown

-Promotes
circulation and
reduces risks
associated with
immobility such as
thrombus
formation and skin
ulcers.
-To aid in wound
healing.

32

and carbohydrate
intake such as
meat, fish and
bread.

- to promote
healing and
prevent from
infection

Collaborative
Management:
Administer
prescribed
Antibiotics
August
08,
2014
(AM
shift)
Day
4

1. Low
selfesteem
related to
concerns
about
inability to
have
children,
changes in
femininity,
effect on
sexual
relationshi
p
Data:
> patient
verbalizes
concern on
inability to
have
children,
changes in
femininity,
effect on
sexual
relationship

After my 8
hours of
nursing
interaction,
care and
interventio
n patient
will be able
to:
a.)
Verbalize
concerns
and
indicate
healthy
ways of
dealing
with them.
b.)
Verbalize
acceptance
of self in
situation
and
adaptation
to change
in
body/selfimage

Provide time to
listen to concerns
and fears of
patient and SO.
Discuss patients
perceptions of
self related to
anticipated
changes and her
specific lifestyle.
Assess
emotional stress
patient is
experiencing.
Identify meaning
of loss for
patient/SO.
Encourage
patient to vent
feelings
appropriately.

- Conveys interest
and concern;
provides
opportunity to
correct
misconceptions,
e.g., women may
fear loss of
femininity and
sexuality, weight
gain, and
menopausal body
changes.
- You need to be
aware of what this
operation means
to patient to avoid
inadvertent
casualness or over
solicitude.
Depending on the
reason for the
surgery (e.g.,
cancer or longterm heavy
bleeding), the
woman can be
frightened or
relieved. She may
33

 Provide
accurate
information,
reinforcing
information
previously given.
Ascertain
individual
strengths and
identify previous
positive coping
behaviors.
Provide open
environment for
patient to discuss
concerns about
sexuality.

Note withdrawn
behavior,
negative self-talk,
use of denial, or
over concern with
actual/perceived
changes

2.
Therapeuti
c health
regimen
managem
After my
ent
hours of
nursing
Data:
care,
interventio

Collaborative
Management:
Refer to
professional
counselling as
necessary

fear loss of ability

to fulfill her
reproductive role
and may
experience grief.
- Provides
opportunity for
patient to question
and assimilate
information.
- Helpful to build
on strengths
already available
for patient to use
in coping with
current situation.
- Promotes sharing
of beliefs/values
about sensitive
subject, and
identifies
misconceptions/m
yths that may
interfere with
adjustment to
situation.
- Identifies stage
of grief/need for
interventions

- May need
additional help to
resolve feelings
about loss.

Assess patients
situation and
34

> patient is
for
discharge
this day

n and
health
teaching
patient will
be able to:
a.)
demonstrat
e effective
problem
solving
integration
changes of
therapeutic
regimen
into
lifestyle.
b.)
identify/use
available
resources
c.) remain
free of
preventable
complicatio
ns/progress
ion of
illness and
sequelae

needs
Encourage
strict adherence
to the medication
regimen
Instruct patient
to eat a variety
of healthy foods
every day. Diet
should include
fruits, vegetables,
breads, chicken,
fish, and beans
Suggest limiting
how much meat
fat, fish, dairy
products, and egg
yolks you eat
Maintain a
healthy weight:
instruct patient to
talk to caregiver
about ideal weight.
Encourage an
exercise program.
It is best to start
slowly and do
more as patient get
stronger. Instruct
patient to try to
exercise at least
30
minutes everyday
.

Encourage

- to note whether
changes need to
be arrange
- to attain
therapeutic effects
.
- to help you feel
better and have
more energy

- Eating too much of

these foods can
cause an increased
estrogen level
in the body.
- Maintaining an
ideal body weight
will also help to
maintain a normal
estrogen level
- Helps to
strengthen the
pelvic muscles
also for your good
cardio strength

- for relaxation
and gain more
strength for daily
activities.
35

patient to have
adequate rest
periods.

PHYSICAL ASSESSMENT ( Cephalocaudal)

The patient was first met lying in bed without any IVF running. She is a
42 year old woman, wearing a set of colored whole dress and was
watching TV with her sister and husband. The patient is alert, and
coherent, giving full and detailed responses to all of the questions
asked. She is 54 with darken brown to black in colored hair slightly
turning grey at the roots. She shared her feelings about the upcoming
surgery.
Vital Signs as follows:
Temperature: 35.3
Respiratory rate: 21 cpm
100/80mmhg

Heart rate: 66 bpm

Blood Pressure:

Skin, Hair, and Nails

Inspection
Skin
- Skin is white to pinkish in color and even in distribution.
- Skin is smooth without lesions or scars; no visible masses or
evidence of ecchymosis.
- Fine scaling of dry skin on lower inferior portion of legs and on
outer portion of arms.
Hair and Scalp
Darken brown to black in colored hair, fine, and even in
distribution
- Scalp is clean and dry
Nails
- Nails are pale pink in color
- No presence of nail clubbing
Palpation
Skin
- Skin is smooth and even, except for at the base of the feet
- No presence of calluses on the base of feet
- With a Skin turgor of 2- 3 seconds
- Skin is dry and cool to touch.
-

36

Hair and scalp

- Smooth with no presence of masses or lesions
- Scalp is dry to touch.
- Hair is thin and fine; darken brown to black in color
Nails
- Nails are smooth and firm. Nail plate is firmly attached to nail
bed.
- With a capillary refill of 1-2 seconds.
Head and Neck
Inspection
Head
- Head is round, symmetric, erect, proportional, and midline to
the clients body; no presence of visible lesions
- Head is held still and upright
- Face is symmetric with an oval appearance.
Neck
- Neck is symmetric with head centered and without bulging
masses.
- Thyroid cartilages move symmetrically as the client swallows.
- Neck movement is smooth and controlled.
Palpation
Head
- No swelling, tenderness or crepitations with movement of the
jaw.
- Jaw can move laterally 1 to 2 cm in each direction.
Neck
- Trachea is midline
- Thyroid gland is not palpable
- No swelling or tenderness of the lymph nodes; lymph nodes
are not enlarged
Eyes and Ears
Inspection
Eyes
- White sclera is seen around the iris
- Cornea is transparent with no opacities. Oblique view shows a
moist overall surface.
- Pupils are equally rounded and respond to light and
accommodation.
- The upper and lower eyelids close easily and meet completely
when closed.
- Eyes are able to move smoothly in an asterisk shape.
- The lower eyelids are upright
- No inward or outward turning eyes
- No presence of swelling, redness, or lesions of the eye.

37

Upper and lower palpebral conjunctiva are free of swelling or

lesions.
- Eyes have a sunken appearance.
- Iris is round, flat, and evenly colored.
Ears
- Ears are equal in size bilaterally. The auricle aligns with the
corner of each eye.
- Earlobes are attached.
- Skin is smooth with no lesions; color is evenly distributed and
consistentwith facial color.
- Small amount of brown flaky cerumen present.
- Canal walls are pink and smooth and without nodules.
Palpation
Eyes
- No drainage noted upon palpation of the nasolacrimal duct.
- No palpable masses
Ears
- No tenderness upon palpation of the auricle and mastoid
process.
- No palpable masses along the pinna
-

Mouth, Nose, and Sinuses

Inspection
Mouth
- Lips are cracked and dark brown in color.
- Teeth have a slightly yellowish discoloration
- No presence of dental carries
- Gums are pink in color
- With moist pale-pink buccal mucosa.
- Frenulum is midline
- Tonsils and uvula show no presence of swelling.
- Throat is pink in color
Nose
- Color is the same as the rest of the face
- Nasal structure is both smooth and symmetric
- Client is able to sniff through each nostril while the other is
occluded
- Nasal mucosa is pink, moist, and free of exudates
Sinuses
- Sinuses do not appear enlarged or swollen
Palpation
Mouth
- No lesions, ulcerations, or nodules upon palpation
Sinuses

38

Frontal and maxillary sinuses are non tender to palpation and

no crepitionis evident.
Percussion
Sinuses
- Sinuses are not tender upon percussion.
Thoracic and Lung
Inspection
- Skin is even in color
- Chest moves symmetrically with breathing
- With a respiratory rate of 21 breaths per minute
Palpation
- Skin surface and lesions are free of masses
- Equal tactile fremitus noted
Percussion
- Resonance is heard throughout all lung fields.
Auscultation
- Clear breath sounds noted
-

Heart and Neck Vessels

Inspection
- Jugular venous pulse is not normally visible when the client
sits upright
- Apical impulses are not visible.
Palpation
- Carotid artery pulses are equally strong.
- Radial and apical pulses are identical.
- No pulsations or vibrations are palpated at the apex and the
base of the heart.
Auscultation
- With a BP of 100/80 mmHg
- With a pulse rate of 66 beats per minute.
- No murmurs or extra heart sounds are heard.
- S1 and S2 sounds are clearly heard.
Peripheral and Vascular
Inspection
- Arms are bilaterally symmetric with minimal variation in size
and shape.
- No edema of the hands or prominent venous patterning
throughout all extremities
- Veins are flat and barely seen under the surface of the skin.
- Consistent with skin color on the rest of the body.
- Legs have equal distribution of hair
- The skin tone of the legs are consistent with those of the rest
of the body
- Legs are free of lesions and ulcerations
39

- No presence of bipedal edema

Palpation
- Skin is cool to touch
- With a good skin turgor
- With a capillary refill of 2- 3 seconds.
- Radial pulses have equal strength bilaterally
- Brachial pulses have equal strength bilaterally
- Skin of the feet and toes are cold to touch.
- No presence of enlarged lymph nodes upon palpation
- Negative Homans sign
Abdominal
Inspection
- Color is consistent with the color of the rest of the body
- No visible veins of the abdomen are present upon inspection
- No presence of ulcerations
- No presence of rashes
- Skin tone of umbilicus is similar with that of abdominal skin
tone.
- Umbilicus is located on midline of the abdomen
- Abdomen has a protruded contour and is round in shape.
- Abdomen is symmetric
Auscultation
- Soft gurgles are heard at a rate of five seconds per sound.
Percussion
- Tympany is percussed over the abdomen.
Palpation
- Flabby, soft non tender,palpable hypogastric area
- No signs of swelling of the umbilicus; no bulges, or masses.
Musculoskeletal
Inspection
- Client is able to stand on heals and toes
- Toes point straight point forward and lie flat, aligned with the
lower leg.
- Client is able to move without limitation
Cervical and lumbar spines are concave; thoracic spine is
convex. The spine is straight when observed from behind
- Joints are symmetric without signs of redness.
- Client has full range of motion without limitation.
- Hands are symmetric in size; fingers lie in a straight line.
- Iliac crests are symmetric in height
Palpation
- No presence of bipedal edema on lower extremities (ankles)
- No presence of joint swelling or tenderness on other areas of
the body

40

Hands and fingers are symmetric, non-tender, and without

nodules.
- Hips are non tender.
- No heat, swelling or nodules noted on the fingers and toes.
Genitourinary
- Had menarch at age twelve
- Client states that he has no recent changes in urinary
elimination pattern.
- Urinates every one or two hours at least once.
- Has no history of difficulty of urination.
- Cervix: smooth, closed
- Uterus: 16 weeks size
Neurological
- Does not experience numbness or tingling.
- No history of seizures
Patient, at times, has may experience a headache, but it is
usually relieved with diversional activities, rest, or medication
such as paracetamol.
- Has no current problem with the sense of smell.
- No difficulty in speaking or swallowing.
- Does not experience muscle weakness or tremors.
- No problems with memory loss.
General Survey
- Ambulatory conscious and coherent
-

DIAGNOSTIC EXAMINATIONS (LABORATORY RESULTS OF THE

PATIENT)

July 07,2014 (In Carmen Hospital)

CERVICOVAGINAL EXFOLIATIVE REPORT:
- Satisfactory for evaluation endocervical/transformation zone
obscuring factors
- Negative for intraepithelial lesion or malignancy
ULTRASOUND WHOLE ABDOMEN:
- Normal both kidneys and urinary bladder ultrasonically
- Uterine myoma, anterior wall as incidental finding
CREATININE
Reference
0.600 1.300 mg/dl

Result
0.8 mg/dl

Significance
Within Normal

41

COMPLETE BLOOD COUNT

Hemoglobi
n

Reference

Result

Significance
Poor concentration

122- 162 g/L

71 g/L

of the oxygen-carrying
proteins in your blood

Hematocri
t

0.377 0.479

0.259

WBC
Segmenter
s
Lymphocyt
es
Monocytes
Eosinophil
s
Basophils
Platelet
count

4.6 10.2
0.37 0.80

9.14
0.57

Low proportion
of the blood
that consists of
red blood cells,
by volume.
(anemia)
Within Normal
Within Normal

0.10 0.50

0.27

Within Normal

0 0.12
0 0.07

0.08
0.07

Within Normal
Within Normal

0 0.025
142 424

0.01
354 x 10^q/L

Within Normal
Within Normal

URINALYSIS
Physical Examination:
o Color Yellow
o Transparency Clear
o pH 6.0
o Specific Gravity 1.025
Chemical Examination:
o Glucose, Protein, Ketone, Blood NEGATIVE
Urine Flowcytometry
RBC
WBC
Epithelial
Cells
Cast

Reference
0 11
0 - 17
0 - 11

Result
3.9/ uL
3.0 / uL
6.8/uL

Significance
Within Normal
Within Normal
Within Normal

0-1

0.78/uL

Within Normal
42

Bacteria

0 - 278

21.2/uL

Within Normal

July 24, 2014

ULTRASOUND (TRANSVAGINAL)
- Slightly enlarged inteverted uterus with echogenic mass
consider
- Uterine myoma, Submucous Tube
- Hypoechoic mass right ovary consider follicle cyst
- Normal sized left ovary
July 28, 2014
COMPLETE BLOOD COUNT
Reference

Result

Significance

RCB

0.38 0.50

0.38

Within Normal

Hemoglobin

13.0 -17.0

12.5

Poor

concentration

of the oxygen-carrying
proteins in your blood.

Leukocyte
concentration
Neutrophils
Lymphocyte

5.0 10 x 10/L

12.5

Within Normal

0.40 0.60
0.20 0.40

0.70
0.30

Within Normal
Within Normal

BLOOD SUGAR

Blood
Glucose

Reference

Result

Significance

3.89 5.83
mmol/L

5.2 mmol/L

Within Normal

August 01,2014
ECG 12 LEADS:
- Sinus rhythmia within normal limits
August 05, 2014
COMPLETE BLOOD COUNT
Reference

Result

Significance
43

Hemoglobin

120 180 g/L

118

Hematocrit

0.38 0.54

0.360

RBC

4.0 6.0 x 10
12/L
5.0 10.0 x 10
10q/L
56%
34%
4%
150 x 450^q/L

4.27

WBC
Segmenters
Lymphocytes
Monocytes
Platelet
count

14.7
0.78
0.17
0.05
257

Poor
concentration
of the oxygencarrying
proteins in your
blood. (anemia)
Low proportion
of the blood
that consists of
red blood cells,
by volume.
(anemia)
Within Normal
Indicative of
infection
Within Normal
Within Normal
Within Normal
Within Normal

MANAGEMENT ( based on the patients case)

SURGICAL MANAGEMENT
TOTAL ABDOMINAL HYSTERECTOMY
Total abdominal hysterectomy is utilized for benign and malignant disease
where removal of the internal genitalia is indicated. The operation can be
performed with the preservation or removal of the ovaries on one or both
sides. In benign disease, the possibility of bilateral and unilateral
oophorectomy should be thoroughly discussed with the patient. Frequently,
in malignant disease, no choice exists but to remove the tubes and ovaries,
since they are frequent sites of micro metastases. In general, the modified
Richardson technique of intrafascial hysterectomy is used. The purpose of
the operation is to remove the uterus through the abdomen, with or without
removing the tube and ovaries.
Physiologic Changes
The predominant physiologic change from removal of the uterus is the
elimination of the uterine disease and the menstrual flow. If the ovaries are
44

removed with the specimen, the predominant physiologic change noted is

loss of the ovarian steroid sex hormone production.
Points of Caution
The predominant point of caution in performing abdominal hysterectomy is
to ensure that there is no damage to the bladder, ureters, or rectosigmoid
colon.Mobilization of the bladder with a combination of sharp and blunt
dissection frees the bladder from the lower uterine segment and upper
vagina. This reduces the incidence of damage to the bladder. By exercising
extreme care in management of the uterine artery pedicle, the surgeon may
minimize the risk of injury to the ureter. The same is true of the management
of the cardinal and uetro sacral ligament pedicles. If the vaginal cuff is left
open with the edges sutured, the incidence of postoperative pelvic abscess is
dramatically reduced.
Instruments Used:
- Self-retaining retractors
- Moist Gauze packs
- 0 synthetic absorbable suture
- Clamps
- Straight Ochsner Clamp
- Curved Ochsner clamps
- Metzenbaum Scissors
- Scalpel
IV THERAPY
Date and time
August 05,2014
(12:30 A.M.)
August 05, 2014
10:55 A.M.
August 05, 2014
( 1:25 P.M.)
August 05, 2014
( 4:45 P.M.)
August 05, 2014
(9:30 P.M.)
August 06, 2014
(7:40 A.M.)
August 06, 2014
(5:48 P.M.)

Bottle
Number
1

Type of Solution, Volume and Rate

DLR 1Liter @30 gtts/min

Received from OR with DLR

1Liter @30 gtts/min (300 level)
DLR 1Liter @30 gtts/min

Fast drip of 500 cc

(Due to no urine output noted)
DLR 1Liter @30 gtts/min

DLR 1Liter @30 gtts/min

DLR 1Liter @30 gtts/min

45

August07, 2014
(5: 55 A.M.)

Terminated as ordered when

consumed

INTRAVENOUS THERAPY
NURSING RESPONSIBILITIES

BEFORE, DURING, AND AFTER

Before the Procedure

Check the doctors order regarding to what type of IVF to be used and
also its volume and rate.
Explain the procedure to the patient.
Gather all materials needed for the insertion of IVF to save time
and not to waste time for looking for other materials.
Wash hands before and after the procedure to prevent contamination
from insertion site.
During the Procedure
Place patient in a comfortable position to facilitate easy insertion of IV
line and to decrease patients fear about the procedure.
Make sure that we give the proper IV fluid and drop rate accurately
because patient may experience fluid overload or dehydration.
Check for its patency by observing the backflow of blood upon
insertion.
After the Procedure
Press the site where the needle was inserted and secure it with plaster.
Check the site of hand where the needle is inserted if bulging is
not visible. If so, reinsertion is to be undertaken.
Advice patient to avoid scratching the site less movement of the
hand where the needle was inserted to keep it in place.
Instruct patient and significant others to inform the nurse on duty if
bulging of the site is visible, if there is back flow of blood of if IVF is not
infusing well.
Observe the IV site at least every hour for signs of infiltration or other
complications fluid or electrolyteoverload and air embolism.
IVF regulation should be checked and monitored upon receiving
patient.
Always check the doctors order for new orders regarding the IVF
supplement of the patient.
Always check if the IVF is infusing well and intact.
Monitor the patients skin integrity.
Provide comfort for the patient.
Remove and dispose used items.
46

Report and record as appropriate.

Place IV tag

DIETARY MANAGEMENT
Date and Time
Upon Admission as referred by
Dr. Aventurado(August 04,
2014 - 3:19 P.M.)
August 05, 2014
(8:30 A.M.) post operation

Ordered Diet
DAT, NPO post midnight upon
scheduled operation

August 05, 2014

(9:47 P.M.)

Soft diet

August 06, 2014

(9:10 A.M.)

Diet as tolerated

May have sips of water

NURSING RESPONSIBILITIES BEFORE, DURING, AND AFTER

Before the Procedure
Check the doctors order.
Check the right client.
Be sure that the diet is properly instructed.
During the Procedure
Monitor if the client complies with the given diet.
Be sure patient is taking or eating food he can tolerate
After the Procedure
Assess for patients condition; how he responds to the diet

47

 DRUG STUDY

o Pre operative Medications

Drug

Dosa Classi
Mechanism
Name
ge/
ficatio
of Action

Freq
n
uency/
Route
CEFOXIT
2
Antibiot Bactericidal:
IN
gms IVTT
ic
Inhibits
(Monow on
(Cephal
synthesis of
Call to
osporin
bacterial cell
el)
second
wall, causing
OR
generat
cell death
ANST
ion)
(-)

Indication

Contraind
ication

Nursing
Interventio
ns

Peritonitis
1. Cultured
& other
Hypersensi
infection
intrativity to
and
abdominal
cephalospo
arranged for
&intrapelvi
rin.
sensitivity
c
- Use
tests before
infections,
and during
cautiously
septicemia,
therapy if
with renal
endocarditi
expected
failure,lact
s,
response is
ation,pregn
gynecologi
not seen.
ancy
cal,
2. Dried
respi.tract,
powder and
bone &
reconstitute
joint, skin
d solutions
& soft
darken
tissue
slightly at
infections,
room
UTI
temperature
including
.
48

uncomplica
ted
gonorrhea.

RANITID 50mg
INE
every 8
(Zantac)
hours
IVTT

Histami
ne-2
(H)
antago
nists

Competitively Duodenal,
inhibits the
benign
action oh
gastric &
histamine at
post-op
the H
ulcers,
receptors of
reflux
the parietal
esophagitis
cells of the
, Zollingerstomach,
Ellison
inhibiting
syndrome,

- With
allergy to
ranitidine,
lactation
- Use
cautiously
with
impaired
renal or

3. Had Vit.K
available in
case
hypoprothro
mbinemia
occurs
4.
Discontinue
if
hypersensiti
vity reaction
occurs.
5. Taught on
side effects
she may
experience:
stomach
upset,
diarrhea
1. Provided
concurrent
antacid
therapy to
relieve pain.
2. If not on
NPO: Take
drug with
meals and
49

basal gastric
acid
secretions
and gastric
acid
secretions
that is
stimulated by
food,
insulin,hista
mine,choliner
gic agonists
gastrin and
pentagastrin.

METOCL
OPRAMI
DE

1O mg
IVTT on
call to
OR

Antiem
etic
Dopam
ener
gic
blocker
- GI
stimula
nt

Stimulates
motility of
upper GI
tract without
stimulating
gastric,
biliary or
pancreatic
secretions;
appears to
sensitize
tissues to

prophylaxis
of stress
ulcer in
seriously ill
patients,
recurrent
hemorrhag
e from
peptic
ulcer &
Mendelson
s syndrome

Relief of
nausea &
vomiting
associated
with
radiation
therapy,
malignant
disease,
labor,
infectious
diseases &

hepatic
function,
pregnancy

- Patients
with
phaeochro
mocytoma,
GI
haemorrha
ge and
mechanical
obstruction
or
perforation
also

at bedtime
3.
Administere
d exactly as
prescribed
4. Taught on
possible
side effects
she may
experience:
nausea,
vomiting,
enlargemen
t of breasts,
decreased
libido,
headache
1. If not on
NPO: Give
with food or
milk if GI
upset
occurs and
preferably
in the
morning to
avoid
disturbance
in sleeping
50

action of
acetylcholine
; relaxes
pyloric
sphincter,
which when
combined
with effects
on motility,
accelerates
gastric
emptying and
intestinal
transit; little
effect on
gallbladder
or colon
motility;
increases
lower
esophageal
sphincter
pressure; has
sedative
properties;
induces
release of
prolactin.

uremia.
Control of
post-op
vomiting &
assist in
intestinal
intubation

epilepsy.

during the
night
- Measured
and
recorded
body weight
to monitor
fluid
changes
2. Taught on
possible
side effects
she may
experience:
Increased in
urination,
dizziness,
drowsiness,
feeling
faint,
headache

51


SALB Nebuliza Anticho
UTAMOL
tion at 6
li
+
A.M.
nergics
IPRATR
(8/4/14)
OPIUM
(Duaven
t)

The
ipratropium
ingredient is
an
anticholinergi
c drug which
relaxes
smooth
muscle in the
lung. The
salbutamol
ingredient is a
beta-2agonist
which
stimulates
Beta-2 sites
in the lungs to
relax the
bronchi.

Bronchodil
ator for
maintenan
ce therapy
of broncho
spasm.

Contraindic
ated with
hypersensi
tivity to
atropine or
its
derivatives
.

1. Monitor
the
patients
vital signs,
noting
hypotension
and an
irregular or
abnormal
pulse.
2. Maintain
a quiet,
comfortable
environment
to minimize
anxiety and
perhaps
decrease
palpitations.
3. Teach the
patient
pursed-lip
breathing,
diaphragma
tic breathing,
and chest
splinting.

52


ALPR
AZOLAM

(Xanor)

250
mcg tab at
9 P.M.
tonight
(8/3/14)

Anxioly
tic
Benzod
ia
pine

Exact
mechanism
of action not
understood;
main sites of
action may
be the limbic
system and
reticular
formation;
increases the
effects of
GABA, an
inhibitory
neurotransmi
tter, anxiety
blocking
effects occur
at doses well
below those
necessary to
cause
sedation,
ataxia.

Manageme nt of
Hypersensi
anxiety
tivity to
disorder,
Benzodiapi
short
nes,
term relief
psychoses,
of
acute
symptoms
narrowof anxiety;
angle
anxiety
glaucoma,
associated
shock,
with
coma,
depression.
acute
Treatment
alcoholic
of panic
intoxicatio
attacks
n with
with or
depression
without
of vital
agoraphobi
signs,
a.
pregnancy,
labor,
delivery,
lactation
- Use
cautiously
with
impaired
liver or
renal

1. Do not
administer
with
grapefruit
juice or
within 48
hours of
grapefruit
juice.
2.
Administere
d drug as
prescribed.
Instructed
on to place
the tablet
on top of
the tongue ,
where it will
disintegrate
and can be
swallowed
with saliva
3. Taught on
possible
side effects
she may
experience:
53

function
debilitation
.

Drowsiness,
dizziness, GI
upset;
depression;
dreams;
crying;
nervousnes
s

Indicatio
n

Contraindi
cation

Nursing
Interventio
ns

Relief of
moderate
to severe
pain not
respondin
g to nonnarcotic
analgesic.
Premedica
tion
analgesic

- Postbiliary tract
surgery or
surgical
anastomis,c
omatose.
Respiratory
depression
&

1. Vital

o Post Operative Medications

Drug
Name

MORPHI
NE

Dosa Classi
Mechanism
ge/
ficatio
of Action

Freq
n
uency/
Route

1
Opioid
Principal
mg, 3
agonist
opium
Epidural
s
alkaloid; acts

Cath
analges
as agonist at
eter every
ic
specific
12
opioid
hours x
receptors in
2 doses
the CNS to
produce
analgesia,eu
phoria,

signs, pain
intensity
rating,
sedation
score, and
degree of
motor and
sensory
block
54

sedation; the
receptors
mediating
these effects
are thought
to be the
same as
those
mediating
the effects of
endogenous
opioids
(enkephalins,
endorphins)

adjunct in
general
anaesthesi
a
especially
in pain
associated
with
cancer, MI
& surgey.
Alleviates
anxiety
associated
with
severe
pain.
Hyponotic
for painrelated
sleeplessn
ess.

obstructive
airway
diseases,
acute
alcoholism,
head
injuries,
raise
intracranial
pressure &
convulsive
state.

2. Kept
opioid
antagonist
and
facilities for
assisted or
controlled
respiration
available in
case of
respiratory
depression
3. Reassure
patient
about
addiction
liability;
most
patients
who receive
opiates for
medical
response do
not develop
dependence
syndromes
4.
Administere
55

d as
prescribed
and give it
slowly to
minimize
likelihood of
adverse
effect.
5. Do not
take
leftover
medication
for other
disorders,
and do not
let anyone
else take
your
prescription
6. Taught on
possible
side effects
she may
experience:
Nausea,
loss of
appetite,
constipation
, sedation,
56

drowsiness,
impaired
visual acuity
KETORO
LAC

30 mg
IVTT
every 8
hours x
3 doses

- NSAID Anti Short term

inflammatory
managem
and analgesic
ent of
Antipyr
activity;
moderate
etic
inhibits
to severe
prostaglandin
acute
Nonopi
s and
post-op
oid
leukotriene
pain
analges
synthesis
ic

NALBUP
HINE
(Nubain
)

5 mg
IVTT
PRN for
pruritus

Opioid
Acts as an
agonist
agonist at
specific
antago
opioid
nist
receptors in
analges
the CNS to

Relief of
moderate
to severe
pain. Preop
analgesia,

- History of
Asthma,
active
peptic
ulceration,G
I bleeding
- CV
bleeding,
Nasal
polyps,
angioedem
a or
bronchospa
sm.
- Renal
impairment,
pregnancy
& lactation
Hypersensit
ivity of
nalbuphine,
sulfies
-

1. Protected
drug vials
from lights
2. Taught on
possible
side effects
she may
experience:
Dizziness,
drowsiness,
burning and
stinging on
application
(if
ophthalmic
use)

1. Kept
opioid
antagonist
and
facilities for
assisted or
57

ic

produce
analgesia
and sedation
but also acts
to cause
hallucinations
and is an
antagonists
at mu
receptors

as a
Pregnancy,
suppleme
Lactation,
nt to
Labor
balanced
- Patients
anesth,
with
surgical
hypersensiti
anaesthesi
vity to
a for
repiratory
obstet
depressants
analgesia
, asthma,
during
anoxia,
labor &
increased
relief of
ICP, acute
pain
MI
following
MI. Post op
somatic &
visceral
pain.

controlled
respiration
available in
case of
respiratory
depression
2. Use
cautiously
emotionally
unstable
patients or
those with
history of
addiction
3. Reassure
patient
about
addiction
liability;
most
patients
who receive
opiates for
medical
response do
not develop
dependence
syndromes
58

 RANITID 50 mg
INE
IVTT
every 8
hours x
3 doses

Histami
ne-2
(H)
antago
nists

Competitively Duodenal,
inhibits the
benign
action oh
gastric &
histamine at
post-op
the H
ulcers,
receptors of
reflux
the parietal
esophagiti
cells of the
s,
stomach,
Zollingerinhibiting
Ellison
basal gastric
syndrome,
acid
prophylaxi
secretions
s of stress
and gastric
ulcer in
acid
seriously
secretions
ill

With allergy
to
ranitidine,
lactation
- Use
cautiously
with
impaired
renal or
hepatic
function,
pregnancy

4. Taught on
possible
side effects
she may
experience:
Dizziness,
sedation,
drowsiness,
impaired
visual
acuity,
nausea, loss
of appetite
1. Provided
concurrent
antacid
therapy to
relieve pain.
2. If not on
NPO: Take
drug with
meals and
at bedtime
3.
Administere
d exactly as
prescribed
4. Taught on
59

that is
stimulated by
food,
insulin,hista
mine,choliner
gic agonists
gastrin and
pentagastrin.

FUROSE
MIDE
(Lasix)

20 mg
IVTT
after
fast drip
of 500
cc IVF

patients,
recurrent
hemorrha
ge from
peptic
ulcer &
Mendelson
s
syndrome

Loop
Inhibits
Edema
Diuretic
reabsorption
due to
of sodium
cardiac,
and chloride
hepatic &
from the
renal
proximal and
disease,
distal tubules
burns,
and
mild to
ascending
moderate
limb of the
hypertensi
loop of Henle,
on,
leading to a
hypertensi
sodium-rich
ve crisis,
diuresis
acute
renal
failure,
chronic
renal

Hypersensit
ivity to
Furosemide
and
sulphonami
des
- Anuria;
hepatic
coma &
precoma;
severe
hypokalemi
a and/or
hyponatrem
ia;
hypovolemi
a with or

possible
side effects
she may
experience:
nausea,
vomiting,
enlargemen
t of breasts,
decreased
libido,
headache
1. Measured
and
recorded
weight to
monitor
fluid
changes
2. Do not
expose to
light, which
may
discolor the
solutions;
do not use
discoloured
drug or
solutions
3. If
60

failure,
nephrotic
syndrome

without
hypotension
.

possible
give it
during the
day ( early
morning) to
avoid sleep
disturbance
during the
night due to
frequent
urination
4. Taught on
side effects
she will
experience:
Increased in
volume and
frequency of
urination;
dizziness,
feeling faint
on arising,
drowsiness;
sensitivity
to sunlight;
increased
thirst; loss
of body
potassium
61

o TAKE HOME MEDICATIONS

Drug
Name

Dos
age/

Fre
quency/
Route
ETOREC 120 mg
OXIB
tab OD
(Arcoxia)
x 5
days
then
PRN

Classi
ficatio
n

Mechanism
of Action

A
Like any
membe
other COX-2
r of a
selective
class
inhibitor
of arthr
("coxib"),
itis/anal
etoricoxib
gesia
selectively
Medicat
inhibits
isoform 2 of
ions
the enzyme
called
cycloCoxibs.
oxygenase
A
(COX-2). This
highly
reduces the
selectiv
generation
e
of prostaglan
inhibito

Indicati
on

Relief of
acute
pain

Contrain
dication

Nursing
Interventions

- Use with 1.
caution in
Teach patient
elderly pe
to take
ople
medicine
- History
or medications
as physicians
of disorder
ordered.
s affecting
the stoma 2. Tell the
ch
patient for
or intestin
the possible
es, such
effects of drug
as
prior to its
ulceration
adverse
or bleedin
reactions and
g
consider such
reactions
62

r
of cyclo
oxygen
ase2(COX2). The
newset
of the
COX-II
inhibito
rs

dins (PGs)
from arachid
onic acid.
Among the
different
functions
exerted by
PGs, their
role in the
inflammation
cascade
should be
highlighted.
COX-2
selective
inhibitors
showed less
marked
activity on
type 1
cycloxigenas
e compared
to
traditional no
n-steroidal
antiinflammatory
drugs (NSAID
). This

Decreased
kidney fun
ction
Decreased
liver
function

mentioned as
normal.
3. Provide the
patient with
the proper
management
upon
taking medicati
ons
4. Tell the
patient to
seek for help
if no such
effects of drug
are noted or
that if
symptoms
prior to his
conditions are
still noted.
5. Tell patient
to maintain
his normal diet
and the
possible
consequences
of the drugs
effect concerni
63

reduced
activity is the
cause of
reduced
gastrointestin
al side
effects, as
demonstrate
d in several
large clinical
trials
performed
with different
coxibs.
TRAMAD 1 tab
OL
3x a
+
day for
1 week
PARACET
AMOL
(ALGESI
A)

Analge
sics/
Opiates
&
Antago
nists

Manage
Binds to mument of
opioid
moderat
receptors.
e to
Inhibits
severe
reuptake of
pain
serotonin and
norepinephri
ne in the CNS

ng on his
appetite

Hypersenti
1. Assess
vity to
type, location,
tramadol,
and intensity
paracetam
of pain before
ol, opioids
and 2-3 hr
, or any
(peak) after
componen
administration.
2. Assess BP &
t of the
RR before and
product.
periodically
during
administration.
Respiratory
depression has
not occurred
with
64

recommended
doses.
3. Assess
bowel function
routinely.
Prevention of
constipation
should be
instituted with
increased
intake of fluids
and bulk and
with laxatives
to minimize
constipating
effects.
4. Prolonged
use may lead
to physical and
psychological
dependence
and tolerance,
although these
may be milder
than with
opioids. This
should not
prevent patient
from receiving
adequate
analgesia.
Most patients
65

who receive
tramadol for
pain d not
develop
psychological
dependence. If
tolerance
develops,
changing to an
opioid agonist
may be
required to
relieve pain.
5. Monitor
patient for
seizures. May
occur within
recommended
dose range.
Risk increased
with higher
doses and
inpatients
taking
antidepressant
s (SSRIs,
tricyclics, or
Mao inhibitors),
opioid
analgesics, or
other durgs
that decrese
66

the seizure
threshold.
6. Overdose
may cause
respiratory
depression and
seizures.
Naloxone
(Narcan) may
reverse some,
but not all, of
the symptoms
of overdose.
Treatment
should be
symptomatic
and
supportive.
Maintain
adequate
respiratory
exchange.
7. Encourage
patient to
cough and
breathe deeply
every 2 hr to
prevent
atelactasis and
pneumonia.

67

 CEFIXIM
E
(Tergece
f)

200mg
cap BID

Antibiot A thirdic
generation
(Cephal
cephalospori
osporin
n that is
third
highly stable
generat
in the
ion)
presence of
betalactamases
(penicillinase
s and
cephalospori
nases) and
therefore has
excellent
activity
against a
wide range of
gramnegative
bacteria. It is
bactericidal
against
susceptible
bacteria.
Cephalospori
ns inhibit
mucopeptide
synthesis in

Effectivel Hypersens
y treats
itivity to
respirato
cephalosp
ry tract,
orin
urinary
tract
infection,
otitis
media
and
gonorrhe
a,
reducing
or
eliminati
ng signs
and
symptom
s of
infection.

1. Perform
culture and
sensitivity
tests prior to
initiation of
therapy and
periodically
during therapy.
Therapy may
be
implemented
pending test
results.
2. Discontinue
if seizures
associated with
the drug
therapy occur.
3. Monitor for
superinfections
(see Appendix
F) caused by
overgrowth of
nonsusceptible
organisms,
particularly
during

68

the bacterial
cell wall.

prolonged use.
4. Monitor I&O
rates and
pattern:
Nephrotoxicity
occurs more
frequently in
patients >50 y,
with impaired
renal function,
in the
debilitated,
and in patients
receiving high
doses or other
nephrotoxic
drugs.
5. Carefully
monitor
anyone with a
history of
allergies,
especially to
drugs. Report
manifestations
of
hypersensitivit

69

y
6. Promptly
report loose
stools or
diarrhea, which
may indicate
pseudomembr
anous colitis.
Discontinuatio
n of drug may
be necessary.

Nursing Responsibilities for All Drugs

Before the administration of drug:

Verify Doctors order
Remember the 10Rs of Drug administration

During the administration of drug:

Verify patients identification
Inform the patient with regards to drug administration
Clean the IV port prior to administration of the drug

After the administration of drug:

Monitor patient for adverse effects
Inform patient that easy bruising may occur
70

Caution patient not to stop taking drug abruptly without first consulting prescriber

71

 III. DECISION ANALYSIS

NURSING CARE PLAN

DATA

NURSI
NG
DIAGN
OSIS
(Upon
1.)
Admission
Deficie
08/04/201
nt fluid
4)
volume
Actual
related
to
and
blood
abnormal
loss as
findings:
eviden

ced by
Subjectiv
heavy
e:
vaginal
Nikalit
bleedin
ngkadaku
g,
akong
decrea
pus on

BACKGROU NURSIN
ND
G
KNOWLEDG
OBJECTI
E
VES
NANDA
After my
5 days of
Definition:
nursing
Decreased
care and
intravascular
intervent
, interstitial
ions
and/or
patient
intracellular
will be
fluid. This
able to:
refers to
dehydration, a.)
experien
water loss
ce
alone
adequat
without
e fluid
change in
volume
sodium.

NURSING
INTERVENTION
S
Independent:
*Monitored vital
signs
* Monitor
active fluid loss
from wound
drainage, tubes,
diarrhea,
bleeding, and
vomiting
*Monitor tempe
ra
ture

RATIONALE EVALUA
TION

- for
baseline
data
- to
maintain
accurate
input and
output

- febrile
state
decreases
body fluids

After 5
days
of nursi
ng
interven
tion,
client
was
able to:
a. Goal
met.
Patient
experie
nces
adequat
72

jud,unya
kalit lang
kusog
kaayu
andakong
dugo nga
1-2 weeks
ra gud
ang gikan
sa last
dugo
nako.

Objective:
- upon
inspectio
n:
abdomen
has a
protruded
contour
and is
round in
shape
palpation:
soft, non
tender

sed
haemo
globin
and
hemato
crit
count.

In Uterine
Myoma:
There is an
imbalanced
levels of
estrogen in
the body
which leads
to the
growth of
tumor as
well as
deterioration
of the
surrounding
tissues
which may
come from
the ischemia
of tumor
growth

and
electroly
te
balance.
b.) will
be able
to
identify
some
manage
ment to
maintain
health.

* Encourage
patient to
drink prescribed
fluid amounts.

*Monitor serum
electrolytes
and urine
osmolality and
report abnormal
values.

Collaborative:
* Administered
prescribed Iv
fluids and
medications

* Has standby 1
unit of blood
PRBC (blood
type A+) for OR

through per
spi ration and
increased
respiration
- Oral fluid
replacemen
t is
indicated
for mild
fluid deficit
- Elevated
haemoglobi
n and
elevated
blood urea
nitrogen
(BUN)
suggest
fluid deficit.
Urinespecific
gravity is
likewise
increased.

e fluid
volume
and
electroly
te
balance
as
evidenc
ed by
urine
output
greater
than 30
ml/hr,
normal
vital
signs
and
normal
skin
turgor.
b. Goal
met.
The pati
ent was
able to
underst
and the
73

abdomen
weakness
and
paleness
observed
- profused
menstrua
tion last
week
- low
haemoglo
bin and
hematocri
t count

Predisposi
ng
Factor:
advancin
g age
hormonal
imbalanc
es

2.)
Pain
related
to post
surgica
l
operati
on(Tota
l
Abdomi
nal
Hyster
ectomy

which
causes
abnormal
bleeding/hyp
ermenorrhea

NANDA
Definition:
Feeling and
an
unpleasant
emotional
experience
arising from
tissue

After my
5 days of
nursing
care and
intervent
ion
patient
will
report a
relief of
pain
sensatio
n.

use

* Monitored vital
signs

* Perform a
comprehensive
assessment of
pain to include
location,
characteristics,
onset, duration,
frequency,

- for
baseline
data ( post
operatively
and on
regular
basis)
- Pain is a
subjective

importa
nce
of takin
g
supplem
ents
especial
ly iron
and
eating
nutritiou
s foods.

Goal
met
74


(Schedule
d day of
operation
08/05/201
4)
Actual
and
abnormal
findings:

Subjectiv
e:
Sakit
kaayu
akong
samad, di
ko
kasabot
sa kasakit
jud

Objective:
> Patient
reported
of pain
with a
pain scale

damage or a
description
of actual and
potential
damage. It
can occur
suddenly or
slowly, the
intensity of
light or
heavy.

In the
patients
case: pain
was felt post
operatively
trauma/dam
age during
the
operation it
is an
expected
outcome as
the
anaesthesia
also is

quality, intensity
or
severity, and
precipitating
factors of pain

* Encouraged
verbalization of
feelings

* Encourage
turning to sides,
coughing, deep
breathing and
relaxation
technique also
some distraction
activities

Orient to time,
date and place

experience
and must be
described
by the
patient in
order to
plan
effective
treatment.

- to assess
the level of
consciousne
ss and to
monitor the
wearing off
of
anaesthesia
- the use of
non
invasive
pain relief
can
increase the
release of
endorphins

patient
was
able to
verbaliz
ed relief
of pain
with
pain
scale of
5/10.

75

of 9/10
>
grimaced
face and
guarded
movemen
t
observed
1hour
after
transport
from the
OR
>
weakness
noted

3.)
Therap
eutic
health
regime
n
manag
ement

wearing off.

NANDA
Definition:
Maintaining

After my
5 days
of
nursing
care,
intervent
ion and
health
teaching
patient
will be
able to:
a.)
demonst
rate

Provide
adequate rest
periods and a
conducive
environment to
sleep to ease
feeling after the
operation

Collaborative
Management:
Administer
prescribed pain
relief
medications

* Assess
patients
situation and
needs

* Encourage
strict adherence
to the medication

and
enhances
the
therapeutic
effect of
pain relief
medications
- to assess
the level of
consciousne
ss and for
patients
comfort
- to give
time for the
patient to
rest due to
traumatic
exposure

- for relief of
pain

Goal
partially
met,
76

(Remainin
g days
during
the
hospital
stay
08/0608/2014)

Objective
:
> low
hemoglob
in and
hematocri
t count
>

an optimum
health or
free from
any
complication
s from an
illness

effective
problem
solving
integrati
on
changes
of
therapeu
tic
regimen
into
lifestyle.
Post
b.)
operative
identify/
should be
use
handle
available
carefully and
resource
closely in
s
order to
prevent from c.)
remain
any
free of
complication
preventa
s through.
ble
Moreover, in
complica
the patients
tions/pro
case she has
gression
an Anemia
of illness
that should
and
be resolved

regimen
* Instruct patient
to eat a variety
of healthy foods
every day. Diet
should include
fruits, vegetables,
breads, chicken,
fish, and beans
* Suggest limiting
how much meat
fat, fish, dairy
products, and
egg yolks you
eat

* Maintain a
healthy weight:
instruct patient to
talk to caregiver
about ideal
weight.
* Encourage an
exercise
program. It is
best to start
slowly and do
more as patient

- to note
whether
changes
need to be
arrange
- to attain
therapeutic
effects

- to help you
feel better
and have
more energy

- Eating too
much of
these foods
can cause an
increased
estrogen
level
in the body.
- Maintaining
an ideal body
weight will

patient
was to
formulat
e a plan
for a
therape
utic
regimen
mainten
ance
,identifi
ed
possible
availabl
e source
of
solution
in her
problem
s and
while on
hospital
she was
free
from
any
complic
ations
77

weakness
and
paleness
noted
> with
surgical
wound on
the
hypogastr
ic area
> for
continuou
s medical
diagnosti
c
treatment
>
discharge
process

with
patients
coordination
and
following the
therapeutic
regimen.

sequelae

get stronger.
Instruct patient
to try to exercise
at least 30
minutes everyda
y.

* Encourage
patient to have
adequate rest
periods.

also help to
maintain a
normal
estrogen
level
- Helps to
strengthen
the pelvic
muscles
also for your
good cardio
strength

- for
relaxation
and gain
more
strength for
daily
activities.

78

 IV. SUMMARYOF FINDINGS, CONCLUSION AND

RECOMMENDATIONS

A. FINDINGS

The finding for my patient is good. But I wasnt able to see

the result of the Biopsy of specimen taken from the surgery
because the patient already discharged and the result will be
taken 5 days after.

Uterine myomas/fibroids are not cancerous and usually

shrink after menopause. Her myoma mass found at the anterior
portion of the uterus, her uterus have been removed which had
all led to the elimination of the signs and symptoms she had
experienced prior to surgery. Throughout her stay in the
hospital, she has been responding well to the medical regimen
given to her and has showed no signs and symptoms
of possible complications or infections. However, patient may
not be able to bear a child due to her surgery. Nevertheless,
the procedure she has undergone eradicates the possibility of
another growth of a myoma mass.

B. CONCLUSION

In conclus i on, I was a ble to come up with a

comp re he ns ive cas e presentation on Uterine Myoma,

especially concerning my patient. Information presented here
were factual, basing on our actual assessments by
interview and by using available secondary sources, such
79

as her chart. I was able to work together to surface this case

study in the best way that I can, using every resource we can find useful
in making every part of this write up. In the process, I was able to
enhance my knowledge about Uterine Myoma, its signs and symptoms
and treatment modalities, as well as on how we nurses, can care for
patients similar with this patient.

C. RECOMMENDATIONS

Recommendations are necessary to be able to improve

health and prevent further complications as possible. This,
in turn, will consider having a better health status be
it physically, emotionally, mentally, and spiritually.
Recommendations would include but not limited to the following:

First, should be able to develop an optimistic attitude

towards the situation in order to promote a positive
inclination of mental and emotional dimension of health.

Se cond , s he shou ld s trictly comply with the me dic

a tion re gime n

s ince pe rs ona l adherence is a determinant of willingness

and eagerness to recover.

Third, she should also be able to verbalize feelings to

her husband to take emotional care and actions. She should
also be able to express any discomfort in order for the health
care provider to ca rry out ce rta in mea s ure s , s hould be
a ble to es ta blis h a di re ct ope n communication with her
husband and health care practitioner to link care and needs.
80

Thus, the proponents of this case study are able to

understand the significance of a good health seeking
behaviour and medical treatment.

Fourth, she should be able to strengthen or maintain

strong faith since spiritual health is an important factor to
be cons ide re d in a chie ving a he a lthy s ta tus .

Als o she s hould e a t foods rich in fi be r, vitamins

and minerals, such as pineapple, mango, orange, green leafy
vegetables, lean meat, dairy products and fish. Patients husband
and support persons can prove functional when they a
reliable to provide comfort, care measures, and assistance. They
can encourage patient to follow care providers instruction particularly
on medication adherence.

As health care providers, we should be able to provide

quality health care services to our patients. As nurses and
physicians, individualized care should be carried out. Open and
welcome approach should be initiated to the patient, and most
especially by showing empathy and recognizing that there are no
enough words to overrule her feelings of heaviness and despondency.
Sensitivity to the patient has verbalized is also necessary
for us to consider in planning care. Physical, social, spiritual,
emotional, and mental feedbacks and motivations can also be
considered in imparting to the client.

81

V. JOURNAL WRITING

MEDICAL JOURNAL FOR FIVE DAYS HOSPITAL DUTY

August 04, 2014 (1:30 P.M.)
Courtesy call to the chosen institution we are going to render our 40
hours hospital duty at the Medical Mission Group Hospitals and Health
Services Cooperative Philippines- Bohol Cooperative Hospital.
At exactly one oclock in the afternoon we were all gathered together with
our Professor Lalaine L. Domapias at the Chief Nurse Office and we waited
the time the chief nurse and senior nurse supervisor to arrive.
At around one thirty in the afternoon we started our meet up by
introducing first ourselves to the chief nurse (Maam Bonibella L. Jamora)
and from what institution we are from. We were given a warm welcomed
and oriented to the institution visions and aim. They introduce to us also
the program which the institution is offering or the so called Cooperatives
Health Program also theyve shared to us some experiences in the
hospital. They also give us as to what is a regular the flow/happening in
the wards and in the special areas.
After that the senior nurse supervisor named Maam Sonny L. Estoy
oriented to us the hospital rules and regulations or the policy, the
reporting time during duty days and also the proper uniform to wear. She
also gives us a chance to see more the hospital by leading us in a short
hospital tour where we were oriented to the different places in the
hospital also she introduce to us to the hospital staff.
We went back to the Chief Nurse office were Maam Sonny did the honour
on arranging our schedule as what shift we will be on the next five days
82

on the our duty. After arranging the schedule we also talk about on the
cases we will get so that the staff in the area can guide us on what we will
do. Maam Sonny also assigned us to the area which our cases most
probably are in.
And so after a long talk as to what possibly may happen the next five
days in our duty we bid goodbye to the chief nurse and senior nurse
supervisor.
August 05, 2014 (AM shift)

My day started with a smile and greeting to everybody in the area

where I assigned for months already as a Nurse Trainee in Station 1. So
fortunate we have a patient who is scheduled to Total Abdominal
Hysterectomy at 6 A.M. and when I started my duty she was still at the

Operating Room.
At around 10 in the morning she was out from the O.R. Endorsement from
the OR nurse on duty was started Initial vital signs was taken and
recorded also I received the IV level and urine output (no urine output
noted). Normal vital signs noted and were referred to her Anesthesiologist
and OB. Doctors order was carried immediately as what the
endorsement said. I continued the monitoring of level of consciousness,
vital signs for the first hour is every 15 minutes, every 30 minutes the
next two hours then every hour for the next hours and the charge nurse
also continues carrying of orders. All are normal as I closely monitored.
The patient as I received was weak with good level of consciousness. She
was ordered to be flat on bed for the next 4 to 6 hours. For the hours she
was asleep and as she wakes up she complains for pain in her back and in
the surgical incision made. In her back was an epidural catheter for
morphine administration. I started immediately the pain reliever
medication before she wakes up but still complains of pain also the
morphine was started at the OR before she was trans out.
She then asked for of water because she feels thirsty. Gladly the ordered
was she may have some sips of water gradually. She was relieved after
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that having some water but still on pain which she described now that has
decreased.
Before I went out on duty patient is still on no urine output. She has
already a Foley Bag catheter in place so the doctor ordered to have a fast
drip on the present IVF and so I endorse to the next shift to monitor
closely the urine output of the patient also that time she is still no flatus
reported.
Thanks to God I end the shift well with proper interventions and
documentation on everything that was ordered by the doctor.

August 06, 2014 (AM shift)

As I started the day, I greeted all the staff a warm good morning. After
that I attended the endorsement to know the update about my patient
also for other patients.
As I received the patient she was on bed on low-moderate high back rest.
She is now on soft diet and has positive flatus and normal urine output.
She reported to be in pain but not as much intensity as yesterday.
I assisted her on gradual ambulation by first on sitting position and slowly
standing. When her doctor made rounds I assisted the doctor and listened
to every order she made for the patient. I carried all the orders as to
complete all doses of her pain reliever medications and made an accurate
urine output also to check if possible she will have a bowel movement
today.
During the after the afternoon happily she had a bowel movement with
moderate amount in soft consistency with yellowish to brown in color. I
ended the shift well with a positive response from my patient who is very
cooperative in the study I am making.
August 07, 2014 (AM shift)
Another day has started and I was very glad to see my patient is
ambulating well inside her room assisted by her sister. She is very
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eager to go home to see her children also she believed that she can
now carry on her activities daily but with limitation and without using
much pressure.
The patient can now tolerate the acute pain she felt but as I assessed her
she was very pale, with dry lips and is weak. As the CBC result state she
has a slight anemia but the doctor said that its all right to not have a
blood transfusion because during the operation she did not loss much
blood, she then encourages the patient to eat a well balanced diet in
enrich her diet with green leafy vegetable , meat most specifically the
organ meat. The doctor agreed with the patient to went home tomorrow
as soon as she can also all the vital signs are normal and make sure to
take all the prescribed take home medications.

August 08, 2014 (AM shift)

A wonderful day has started. I talked with the patient and then she ask
me if she can now go home as what her doctor said yesterday. Gladly
her doctor made a rounds and ordered some take home medications
and to discharge the patient. I assisted the patients husband in the
discharging process and for the last time I interacted well to the
patient to know more or assessed more her status.
She then honestly confessed to me that she is on a tight budgeting when
it comes to her condition now because they are just in a middle stage
when in it comes to income monetary and she is just new in her work as a
new nurse in HNU. Her husband also do have a small business in Carmen
related to farming business. She prepared well this surgery make sure she
will excess in her bill.
Having diagnosed with Uterine Myoma and after the surgery makes her
feel less as woman, for having removed her uterus and her now inability
to conceived makes her feel less. They are planning together with her

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husband to have a child and this time a girl because both of her kids are
boys, but sadly the chances are unlikely.
As I talked with her husband he stated that its all right for him to have
not another child as long as his wife is well or in good condition. He is now
contented with his two boys which they treasure most.
In the end, the patient is satisfied with the operation and her stay in the
hospital. She still complains with pain no worries she has some take home
medications to relieve pain. I reminded them to follow up her biopsy result
in the laboratory 5 days from now and bring it in the scheduled check up
day also I instructed her in her take home medications which made me
easy to instruct since she is a nurse and knows all the medications she is
taking. I can say that having a patient who is a nurse or from a medical
profession have an advantages and disadvantages. Advantages because
you can gain more cooperation and support, and disadvantages because
you have to give your best to give best quality of care as possible. It all
went well and was able to discharge in fair and stable condition the
patient.
August 09, 2014 (AM shift)
The culmination day. We all went on AM shift and had a short meeting
together. We also had some brain storming on the cases we had
gathered.
At around 10 oclock in the morning the food we ordered was delivered
and together we eat with Maam Sonny and Rubie. We also give some
pack of foods in the ward, ICU, and ER.
The 5 days experience was successful together with my groupmates Mr.
Jessie Louie Payag, Ms. April Melody Legazpi, Ms. Betelguesse Arcay, and
Mrs. Merlyn D. Bantugan. The experienced was worth it and in fact it is
different from my daily routine in my duty because this time I am more
assessing and focusing on one patient and it makes me feel amazing to
discover some new things which I didnt know.

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 By doing this study I had found out more about the disease which at first
glance or heard we thought we know but merely not.
As agreed we just had a half day in our duty due to our duty schedules in
our individual work. We thank the institution for giving us an opportunity
to handle patient in accordance to our assign system, give our heartfelt
donation and after was a short talk about the hospital.
We also remind them about our certificates which we will be giving two
weeks after. The half day was filled with happiness and fullness in foods.
Its an experience thats worth treasuring for.

VI. BIBLIOGRAPHY

Book source:

Maternal and Child Health Nursing: Care of the Childbearing

and Childrearing Family (5th Edition) By: Adele Pillitteri
Brunner &Suddarths Textbook of Medical- Surgical Nursing
(12th Edition) By: Suzanne C. Smeltzer, Brenda G. Bare, Janice
L. Hinkle, Kerry H. Cheever
Nurses Pocket Guide (Diagnoses, Prioritized Interventions,and
Rationales) Eleventh Edition By: Marilyn E. Doenges, Mary
Frances Moorhouse, Alice C. Murr
2010 Lippincotts Nursing Drug Guide By: Amy M. Karch
MIMS 108th Edition 2006 Philippines PIMS

Internet source:
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http://nursingcrib.com/nursing-notes-reviewer/maternal-childhealth/myoma-uteri/
http://www.scribd.com/doc/27323168/Nursing-Care-Plan-UterineMyoma
http://nurseslabs.com/6-hysterectomy-tahbso-nursing-care-plans/
https://www.scribd.com/doc/33880230/Uterine-Myoma

https://www.scribd.com/doc/38186951/Myoma-Case-Study

http://nurseslabs.com/lydia-e-halls-care-cure-core-theory/

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