MESENTERIClymphoma!

St.
Paul University Manila

(St. Paul University System)
College of Nursing and Allied Health Sciences
Nursing Care Study

(Application of Nursing Process)
I. ASSESSMENT
A. General Information
This is the case of L.L., a Filipino Citizen and a Roman Catholic, who was
brought to the Emergency room of East Avenue Medical Center on August 10, 2010 at
around 7:45 am. The client is a fifty-seven (57) year old female, widow; she has 4
children and resides at 6720 Libis Espina, Caloocan City.
One year prior to admission, the client experienced general weakness, weight loss,
abdominal pain, and pallor and was confined at Caloocan Local Hospital with findings of
myoma.
3 days prior to confinement, the client experienced pallor, weakness, difficulty of

breathing, diarrhea, vomiting and decreased sensorium.
The client has a chief complaint of episodes of diarrhea with vomiting for 3 days.
Her admitting vital signs were as follows: pulse rate of 105 beats per minute, respiratory
rate of 48 cycles per minute, blood pressure of 120/80 mmHg, and temperature of 36.8 oC.
Upon assessment, the client has pale palpebral conjunctiva, globular abdomen, and
abdominal girth of 79cm with a palpable mass of 24 x 10 x 14 cm. The gynaecological
assessment stated the client uses 4-5 pad per day during her menstrual cycle and has
normal external vagina, parous, and closed, soft cervix. She also has difficulty of
breathing and orthopnea. The client’s initial diagnosis was Ovarian New Growth,
probably malignant.
On August 11, 2010, the client underwent exploratory laparotomy, adhesiolysis,

omentectomy, and biopsy of the mesenteric mass, and Left salphingo-oophorectomy. She
was then inserted with a nasogastric tube for decompression, an indwelling catheter, tube
drain to Jackson Pratt, Foley catheter to urine bag and central venous line. The client was
with an endotracheal tube hooked to mechanical ventilator, size 7.5, Level 19, with the
following settings: FiO2 of 40%, tidal volume of 400 mL, BUR of 12, PEEP of 4cm/H 20,
AC Mode.
The client’s final diagnosis is Abdomino-Pelvic Mass, Ovarian New Growth

Probably Malignant (t/c mesenteric lymphoma).
B. Nursing History (Based on the Functional Health Pattern by Gordon)
During the time when the client was handled, the client was with endotracheal tube
hooked to a mechanical ventilator which forbids the student nurse from obtaining
relevant information from the client. The student nurse also was not able to interview the
client’s relative because they were not present during the time that the client was handled.
C. DEVELOPMENTAL TASKS
Sigmund Freud’s Psychosexual Theory
The client falls under the Genital Stage of Freud’s Psychosexual Theory. On this
stage, the person’s main focus of energy is towards full sexual maturity. She should be
manifesting sexual maturity development and establishing satisfactory relationship with
the opposite sex. The client was able to achieve this stage because at the age of 57, she
was able to establish a family, although her husband was already dead.
Erik Erikson’s Eight Stages of Development
According to Erikson’s eight stages of development, the client is in the late

adulthood stage therefore he is under the central task of Integrity versus Despair. The
client can look back on good times with gladness, on hard times with self-respect, and on
mistakes and regrets with forgiveness and finds a new sense of integrity and a readiness
for whatever life or death may bring.
Jean Piaget’s Cognitive Theory
In Jean Piaget’s Cognitive Development theory, the client is in the Formal

Operational stage of the Formal Operational Thought. She has the ability to think about
problems she have, able to make decisions for herself and can also think logically in her
mind. However, because of the client’s hospitalization, her decision making skills had
some changes. Currently, her children are the ones who decide and anticipate the needs of
the family.
Lawrence Kohlberg’s Moral Development Theory
In Lawrence Kohlberg’s Moral Development Theory, the client is at the

Principled Conscience under the Post-Conventional Stage. The client is concerned with
maintaining the principles and law of the family and the society. In her confinement, she
complies with the advice of the doctors because she believes that it would help her
recover.
II. PHYSICAL ASSESSMENT
Date performed: August 16, 2010
Time performed: 3:00 PM
Client’s Initial: L.L.
Client’s Admitting Diagnosis: Ovarian New Growth, Probably Malignant
Appearance and mental status
The client is fairly kempt, awake, appears weak, and on semi-fowler’s position. The client is on shallow labored breathing with the use of accessory muscles. The client is
cooperative as much as she can with the student nurse. The client was with an endotracheal tube hooked to mechanical ventilator, size 7.5, Level 19, with the following settings:
FiO2 of 40%, tidal volume of 400 mL, BUR of 12, PEEP of 4cm/H 20, AC Mode. The client has a Glasgow Coma Scale (GCS) of (eye opening-4; verbal response-X; motor
response-4).
The client has no body odor, but foul breath was noted. The client’s posture while standing and walking were not assessed because of her inability to perform the said
activities. The client has an IVF of PNSS 1 L for 8 hours inserted at Right Central venous pressure at 100 cc level and D5NR 1 L for 10 hours inserted at Right cephalic vein at full
level. The client also has a nasogastric tube to bed side bottle draining bilious output inserted in the right nostril for decompression, with tube drain to Jackson Pratt with dark
reddish output, moderate in amount, and with an Indwelling Foley Catheter attached to urine bag and hooked at bedside with urine output of 100 milliliters, dark yellowish in
color. The client’s post operation dressing is dry and intact. The client also has an abdominal binder and elastic bandage on both legs.
Vital Signs:
The client has the following vital signs during the physical assessment:
Temperature: 36°C ;
Pulse Rate: 72 cycles per minute;
Respiratory Rate: 20 breaths per minute and;
Blood Pressure: 110/70 mmhg.
AREAS TO BE ASSESSED METHODS OFASSESSMENT NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION
Rounded (normocephalic and symmetric,
Inspection Head Circumference of 22.5
with frontal, parietal, and occipital
(Size, shape, symmetry and inches. Rounded and smooth skull
prominences); smooth skull contour; no Normal skull on inspection
deformities) contour. No deformities.
deformities
Skull
Palpation Smooth, uniform consistency;
Smooth, uniform consistency; absence of
(Palpate for lumps, nodules or absence of masses, lumps,
nodules or masses, lumps, depression,
masses, depression, tenderness depression, tenderness and Normal findings on palpation
tenderness and lesions.
and lesions) lesions.
White scalp, no lice, with
A normal deviation of white
Inspection White scalp, no lice, no dandruff, no dandruff flakes white in color, no
Scalp & hair due to the client’s age.
(Color, lesions, hair distribution lesions, hair evenly distributed, thick, lesions, dry, grayish-white hair
Hair Abnormal findings of
and consistency) shiny, free from split ends unevenly distributed, thin, shiny,
dandruff flakes on the scalp.
free from split ends
HEAD
Round in shape, symmetrical
facial movements, presence of
Oval, square or round in shape,
wrinkles on forehead and outer
Inspection symmetrical facial movements, smooth,
canthus of the eyes, no
(Shape, texture, symmetry of free from wrinkles, no involuntary Normal face deviations of
Face involuntary movements, and
movements, facial expressions, movements, and facial expression wrinkles.
facial expression depends on
edema and hollowness) depends on mood. Symmetric nasolobial
mood and situation. Symmetric
folds. No signs of edema and hollowness.
nasolobial folds. No signs of
edema and hollowness.
Temporal arteries are palpable but
Temporal Temporal arteries are not protruding but
Inspection/Palpation are not protruding during Normal temporal arteries.
arteries are palpable.
inspection and palpation.
Inspection Hair evenly distributed; skin intact. Evenly distributed hair; skin is intact
Eyebrows (hair distribution, alignment, and Eyebrows symmetrically aligned; without lesions. Eyebrows Normal eyebrows.
EYES AND
skin quality and movement) equal movement. symmetrically aligned; moves equally
VISION
Inspection
Equally distributed; curled slightly Eyelashes are equally distributed and
Eyelashes (Evenness of distribution and Normal eyelashes.
outward. are curled slightly outward.
direction of curl)
Inspection Eyelids have intact skin; No
Skin intact; no discharge; no
(Surface characteristics, discoloration and discharge was noted.
discoloration. Lids close
Eyelids position in relation to the cornea, Lids close symmetrically and Normal findings on eyelids.
symmetrically, bilaterally blinking.
ability, frequency of blinking, bilaterally blinking. Absence of edema
No edema and scaling.
edema, discharge and scaling.) and scaling.
Inspection Sclera appears white and without
Sclera Sclera is white. No lesions and edema. Normal findings on sclera
(Color and lesions) lesions and edema.
Inspection Transparent in color. Capillaries are
Bulbar Transparent; capillaries evident. No
EYES AND (Color, texture, edema and evident. Absences of edema and Normal bulbar conjunctiva.
conjuctiva edema and lesions.
VISION lesions.) lesions.
Palpebral Inspection Shiny, smooth, and pink or red in Shiny, smooth, and pale in color.
Pale palpebral conjunctiva
conjunctiva (Color, texture, and lesions.) color. Without lesions and edema. Without lesions and edema.
Inspection and Palpation No edema or tenderness over the Normal finding on lacrimal
Lacrimal gland No edema or tenderness
(Edema and tenderness) lacrimal gland gland.
Transparent, shiny, and smooth. No
Normal deviation of Arcus
Inspection abrasions were seen. Details of the Transparent, shiny, and smooth;
serilis finding on the client’s
Cornea (Clarity, texture, abrasions and iris are visible. A thin, grayish white details of the iris is visible. Evident
cornea due to the clients
elevations) ring around the margin called arcus arcus serilis. No abrasions.
aging process.
serilis is evident in older people.
Inspection Client blinks when the cornea is
Client blinked when the cornea was
Cornea (Corneal sensitivity to determine touched, indicating that the Normal cornea.
th touched.
function of the 5 cranial nerve) trigeminal nerve is intact.
Black in color, pupil is equal, round,
EYES AND Black in color, PERRLA (pupil is
Inspection reacts to light and accommodation,
VISION equal, round, reacts to light and
(Color, shape, symmetry of size, constricts when light is pointed to eyes
Pupils accommodation), constricts when Normal pupils.
reaction to light and and dilates when light is removed. The
light is pointed to eyes and dilates
accommodation) size of the pupils are equal on both
when light is removed.
eyes, about 3 mm in diameter
Inspection
(Function of the retina and
When looking straight ahead, the
neurological function of the When looking straight ahead, client
Visual fields client agreed and nodded that she can Normal visual fields.
retina and neuronal visual can see objects in the periphery.
still see objects in the periphery.
pathways to the brain and second
(optic) cranial nerve
Inspection Both eyes coordinated, move in
EYES AND Extraocular (Assess for the six ocular Both eyes coordinated, move in unison, with parallel alignment when
Normal extraocular muscle.
VISION muscle test movement to determine eye unison, with parallel alignment. the test was done on the client’s
alignment and coordination) extraocular muscle.
The client was not able to

The client was not able to read print
read print due to the presence
Inspection with font style of Times New Roman
Visual Acuity Able to read print. of Endo tracheal tube and
(Near vision) and size of 12 without eyeglass with a
just nodded when asked if
distance of 14 inches.
she couldn’t see the print.
Color same as facial skin.
Inspection Uniform in color. Symmetrical.
Symmetrical. Auricle aligned with Normal auricles upon
(Color, symmetry of size, and Auricle aligned with the outer canthus
outer canthus of eye, about 10 O from inspection.
position) of eye.
Auricles vertical.
EARS AND Palpation
Mobile, firm, and not tender; pinna Mobile and firm. Pinna recoils after it
HEARING (Texture, elasticity, and areas of Normal auricles on palpation.
recoils after it is folded. is folded. No tenderness was noted
tenderness)
Distal third contains hair follicles.
Presence of hair follicles. Dry
Inspection Dry cerumen. Grayish-tan in color;
External ear cerumen which is golden brown in
(Cerumen, skin lesions, pus, and or sticky, wet cerumen in various Normal external ear canal.
canal color. Absence of blood, pus and
blood) shades of brown. No blood, pus and
swelling.
swelling.
Not done because otoscope is not
Tymphanic Inspection Pearly gray in color,
available during the physical Not done.
membrane (Color and gloss) semitransparent.
examination.
Student nurse needs to increase
Inspection Client is not able to hear
Normal voice tones audible. volume of voice or repeat the question
(Response to normal voice) normal voice tones clearly
twice for her to hear.
EARS AND Gross hearing Client was not able to hear
Watch Tick Test Able to hear ticking on both ears. Not able to hear ticking on both ears.
HEARING and acuity tests the ticking of the watch.
Sound is heard in both ears or is
Not done because of the unavailability
Tuning Fork Test localized at the center of the head Not done.
of tuning fork.
(weber negative)
Symmetric and straight. It is
Inspection Symmetric and straight. Proportional positioned at the lateral center of the
(Shape, size, or color and flaring to face. No discharge or flaring. face. Nose is proportionate to the face Client’s nose is normal.
or discharge from the nose) Uniform in color. and uniform in color. Nasogastric tube
inserted at the right nostril.
Palpation
Normal nose on palpation.
Nose (Tenderness, masses, and Not tender on palpation. No lesions
Not tender and no lesions.
displacements of bone and noted.
NOSE AND
cartilage.)
SINUSES
Air moves freely on her left nostril as
Assessment Air moves freely as the client the client breathes. Right nostril was Normal findings on left
(Patency of both nasal cavities) breathes through the nares. not assessed due to the presence of nostril.
Nasogastric tube.
Inspection Nasal septum intact and in the
Nasal Septum Intact and positioned in the middle. Normal nasal septum.
(position and integrity) middle.
Palpation
Facial Sinuses Not tender. Not tender on palpation Normal facial sinuses.
(Tenderness)
Inspection/Palpation Abnormal findings of pale
Lips and Buccal Uniform pink color. Moist, smooth, The lips are symmetrical, pale in
(Color, moisture, texture and colored and dry and peeling
Mucosa glistening, and elastic texture. color, dry, and peeling.
presence of lesions) lips.
MOUTH
AND ORO- 32 adult teeth, smooth, white, shiny
Upper and lower teeth are yellowish in
PHARYNX Inspection tooth enamel. Pink gums, moist, firm Abnormal findings of teeth,
Teeth and Gums color. Gums are also pink and moist
(number of teeth, texture, color) texture to gums. No retraction of yellowish in color
on inspection.
gums.
Central position, pink color; moist;
Inspection The client’s tongue is centered and Normal position, color,
slightly rough; thin whitish coating.
Tongue (Position, color, texture, pink in color with whitish coating and texture and movement of the
No lesions, and with raised papillae
movement) raised papillae. No lesions noted. tongue.
(taste buds)
MOUTH
AND ORO- Inspection Uvula is positioned in the middle of Normal positioning and
Uvula Positioned in middle of soft palate.
PHARYNX (Position, and mobility) the soft palate. mobility of the uvula.
Client’s tonsils are pink in color,

Inspection Pink and smooth, no discharge, of
Tonsils smooth, without discharge noted. Normal finding.
(Color, discharge, & size) normal size or not visible.
Tonsils’ size is Grade I.
Neck muscles are equal in size. Head
Inspection Muscles equal in size; head centered.
Neck Muscles is located in the center, and no Normal findings.
(Abnormal swellings or masses) No swelling and masses.
swelling or masses noted.
Inspection Coordinated, smooth movements Client’s is not able to move her head
Neck Muscles Abnormal head movement.
(Head movement) with no discomfort. by herself.
Palpation
Lymph Nodes Not palpable. Lymph nodes are not palpable. Normal lymph nodes
(Enlarged lymph nodes)
Not visible on inspection. Gland
Inspection Thyroid gland is neither visible nor
ascends during swallowing but is not
(swelling and visibility) swelling.
visible.
NECK
Lobes may be palpated. If palpated,
Palpation lobes are small, smooth, centrally Lobes of the thyroid gland are not
Thyroid gland Normal findings
(Smoothness) located, painless, and rise freely on palpable.
swallowing.
Auscultation
(a soft rushing sound created by Absence of bruits. No bruits auscultated.
turbulent blood flow)
Carotid arteries on both sides are Normal carotid artery
Carotid artery Palpation Are not protruding but palpable.
palpable but not protruding. pulsation.
Client’s muscles on both upper
UPPER Inspection extremities are thin and
Equal size on both sides of body. No Abnormal muscle atrophy on
EXTRE- Muscle (Size and symmetry, contractures inappropriate on his body built.
contractures and tremors. the upper extremities.
MITIES and tremors) No contractures and tremors
noted.
Palpation Normally firm with smooth coordinated Muscles are smooth with
Normal muscle tonicity
(muscle tonicity) movements. coordinated movements.
Muscles of the client were tested Upper extremities’ muscles
Muscle
through extension of extremities. also have 75 percent of
Muscle strength test Equal strength on each body side.
Client exhibited equal strength on strength (grade IV) but still
both sides. on normal range.
Normal bones upon
Inspection No deformities. No deformities.
inspection.
Bones
UPPER Palpation No tenderness. swelling noted on Abnormal swelling on the
No tenderness or swelling
EXTRE- (Edema and tenderness) palpation. upper extremities.
MITIES Inspection
No swelling No swelling was noted
(swelling)
Palpation Normal findings on joints on
Joints Joints move smoothly. No
(tenderness, smoothness of No tenderness, swelling, crepitation, or the upper extremities.
presence of tenderness, swelling,
movement, swelling, crepitation, nodules. Joints move smoothly.
crepitation
and presence of nodules
Pulse rate palpated over the brachial and Brachial and radial pulse is weak.
Brachial and Palpation Weak brachial and radial
radial pulse. Normal radial pulse count is Clients pulse has a normal rate.
radial arteries pulses.
60-100 beats per minute for adult people. PR=72 bpm
Flexion of the elbow after sticking of the
Deep tendon Not done because reflex hammer
Elicit reflex reflex hammer. Responses are Not done.
reflex is not available.
symmetrical on both arms
Abnormal capillary refill of 4
Nails are thick, long and dirty.
UPPER Nails are trimmed and clean. Skin is seconds. Nails are thick,
Finger pads are yellowish. No
EXTRE- Nails and skin Inspection uniform in color. No swelling or lesions. untrimmed and dirty. Finger
swelling and lesions was noted
MITIES Capillary refill of 2-3 seconds. pads are yellowish
Capillary refill = 4 seconds
Inspection Males: breast even with the chest wall; if
(size, symmetry, and obese, may be similar to the shape of the
Breasts are of normal size and
contour/shape. Localized female. Skin uniform in color (same in
symmetric. Skin is uniform in
discoloration or appearance as skin of abdomen and
Breast color, smooth and intact. No Normal breast.
hyperpigmentation, retraction, or back). Skin smooth and intact. Diffuse
striaes, moles and nevi were
dimpling, localized symmetry horizontal or vertical vascular
noted
hypervascular areas, swelling or pattern in light-skinned people, striae,
edema) moles and nevi.
Palpation There are no presences of masses,
No tenderness, masses, nodules, or nipple
Breast (masses, tenderness, and any nodules or nipple discharge. No Normal breast.
discharge.
discharge from the nipples) tenderness was noted
BREAST
Round or oval and bilaterally the same.
AND
Inspection Color varies widely, from light to dark Areola in both breast is round,
AXILLAE
(size, shape, symmetry, color, pink. Irregular placement of sebaceous bilateral and dark brown in color
Areola Normal areola.
surface, characteristics, and any glands on the surface of the areola with few small growing hair. No
masses or lesions. (Montgomery’s tubercles). Absence of lesions and masses were noted.
masses or lesions.
Round, overted, and equal in size; similar

in color, soft and smooth; both nipples Both nipples are round, overted,
Inspection
point in the same direction. No discharge equal in size, dark brown in color,
Nipples (size, shape, position, color, Normal nipples.
except from pregnant or breast-feeding. soft and smooth. No discharge
discharge)
Inversion of one or both nipples that is was noted
present from puberty.
BREAST There is no noted tenderness,
Palpation No tenderness, masses, nodules, or nipple
AND Nipples masses, nodules or nipple Normal nipples.
(masses, tenderness, and nodules) discharge.
AXILLAE discharge
HEART
AND Inspection and palpation
CENTRAL Aortic and Normal findings on the aortic
(note for presence or absence of No pulsation No pulsation
VESSELS Pulmonic area and pulmonic area
pulsations)
Inspection and palpation Pulsation palpable in fifth left intercostal Palpable pulse in the fifth left
Normal findings on the
Tricuspid area (note for presence of apical space at or medial to midclavicular line. intercostals space. No lifts and
tricuspid area of the heart
pulsation and location) No lifts and heaves. heaves was noted
Inspection and palpation

Normal findings on the
Epigastric area (note for presence of Aortic pulsation Presence of aortic pulsation
epigastric area
abdominal aortic pulsation)
Aortic, Auscultation S1: heard at all sites, louder at apical area S1: heard at all sites, louder at Normal findings upon
Pulmonic, S2: heard at all sites, louder at base of the apical area auscultation of the aortic.
Tricuspid, heart S2: heard at all sites and louder at Pulmonic, tricuspid and
Apical S3: in children and young adults the base of the heart Apical area.
S4: older adults S3: not heard
S4: not heard
Symmetric pulse volume. Full palpation Pulse volume is symmetric and
Palpation and thrusting quality. Quality remains with thrusting quality which
Normal findings upon
Carotid Artery (for pulses, elasticity, and same when client breathes, turns head remains the same when client
palpating the carotid artery
quality) and changes from sitting to supine breathes, turns head and changes
position. Elastic arterial wall. position.
Normal findings upon

Ausculatation
Carotid Artery No sound heard upon auscultation No sound was noted. auscultation of the carotid
HEART (note for presence of bruits)
artery
AND
CENTRAL Normal findings upon
VESSELS Inspection Veins are not visible and there are
Jugular veins Veins not visible inspection of the jugular
(note for distention) of signs of distention
veins
Shallow labored breathing
There is the use of accessory
with use of accessory
Inspection muscles and shallow labored
Quiet, rhythm, and effortless respirations. muscles. Time of expiration
(Breathing pattern) breathing. Time of expiration is
is twice longer than the
longer than the expiration.
inspiration.
Anterior Inspection Anteroposterior to transverse diameter in Normal findings of the

THORAX Chest is symmetric.
Thorax (Shape, symmetry, deformities) ratio of 1:2. Chest symmetric. anterior chest.
Trachea has bronchial and tubular breath

sounds. Crackles heard at the mid base
Auscultation Presence of crackles on both
Bronchovesicular and vesicular breath right of the lung and crackles
(trachea and anterior chest) lungs.
sounds beginning over the bronchi heard at basal lower lung.
between the sternum and the clavicles.
Percussion notes resonate down to the
sixth rib at the level of the diaphragm but Percussion notes dullness over the
Percussion are flat once over the areas of heavy lung tissue. Dull on the heart and Dullness was noted over the
muscle and bone, dull on areas over the liver areas. Tympanic over the lung tissue.
heart and the liver, and tympanic over the stomach.
underlying stomach.
Skin intact; uniform in temperature.

Chest wall intact; no tenderness; no Uniform skin temperature w/ no Normal anterior thorax upon
Palpation
masses. Costal angle is less than 90 O, tenderness and masses. Skin and palpation.
(Lesions, costal angle)
and the ribs insert into the spine at chest wall are intact.
approximately a 45 O angle.
Anterior Abnormal finding of
Thorax Full symmetric chest expansion. Thumbs
Palpation 2 cm chest expansion w/ the use Inability to exhibit full
separate 3-5 cm 1 ½ to 1 ½ inches during
(Respiratory excursion) of accessory muscles expansion of lungs with 2
deep expiration.
centimeter chest expansion.
Bilateral symmetry of vocal fremitus.
Palpation Normal vocal fremitus of the
Fremitus is normally decreased over the The vocal fremitus is symmetric.
(vocal (tactile) fremitus) anterior thorax.
heart and breast tissue
THORAX Trachea has bronchial and tubular breath
Crackles are heard on the mid-
sounds.
Auscultation base of the right lung field and Crackles are heard during
Bronchovesicular and vesicular breath
(trachea and posterior chest) basal crackles over the left lung auscultation.
sounds beginning over the bronchi
field.
between the sternum and the clavicles.
Anteroposterior to transverse diameter in
Posterior Inspection ratio of 1:2. Chest symmetric. Spine Spine is vertically aligned and
Thorax (Shape, symmetry, spinal vertically aligned. Spinal column is straight. Right and left shoulders Normal findings
alignment, and deformities) straight, right and left shoulders and hips are equal in height.
are at the same height
Percussion Percussion notes resonate, except over
(to determine if lung is filled Percussion notes resonate, except
scapula. Lowest point of resonance is at
with air, liquid or material) over scapula. Dullness is noted Normal findings
the diaphragm. Percussion on the ribs
upon percussion on the ribs.
normally elicits dullness.
Skin intact; uniform in temperature.

Palpation Chest wall intact; no tenderness; no Skin is intact. No tenderness and
Abnormal respiratory
(Lesions, respiratory masses. Full symmetric chest expansion. masses noted. Respiratory
excursion of 2 ½ cm.
excursion) Thumbs separate 3-5 cm 1 ½ to 2 inches excursion of 2 ½ cm.
Posterior during deep expiration.
THORAX
Thorax Bilateral symmetry of vocal fremitus.
Fremitus is heard most clearly at the apex Vocal fremitus is bilaterally
Palpation
of the lungs. Low-pitched voices of symmetrical and is easily Normal findings
(vocal (tactile) fremitus)
males are more readily palpated than palpated
higher pitched voices of females.
Unblemished skin, uniform in color,
Inspection Not assessed. The client’s post
silver-white striae (stretch mark) or The client’s post operative
(skin integrity, contour, and operative dressing is dry and
surgical scars. Flat, rounded (convex), or dressing is dry and intact.
symmetry) intact.
scaphoid (concave).
Symmetric movements caused by
Not assessed. The client’s post
Inspection respiration. Visible peristalsis in very The client’s post operative
operative dressing is dry and
(Abdominal movement) lean people. Aortic pulsations in thin dressing is dry and intact.
intact.
persons at epigastric area.
Four Auscultation
ABDOMEN quadrants of Audible bowel sounds. Absence of The client’s post operative The client’s post operative
(bowel sounds, vascular sounds,
Abdomen friction rubs. dressing is dry and intact. dressing is dry and intact.
and peritoneal friction rubs)
Percussion Tympany over the stomach and gas-filled

The client’s post operative The client’s post operative
(presence of tympany, and bowels; dullness, especially over the liver
dressing is dry and intact. dressing is dry and intact.
dullness . and spleen, or a full bladder.
No tenderness; relaxed abdomen with
Palpation
smooth, consistent tension. Tenderness tenderness and muscle guarding Abnormal tenderness and
(tenderness and/or muscle
may be present near the xiphoid process, was noted. muscle guarding was noted.
guarding)
over cecum, and over the sigmoid colon.
Palpation May not be palpable. Border feels
Liver Liver was not palpated. Not done
SPECIFIC (enlargement and tenderness) smooth.
ORGAN Palpation
Bladder Not palpable. Not palpable. No urinary retention.
(possible urinary retention)
Muscle is thin but with smooth

Inspection
Equal size on both sides of body. No and coordinated movements.
(Size and symmetry, contractures Normal findings
contractures and tremors. Visible veins were also noted.
and tremors)
LOWER
EXTRE- Muscle
MITIES Muscles on the left leg are
Palpation Normally firm with smooth coordinated smooth with coordinated
Normal findings
(muscle tonicity) movements. movementIt is firm and smooth
on palpation.
Lower extremities’ muscles

Muscle strength on the lower
also have 75 percent of
Muscle Muscle strength test Equal strength on each body side. extremities is equal on both sides
strength (grade IV) but still
with muscle strength Grade of IV.
on normal range.
LOWER Bones
EXTRE- Inspection No deformities. No deformities. Normal findings
MITIES No tenderness. Swelling noted on Swelling noted on both legs.
Palpation
No tenderness or swelling both legs. With elastic bandage With elastic bandage on both
(Edema and tenderness)
on both legs. legs.
Inspection
Joints No swelling No swelling Normal findings
(swelling)
Palpation There are no tenderness, swelling,
(tenderness, smoothness of No tenderness, swelling, crepitation, or crepitation or nodules that was
Joints Normal findings
movement, swelling, crepitation, nodules. Joints move smoothly. noted. Joints could also move
and presence of nodules smoothly
Popliteal,
posterior tibial, Palpation Pulses are palpated over the popliteal, Palpable pulses over the popliteal,
Normal findings.
and pedal posterior tibial, and pedal arteries. posterior tibial, and pedal pulse
LOWER arteries
EXTRE- Flexion of the elbow after sticking of the
Deep tendon Not done due the unavailability of
MITIES Elicit reflex reflex hammer. Responses are Not done.
reflex reflex hammer.
symmetrical on both arms
There is presence of thick,
untrimmed and dirty nails Presence of thick, untrimmed
Nail is trimmed and clean. Skin is
Skin is uniform in color. There is and dirty nails. Capillary
Nails and skin Inspection uniform in color. No swelling or lesions.
no swelling and lesions that was refill of 4 seconds was also
Capillary refill of 2-3 seconds.
noted. Capillary refill = 4 noted
seconds
FEMALE
Inspection
GENITALS Triangular distribution, often spreading
Pubic Hair (distribution, amount, and Not assessed for privacy Not assessed for privacy
AND up the abdomen.
characteristics of pubic hair)
skin is intact. Appears slightly wrinkled

Inspection
and varies in color as widely as other
Penis (lesions, nodules, swelling, and Not assessed for privacy Not assessed for privacy
INGUINAL body skin.. Small amount of thick white
inflammation)
smegma between the glans and foreskin.
AREA
Palpation
Smooth and semifirm. Is slightly
Penis (tenderness, thickening, and Not assessed for privacy Not assessed for privacy
movable over the underlying structures.
nodules)
Inspection
INGUINAL Pink and slit like appearance at the tip of
Urethral meatus (swelling, inflammation, and Not assessed for privacy Not assessed for privacy
AREA the penis.
discharge)
Scrotal skin is darker in color than that of
Inspection the rest of the body. Size varies with
Scrotum (appearance, general size, and temperature. Scrotum appears Not assessed for privacy Not assessed for privacy
symmetry) asymmetric (left testis is usually lower
MALE than the right)
GENITALS Testicles are rubbery, smooth, and free of
AND Palpation
nodules and masses. Epididymis is
INGUINAL (status of underlying testes,
Scrotum resilient, normally tender, and softer Not assessed for privacy Not assessed for privacy
AREA epididymis, and spermatic
than the spermatic cord which is firm to
cord.
touch.
Inspection
Inguinal area No swelling or bulges. Not assessed for privacy Not assessed for privacy
(bulges)
Intact perianal skin; usually slightly more
pigmented than the skin of the buttocks.
Inspection
Anus Anal skin is normally more pigmented, Not assessed for privacy Not assessed for privacy
(color, integrity, and lesions)
coarser, and moister than perianal skin
RECTUM and is usually hairless.
Palpation Anal spinchter has good tone. Rectal wall
Anus (tonicity, nodules, masses, and is smooth and not tender. Brown colored Not assessed for privacy Not assessed for privacy
tenderness) feces.
Summary of abnormal findings:
During inspection of the scalp, dandruff flakes was noted. Pale palpebral conjunctiva was
noted upon inspection of the eyes. The client was not able to read print due to the presence of
Endo tracheal tube and just nodded when asked if she couldn’t see the print. In addition, client is
not able to hear normal voice tones clearly as well as the ticking of the watch during the watch
tick test. The client also has a pale colored, dry and peeling with teeth, yellowish in color.
On inspection, client has thin upper extremities and visible swelling on both arms. Upon
palpation, client has weak brachial and radial pulses. Nails are thick, untrimmed and dirty on
both upper and lower extremities with capillary refill of 4 seconds. Finger pads are yellowish in
color.
During the inspection client was seen on shallow labored breathing with use of accessory
muscles with time of expiration twice longer than the inspiration. Presence of crackles on both
lungs during auscultation. Upon percussion of the anterior thorax, dullness over the lung tissue
was noted. The client was unable to exhibit full expansion of lungs with 2 cm chest expansion on
anterior thorax and 2 ½ cm on posterior side. The post operative dressing was dry and intact but
with tenderness and guarding behavior upon palpation. The client has pitting edema on both legs
and wears elastic dressing.
III. MEDICAL PLAN OF CARE
To ensure and confirm diagnosis, series of diagnostic tests and laboratory exams
should be done to the client that will verify the diagnosis:
a. Client’s Health History - Health history of the client may reveal past or recent
illness.
b. Physical examination – To assess present health condition of the client as well
as the signs and symptoms present to him.
c. Complete Blood Count- to assess presence of infection and
d. Blood Coagulation – to measure time required for clotting
e. BUN- indicator of renal function
f. Urinalysis- use to assess the effects of CVD on renal function and the existence
of concurrent renal or systemic disease.
g. Electrolytes- affects cardio contractility specifically Na, K, Ca
h. Electrocardiogram- graphical recording of the electrical activities of the heart
i. Arterial Blood Gas- to evaluate oxygenation and acid/base status in the body
j. Pulse Oximetry- device used to measure the oxygen saturation of arterial
blood. To determine the percentage of oxyhemoglobin in blood.
To maintain effective airway of the client:
a. Keep client on moderate high back rest to promote proper lung expansion and to
prevent aspiration.
b. Encouraged client to do deep breathing exercises to maximize expansion of the lungs
and smaller airways
c. Maintained mechanical ventilator settings as ordered by the physician to assist
breathing.
To ensure condition, progress and response to treatment, continuous monitoring of the

client is required:
a. Monitor vital signs and record. This is done to be able to evaluate the body’s response
to treatment.
b. Monitoring fluid intake and urinary output every hour and record to be able to assess
the kidney function based on the amount of her daily intake of fluids, through oral
means and intravenous fluid administration, and urinary output.
c. Monitor neurologic vital sign- to assess neurologic status of the client
To maintain adequate nutrition and hydration:
a. NGT (nasogastric tube) -A tube that is passed through the nose and down through the
nasopharynx and esophagus into the stomach. It is done to put substances into the
stomach, and so it may be used to place nutrients directly into the stomach when a
client cannot take food or drink by mouth. In this case, done for decompression, or
lavage of abdominal fluids in the stomach.
b. IVF of PNSS- to replace fluid and electrolyte loss
c. IVF of D5NR – to serve as a source of glucose while the client is on NPO
d. Nothing per orem as ordered.
To facilitate treatment of the condition, medications should be given as prescribed:
a. Metronidazole 500g IV every 8 hours

b. Ceftazidime 1 gm IV every 8 hours
c. Tranexamic acid 1 gm IV every 8 hours
d. Omeprazole 40 mg IV once a day
e. Morphine Sulfate 2g IV every 2 hours round the clock, watch out for morphine
toxicity
f. Morphine sulfate 1g IV for severe pain
g. CBG every 4 hours
To prevent spread of infection and further complications:
a. Wash hands before and after assessing the client and after each procedure
b. Wear mask and gloves in every procedure that is needed to be done
c. Practice aseptic technique in every procedure to prevent infection
d. Encourage hygiene to prevent growth of microorganisms
To prevent recurrence of the disease:
a. Compliance of medications as prescribed by the physician

b. Always keep the client’s back dry
c. To prevent further injuries.
To prevent further injuries:
a. Observe safety precaution by raising side rails.

b. Assist in activities of daily living.
IV. Laboratory Results
A. Arterial Blood Gas
REFERENCE NURSING
RESULTS SIGNIFICANCE
RANGES RESPONSIBILITY
August 13, 2010 August 15, 2010
pH 7.35 – 7.45 7.53 7.5 This is a measurement of chemical balance of the body and is a Explain the need for ther
ratio of acid and bases. procedure ; tell the client
PCO2 35.0 – 45.0 23.3 26.1 It is a measurement of ventilation. This detects a respiratory that no fasting is needed.
abnormality and to determine the alkalinity or acidity of the
blood. When taken as an arterial sample, it directly reflects how Apply pressure or a
well air is exchanging with blood in the lungs. pressure dressing to the
Increase or decrease in the partial carbon dioxide would indicate site to prevent further
whether the imbalance is respiratory or metabolic in nature. bleeding.
PO2 80.0 – 100.0 503.1 180.4 Measures the effectiveness of the lungs to oxygenate the blood.
The severity of impairment of the ability of the lungs to diffuse Observe the site for
oxygen across the alveolar membrane into the circulating blood is bleeding
indicated by the level of partial pressure of oxygen.
Thus, it is associated with chronic obstructive pulmonary disease Monitor oxygen level of
and pneumonia. the client to prevent
HCO3 22-26 20.5 20.4 This is indicative for the process responsible for the homeostasis oxygen toxicity or
of the metabolic system. A sudden decrease. Or increase is atelectasis
indicative of homeostatic interference.
uncompensated, uncompensated,
Respiratory respiratory
Acidosis Acidosis
B. Hematology
Normal Result
Examination Unit Significance Nursing Responsibilities
Value August 12, 2010
WBC 4.0-11 K/UL 27.6 It serves as a usual guide to the severity of the disease. Thus The client or the client’s
identifies a certain person with increase susceptibility to significant other should be
infection. informed of the reasons the
Increase values indicates an immune response to infection. specimen was ordered, how it is to
Hemoglobin 140-170 gm/L 126 It serves as a vehicle for transportation of oxygen and CO2. be collected, the equipment
It also serves as one of the primary buffer substances in needed, and the stinging sensation
extracellular fluid and helps maintains acid-base balance by that may be felt. There are no fluid
the process of chloride shift. restrictions before collection of the
specimen.
Decrease values have been detected due to hemolytic
reaction due to infectious agents. Age is also a contributing Label the obtained specimen and
factor to the decrease erythrocyte count in this age group. secure it properly
Hematocrit 0.40-0.50 gm/L 0.34 This means to separate blood which underscores the
mechanism of the test. Since the plasma and the blood cells Apply pressure or a pressure
are separated by centrifugation. dressing to the venipuncture site to
Decrease values have been detected due to hemolytic prevent further bleeding. Observe
reaction due to the presence of infectious agents. the site for bleeding.
Neutrophil 0.5-0.7 0.916 It is an important type of white cells in the body’s reaction
to inflammation. They constitute a primary defense against Provide safety to the client
microbial invasion through the process of phagocytosis.
These cells can also cause some damage to body tissues by
their release of enzyme and endogenous pyrogens.
Increase percentage of neutrophils represents severity of
infection.
Normal Result
Value August 12, 2010
Lymphocyte 0.2-0.5 % 0.038 N These cells are the sources of immunoglobulins and of The client or the client’s
cellular immune response and play an important role in significant other should be
immunologic reaction. informed of the reasons the
Platelet 150-400 K/UL 91 Platelet development takes place primarily in the bone specimen was ordered, how it is to
marrow and possibly in the lungs. This test is also used in be collected, the equipment
following the course of the disease due to the activated needed, and the stinging sensation
coagulation mechanism resulting in local formation of the that may be felt. There are no fluid
thrombin. restrictions before collection of the
Decrease values indicates delayed coagulation in cases of specimen.
bleeding or blood loss
MCV 60-100 fL 83.9 N It is the measure of the average volume or size of a single Apply pressure or a pressure
RBC. When MCV is decreased, RBC is said to be dressing to the venipuncture site to
abnormally small. This is associated with iron deficiency prevent further bleeding. Observe
anemia the site for bleeding
MCHC 320-360 gm/dL 336 N It is the measure of the average amount or weight of Hgb
within an RBC Label the obtained specimen and
RDW 11-16 % 15.6 N It is the measure of the average concentration or percentage secure it properly
of Hgb within a single RBC
C. Metabolic Profile
Normal Result
Value 8/10/10 8/12/10 8/13/10
BUN 53-115 umol/L 19.34 22.54 It is measuring the nitrogen portion of the urea, is used as Explain the need for this
glomerular function and production and excretion of the procedure to client.
urea. The rate at which BUN rises is influenced by degree of tell the client that no fasting
tissue necrosis, protein catabolism and the rate at which the is needed.
kidneys excrete urea nitrogen.
Creatinine 53-115 umol/L 164 158 176 It signifies Impaired renal function. Creatinine is the by- Apply pressure or a pressure
product in the breakdown of muscle creatinine phosphate dressing to the site to prevent
resulting from energy metabolism. It is produced at a further bleeding.
constant rate depending on muscle mass of the person and is
removed from the body by the kidneys. A disorder in kidney Observe the site for bleeding.
function reduces excretion of creatinine, resulting in
increased levels of blood creatinine.
Sodium 135-145 mmol/ 132 141 Sodium maintains the osmotic pressure and acid-base
L balance and to transmit nerve impulses. Sodium
concentration is under control of the kidneys and the central
nervous system acting through the endocrine system.
Potassium 3.5 – mmol/ 4.4 4.6 4.1 Potassium level evaluates changes in body potassium and is
5.5 L helpful in diagnosing disorders of acid-base and water
balance in the body. It is not an absolute value and varies
with the circulatory volume and other factors such as taking
diuretics.
Albumin 34-50 g/L 29 18 This test can help determine if a patient has liver disease or
kidney disease, or if the body is not absorbing enough
protein Albumin helps move many small molecules through
the blood, including bilirubin, calcium, progesterone, and
medications. It plays an important role in keeping the fluid
from the blood from leaking out into the tissues.
Calcium 2.12- mmol/ 2.07 1.67 1.96 Calcium helps build strong bones and teeth. It is important
2.52 L for heart function, and helps with muscle contraction, nerve
signaling, and blood clotting.
Decrease level of Calcium may indicate malabsorption in the
intestinal tract.
chloride 98-107 mmol/ 99 112 It works with other electrolytes such as potassium, sodium,
L and carbon dioxide (CO2) to help keep the proper balance of
body fluids and maintain the body's acid-base balance.
Increase levels may indicate dehydration especially since the
client underwne t diarrhea and vomiting for 3 days.
D. URINALYSIS ( August 11, 2010 )
Normal
Examination Result Interpretation Significance Nursing Responsibilities
Value
Color Pale Yellow Normal Result The color of the urine ranges from pale yellow to amber The client should be told the type of
Yellow because of the pigment chrome. It indicates the specimen needed and the best time of day
to Amber concentration of the specific gravity of urine. The color of to collect it.
the urine is primarily due to the urochrome( pigments that
are present in the diet or formed form the metabolism of the Explain the purpose and specific method
bile). Due to the present of the abnormal pigments the color of urine collection to the client. Give the
of urine changes in many disease sates client the proper specimen jars and
Appearance Clear Cloudy Normal Result The normal urine should be clear. However, normal urine cleansing agents, if necessary. The
may also be cloudy which provides a warning abnormality perianal area should be washed if it soiled
such as pus, RBC, or bacteria. However, excretion of cloudy with feces.
urine may not be abnormal since the change in pH may
cause precipitation within the bladder of normal urinary
constituents. Alkaline urine may appear cloudy because of
phosphates, acid urine may appear cloudy because of urates
Odor Aromatic Aromatic Normal Result The aromatic odor of fresh normal urine is caused by the
presence of volatile acid.
Ph 4 – 6.8 5 Normal Result This is an indication of the renal tubule’s ability to maintain A small amount of fresh urine is required,
normal hydrogen ion concentration in the plasma and enough to moisten a small strip of pH
extracellular fluid. paper.
Specific 1.005 – 1.030 Normal Result Specific gravity is a measurement of the concentration of A freshly avoided specimen of at least
Gravity 1.030 urine. It is a means by which the kidney’s ability to 30ml is needed for most urinometers.
concentrate urine is measured. The range of urine specific Food and fluid restrictions are not
gravity depends on the state of hydration varies with urine necessarily before collection of the
volume and the loads of solid excreted. specimen.
Normal
Examination Result Interpretation Significance Nursing Responsibilities
Value
Glucose (-) (-) Normal Result Glucose can indicate if the client is diabetic, confirming a Foods and fluids are restricted overnight
diagnosis of diabetes, monitoring the effectiveness of for 8 hours before collection of a fasting
diabetic control. Urine normally contains no glucose. urine specimen. The client may have a
Glucose is always present in the glomerular filtrate but it is glass of water after then first specimen is
reabsorbed in the proximal tubule. When the blood glucose taken to ensure adequate urine formation
level exceeds the renal threshold for the reabsorption of for the collection of the second- voided
glucose, some glucose spills into the urine. specimen.
WBC 0-17 46 Increased WBC The presence of more than 5 white blood cells can indicate It is important for a careful examination of
bacterial infection in the urinary tract. It also acts as a urinary sediment for leukocytes
protective mechanism for invasion of bacteria in pneumonia
RBC 0-11 76 Increased RBC Red cells are occasionally found in the urine but the There are no food or fluid restrictions
uL persistent findings of even small number of RBCs should be before collection of the specimen.
thouroughly investigated since these cells come from kidney
and indicate serious renal disease.
E. Blood Coagulation Studies
RESULTS
NORMA UNI
EXAMINATION 8/10/1 8/12/1 INTERPRETATION NURSING RESPONSIBILITIES
L VALUE T
0 0
Prothrombin time 12.5 sec 11.8 12.3 It measures how long it takes blood to clot. A Explain the need for this procedure to
Prothrombin time test can be used to check for client.
bleeding problems. tell the client that no fasting is needed.
Activated Partial 38 sec 47.2 41.5 It measure of the integrity of the intrinsic and
Thromboplastin common pathways of the coagulation cascade. Apply pressure or a pressure dressing to
The APTT is the time, in seconds, for patient the site to prevent further bleeding.
Time
plasma to clot after the addition of an intrinsic
pathway activator, phospholipid and calciu. Observe the site for bleeding
V. DATA FROM THE TEXTBOOK
MYOMA
When a benign (not recurring or progressive) tumor grows in the muscles of the uterus, it is
known as uterine Myoma. These tumors can grow very large, sometimes growing as large as a
melon. The typical Myoma, however, is around the size of an egg. When the Myoma penetrates
the entire wall of the uterus, it is referred to as uterus myomatosus. In certain very rare cases
(less than 1/2 of 1% of the time) the tumors can become malignant. When this happens, it is
known as sarcoma.
Symptoms of Uterine Myoma may include:

- hyper menorrhea
- lower abdominal pain
- lumbago
- dymenorrhea
- irregular vaginal bleeding
- dizziness
- anemia.
When the Myoma pushes on the intestines or the bladder, it can result in constipation, pain of the
bladder, or a constant need to urinate. If the tumor pushes on the nerves in the spinal cord, it can
result in pain of the back or the legs.
The causes of uterine Myoma are not fully understood. Some research suggests that Uterine
Myoma is less common in women who have had at least two children. For at least one form of
uterine Myoma, there seems to be a genetic predisposition.
Uterine Myoma often goes undetected. Ultrasounds, CT Scans, or MRIs may be necessary to
fully diagnose uterine Myoma. If you have symptoms of Uterine Myoma, your health care
provider will help you determine the best way to diagnose the problem.
Once it is diagnosed, Uterine Myoma can be treated through hormonal and/or herbal treatments.
Hormonal treatment typically do not cure the Uterine Myoma. Rather, they give a temporary
relief of the symptoms of Uterine Myoma. In addition, these hormones may have certain side
effects. If these hormone treatments do not work, surgery is typically an option. Surgical options
include the surgical removal of the Myoma tumors (known as an enucleation) or a complete
hysterectomy. Recent advances in laser surgery may make this an option also. If this is the case,
the surgery can become much less invasive, and can be done laparoscopically.
OVARIAN NEW GROWTH/CYST
Ovarian cysts are sacs containing fluid or semisolid material that develop in or on the surface of
an ovary.
Description
Ovarian cysts are common and the vast majorities are harmless. Because they cause symptoms
that may be the same as ovarian tumors that may be cancerous, ovarian cysts should always be
checked out. The most common types of ovarian cysts are follicular and corpus luteum, which
are related to the menstrual cycle. Follicular cysts occur when the cyst-like follicle on the ovary
in which the egg develops does not burst and release the egg. They are usually small and
harmless, disappearing within two to three menstrual cycles. Corpus luteum cysts occur when the
corpus luteum—a small, yellow body that secretes hormones—doesn't dissolve after the egg is
released. They usually disappear in a few weeks but can grow to more than 4 in (10 cm) in
diameter and may twist the ovary.
Ovarian cysts can develop any time from puberty to menopause, including during pregnancy.
Follicular cysts occur frequently during the years when a woman is menstruating, and are non-
existent in postmenopausal women or any woman who is not ovulating. Corpus luteum cysts
occur occasionally during the menstrual years and during early pregnancy. (Dermoid cysts,
which may contain hair, teeth, or skin derived from the outer layer of cells of an embryo, are also
occasionally found in the ovary.)
Some ovarian cysts cause problems, such as bleeding and pain. Surgery may be required to
remove cysts larger than 5 centimeters in diameter.
Primary factors that cause ovarian cysts:
There are many primary factors, which lead to ovarian cysts. These factors should not be isolated
however, as sometimes the combination of these factors can together lead to the causes of
ovarian cysts.
Genetic predisposition: Genetic predisposition is often considered the leading cause of

ovarian cysts. Research has shown that the genetic pattern of women who suffer from this
chronic condition is different as compared to women who never get ovarian cysts or
PCOS. However, this should not be a death warrant as many times the genetic
characteristics can be modified with the help of environmental factors and proper lifestyle
related changes.
Poor dietary choices: Eating poorly can cause hormonal imbalance that can weaken
your immune system making you more vulnerable to ovarian cysts. Avoiding foods that
are rich in carbohydrates and sugar are important and making sure you are getting enough
fresh vegetables, fruits, and all essential nutrients each and everyday are important to
help your body flush out toxins that can aggravate ovarian cysts problem.
Weak immune system: Like I just mentioned a weak immune system can be trouble, as
it is not able to put up a natural fight against ovarian cyst triggers. Many factors including
dietary factors and sleep deprivation can lead to weakened immune system.
Insulin resistance: High level of insulin can stimulate ovarian androgen production,
which leads to the production of male hormones. This reduces the serum sex-hormone
binding globulin or SHGB. The SHBG can in turn aggravate the ovarian cyst condition to
quite an extent.
Failed ovulation process: Sometimes, the ovaries fail to release egg on a monthly
basis. This fails to produce progesterone and brings about hormonal imbalance. This can
then lead to the formation of ovarian cysts.
Besides the above primary factors, toxins in liver and even environmental toxins can
aggravate and cause ovarian cysts. Hence, ovarian cyst condition is not a simple one to
understand or treat.
Diagnosis of Ovarian Cysts
Diagnosis Tests
A healthcare provider may perform the following tests to determine if a woman has an ovarian
cyst or to help characterize the type of cyst that is present:
Endovaginal ultrasound: This is a special imaging test developed to examine the pelvic organs
and is the best test for diagnosing an ovarian cyst. An endovaginal ultrasound is a painless
procedure that resembles a pelvic exam. This type of ultrasound produces the best image because
rather than a scan, a small probe is inserted in the virginal and can be positioned closer to the
ovaries.
Other imaging: CT scanning aids in assessing the extent of the condition. MRI scanning may
also be used to clarify results of an ultrasound.
Laparoscopic surgery: A procedure when a surgeon fills a woman's abdomen with a gas and
makes small incisions through which a thin scope (laparoscope) can pass into the abdomen. The
surgeon identifies the cyst through the scope and may remove the cyst.
Serum CA-125 assay: This is a blood test that checks for a substance called CA-125, which is
associated with ovarian cancer (the CA stands for cancer antigen). This test is used in the
assessment of epithelial ovarian cancer and may help determine if an ovarian mass is harmless or
cancerous. However, sometimes non-harmful conditions may result in the elevated levels of CA-
125 in the blood, so the test does not positively establish the diagnosis of ovarian cancer.
Hormone levels: A blood test to check LH, FSH, estrogen, and testosterone levels.
Checking these levels is used to indicate potential problems concerning those hormone levels.
Pregnancy testing: The treatment of ovarian cysts is different for a pregnant woman than it is
for a non-pregnant woman. An ectopic pregnancy (pregnancy outside the uterus) must be ruled
out because some of the symptoms of ectopic pregnancy may be similar to those of ovarian
cysts.
Culdocentesis: This test involves taking a fluid sample from the pelvis with a needle inserted
through the vaginal wall behind the uterine cervix.
MESENTERIC LYMPHOMA
The mesentery is a type of connective tissue in the abdominal cavity that contains lymph nodes.
Cancer sometimes arises from these nodes and is called mesenteric lymphoma. Because of the
particular circulatory properties of the mesentery, mesenteric lymphoma, unlike most other
lymphomas, frequently does not cause symptoms until the tumors have become quite large.
Fortunately, there is a particular sign that appears on an abdominal CAT scan that is very
specific for mesenteric lymphoma.
Anatomy of the Mesentery
The mesentery is a network of fatty connective tissue that suspends and connects some of the
organs inside the abdomen. The mesentery is poorly supplied with blood and with vessels of the
lymphatic system. It does contain some lymph nodes, and so tumors can occasional grow in
them. Because of the poor circulatory connection with the rest of the body, mesenteric
lymphoma often does not cause the constitutional symptoms typical of other lymphomas, per
Harrison's Principles of Internal Medicine.
Constitutional Symptoms of Lymphoma
Other lymphomas frequently cause weight loss, low-grade fever, night sweats, fatigue and
malaise. These symptoms usually occur before lymph nodes become noticeably swollen or
painful, and are often what bring lymphoma patients in to see the doctor. They are caused by the
release of chemical signals, called cytokines, from the tumor into the blood stream and lymph
system. Because the mesentery is poorly connected with these systems, cytokines often do not
become widely disseminated in mesenteric lymphoma and these symptoms often do not occur.
Symptoms of Mesenteric Lymphoma
Most of the noticeable symptoms of mesenteric lymphoma result from the tumors becoming
large enough to affect normal intestinal function. The most common complaint of patients with
mesenteric lymphoma is abdominal pain, sometimes accompanied with nausea, vomiting or
constipation. The pain is usually diffuse, and often described as being deep within the abdomen.
Sometimes a patient may even notice an unusual lump in the abdomen.
The Sandwich Sign
A particular finding on an abdominal CAT scan is highly suggestive of a mesenteric lymphoma.

It is called the "sandwich sign," because of the characteristic appearance of the darker "buns" of
the tumor enclosing either side of a lighter middle region. This sign is highly characteristic of
mesenteric lymphoma and is unlikely to arise from anything else.
Finding Mesenteric Lymphoma
Because mesenteric lymphomas can become quite large before causing symptoms, many tumors
are found incidentally, while looking for something else. Frequently, an abdominal CAT scan
will be performed for some other reason and the sandwich sign will show that there is mesenteric
lymphoma present. Physicians have encountered mesenteric lymphomas incidentally during the
course of unrelated abdominal surgery. Fortunately, these tumors usually do not spread
aggressively and surgical removal is often an effective treatment.
VI. ANATOMY AND PHYSIOLOGY
FEMALE REPRODUCTIVE SYSTEM
Definition
The female reproductive system is composed of organs that produce female eggs (called female
gametes or ova); provide an environment for fertilization of the egg by a male sperm (male
gamete); and support the development and expulsion of a fetus in pregnancy and childbirth.
Description
The normal female reproductive system is composed of external and internal genitals (genitalia).
External genitals
The external genitals (together, they are called the "vulva") are composed of the genital
structures visible from outside the body: the greater lips (labia majora); the lesser lips (labia
minora); the clitoris; and the opening of the vagina to the outside (the other end of the vagina
opens inside the body to the womb). The labia majora are two large lips that protect the other
external genitals. The outer surface of these lips is covered with oil-secreting (sebaceous) glands;
their inner surface has hair. The lesser lips (labia minora) are found just inside the greater lips
and protect the immediate opening to the vagina (this opening is called the "introitus," Latin for
"entrance") and the opening to the urethra (which carries urine from the bladder out of the body).
The clitoris is a small structure found at the top of the lesser lips; it is very sensitive to
stimulation and may become erect. The perineum is the area between the vagina and the anus in
the female (in the male, the perineum is the area between the scrotum and the anus). Two glands,
one located on either side of the introitus, are called Bartholin's glands; they secrete a mucus that
provides lubrication during sexual intercourse.
Internal genitals
The internal genitals are the vagina, the womb (uterus), the fallopian tubes, and the ovaries. The
vagina extends approximately 3 to 4 inches (7 to 10 cm) from the outside of the body to the
opening of the womb. The lower third of the vagina (closest to the outside) is encircled by
muscles that control its opening and closing. The womb is the organ found at the top of the
vagina and consists of two main parts: the neck (cervix) and the body (corpus). The neck is the
opening of the womb to the vagina that allows sperm to enter the womb and allows menstrual
fluid to exit. The neck is an important means of protecting the body of the womb from disease-
causing germs; a thick mucus normally covers the neck of the womb but changes in consistency
during ovulation to allow sperm to penetrate. The body of the womb is the main part of the
womb—the womb in the narrower sense of the word. It can enlarge to hold a developing fetus
during pregnancy. The inner lining of the body of the womb is called the endometrium, which
thickens and then sheds menstrual fluid during each menstrual period if fertilization does not
occur.
The fallopian tubes (also called the oviducts or uterine tubes) are muscular structures that
extend from the upper edges of the womb to the ovaries. The fallopian tubes facilitate the
transfer of a mature egg from one of the two ovaries to the body of the womb. A fallopian tube is
the site of normal fertilization. The ovaries are a pair of small oval-shaped structures and are
suspended near the fallopian tubes by ligaments. A female human being will not produce any
new developing eggs (oocytes) after she is born; although she is born with approximately two
million eggs, only about 300,000 to 400,000 remain at onset of puberty, and only about 300 of
these will develop fully and enter a fallopian tube for possible fertilization. The eggs start as
oocytes and develop in what are called ovarian or Graafian follicles, small spherical sacs that
burst when the mature egg (called an ovum) is ready to be released into a fallopian tube for
possible fertilization, or for discharge in the menstrual fluid if fertilization does not take place.
The human egg is a round cell that, when mature, is surrounded by a number of protective layers
(the oolemma, zona pellucida, and zona radiata). It contains half the number of chromosomes of
a human cell that is not egg or sperm (that is, 23 instead of 46 chromosomes) and is therefore
called a haploid (one-fold) cell. When the egg is fertilized by sperm, the resulting cell will have
the full number of forty-six chromosomes and will be considered a diploid (two-fold) cell.
FUNCTIONS
Menstruation
The menstrual cycle ranges from 21 to 40 days in most women, with an average cycle lasting 28
days. The first time a girl has a period (the onset of menstruation) is called "menarche"; the
permanent cessation of menstruation some decades later is called "menopause" and marks the
traditional end of a woman's ability to reproduce. In the 1990s, women past menopause have
been impregnated with another woman's egg after it has been fertilized by artificial insemination,
and these older women have successfully given birth to healthy babies.
Menstruation occurs when the lining of the womb begins to shed menstrual fluid; the first day of
bleeding is the first day of the menstrual cycle. The menstrual cycle has two phases. The
follicular phase extends from the first day of the cycle until immediately before a mature egg
gets released from the ovary.
In the second phase of the menstrual (ovulatory) cycle, called the "luteal" phase, the mature
follicle bursts and releases an egg, a process called ovulation. The second phase of the menstrual
cycle lasts approximately fourteen days until the first day of the next period (using as an example
the average 28 day menstrual cycle). The ruptured empty follicle collapses to form the corpus
luteum.
Fertilization
During the ovulatory phase of the menstrual cycle, the mature egg is released from the ovary and
swept into the fallopian tube. If sperm cells are present in the fallopian tube, fertilization may
occur. Pregnancy begins at the moment of fertilization (also called conception), when the sperm
penetrates the egg. The fertilized egg, also called a zygote, then begins to move down the
fallopian tube into the womb, where it implants itself in the thick tissue of the lining of the
womb. In the womb, this replicating cluster of cells is called a blastocyst; after two weeks of
development, it is called an embryo; eight weeks after conception, it is called a fetus.
Hormones
A complex balance of hormones is required for reproduction. There are two main groups of
hormones that are necessary for normal functioning of the female reproductive system.
The first group contains hormones of the central nervous system (CNS). A part of the brain
called the hypothalamus is the main area of hormonal control; it secretes so-called releasing
hormones that travel to the pituitary gland located at the base of the brain. Gonadotropin-
releasing hormone (GnRH) secreted by the hypothalamus triggers the release of gonadotropic
hormones from the anterior pituitary gland. Gonadotropin refers to any hormone that stimulates
the gonads (the structures capable of producing eggs or sperm; that is, the ovaries or the
testicles); regulates their development and their hormone-secreting functions; and contributes to
the production of eggs or sperm.
There are two gonadotropic hormones secreted by the anterior pituitary gland: the follicle-
stimulating hormone (FSH) and the luteinizing hormone (LH). The development of the ovarian
follicles is dependent upon these hormones. FSH (as its name suggests) stimulates the
development of several follicles in each cycle. During the first half of the follicular phase,
increasing levels of FSH cause maturation of ovarian follicles (only one follicle will mature
completely). It is the LH that begins the second phase of the menstrual cycle, when a surge of
LH causes the mature follicle to burst and release an egg. FSH and LH also control the
production of ovarian hormones (the second group of hormones regulating the female
reproductive system).
The ovarian hormones in turn are divided into two groups: ovarian peptide hormones and ovarian
steroid hormones.
There are two ovarian peptide hormones, inhibin and relaxin. Inhibin is secreted by the granulosa
cells of the follicles. It inhibits the releasing of FSH from the anterior pituitary gland and also
inhibits the release of GnRH from the hypothalamus, Thus inhibin has a role in controlling
further follicular development. Relaxin is produced near the end of pregnancy by the corpus
luteum and promotes relaxation of the birth channel.
There are two biologically extremely active ovarian steroid hormones: estrogen and
progesterone. Estrogen is produced by the granulosa cells of developing follicles and by the
corpus luteum following ovulation. This production of estrogen is dependent upon luteinizing
hormone (LH). The most potent estrogenic hormone in human beings is estradiol. It is
synthesized and secreted by ovarian follicles, specifically by the theca interna cells (these cells
synthesize androstenedione, which is then converted into estradiol and estrone). Estradiol can
also be synthesized by the fetoplacental unit and, perhaps, by the adrenal cortex. It has the
following biological functions: to promote the growth and maturation of the female secondary
sex characters; to induce estrus; in conjunction with progesterone to prepare the endometrium for
implantation of a fertilized ovum; and to support pregnancy.
Progesterone is a hormone produced by the corpus luteum. (It can also be secreted by the
placenta and by the adrenal cortex.) Together with estrogen, it prepares the endometrium for
implantation of the fertilized ovum, it maintains the uteroplacentofetal unit, and it promotes the
development of the fetus.
Another important endocrine organ secreting the steroid hormones (estrogen and progesterone) is
the placenta. It helps maintain the uterine mucosa during pregnancy. The placenta also produces
and secretes chorionic gonadotropic hormone. The actions of human chorionic gonadotropin
(hCG) resemble those of LH. The presence of hCG in urine in early pregnancy is the basis of
most pregnancy tests. Human chorionic gonadotropic hormone maintains the secretory integrity
of the corpus luteum.
VII. SIGNS AND SYMPTOMS TABLE
Signs and
Signs and Symptoms from the Symptoms
Rationale
Textbook manifested by
the client
Dependent edema- an abnormal Due to arterial and venous insufficiency
accumulation of fluid in particularly in the lower extremity
intercellular spaces of the body;
+
edema affecting most severely the
lower most important parts of the
body
Dyspnea- a distressful subjective Decreased lung compliance or increased
sensation of uncomfortable airway resistance. The right ventricle of
breathing that may be caused by the heart is affected ultimately by lung
+
many disorders, including certain disease because it must pump blood
heart and respiratory conditions, through the lungs against greater
strenuous exercise or anxiety. resistance
Pallor- absence of skin coloration; It is caused by lack of oxyhemoglobin
+
a decrease in the color of the skin
Restlessness- inability to relax, Increase workload of the heart
+
rest or be stilled
Shortness of breath- the feeling Areas of the lungs are not adequately
of being deprived of oxygen + ventilated because of secretions and
mucosal edema
Tachycardia- abnormally rapid Compensatory mechanism of grasping
heart rate; more than 100 cycles + for air and vasoconstriction
per minute
Tachypnea- very rapid Increased breathing rate to have a
respiration; more than 20 breaths + sufficient gas-exchange in the body
per minute
Use of Accessory Muscle - When
breathing requires extra effort, the
The use of accessory Muscle is done to
accessory muscles such as the
straighten the vertebral column are
sternocleidomastoid, scalene, +
brought into use to increase the force of
pectoralis major, trapezius, internal
inspiration and to meet the high
intercostals, and abdominal
ventilation demand
muscles to stabilize the thorax
during respiration.
Sputum Production - Irritation of
the respiratory system causes both
Inflammation or edema of the mucous
inflammation of the air passages +
membrane of the mucosa.
and a notable increase in mucus
secretion
Weight loss – sudden decreased
It is due to the decrease of appetite
of weight +
experienced.
Crackles – a common, abnormal
respiratory sound consisting of Producing of exudates that interferes
discontinuous bubbling noises + with the diffusion of carbon dioxide
heard on auscultation of the chest and oxygen
during inspiration.
Orthopnea - inability to breathe An effort to achieve adequate gas
easily except in an upright position + exchange without coughing or
breathing deeply
Rising fever - is any temperature Serious bacterial infection
higher than 38 oC -
Dry Skin- presence of poor skin There is an increase urine output

+
turgor and scaly skin that causes dehydration
Nausea – tendency to vomit Accumulation of ketone bodies in
+
the circulation
Vomiting – matter expelled Accumulation of ketone bodies in
ejection of contents of stomach + the circulation that leads to
through the mouth metabolic acidosis
Weakness- lack of strength or Due to muscle disuse and nerve
potency + injury ; Disordered protein and
carbohydrate metabolism
Abdominal pain Follicles fail to ovulate and fail to
+ undergo atresia and continue to
grow
Palpable mass at left hypogastric Follicles fail to ovulate and fail to
region 24 x 10 x 14 cm + undergo atresia and continue to
grow
abdominal girth of 79cm Follicles fail to ovulate and fail to
+ undergo atresia and continue to
grow
Change in volume of
menstruation 4-5 sanitary pads a + Increase in blood flow volume
day
VIII. PATHOPHYSIOLOGY
Predisposing Factors: Precipitating Factors:

Female Multiparity
57 y/o(menopausal stage Hyperestrogenic state
Stress
Increase hormonal production of estrogen and luteinizing hormone
Proliferation of smooth muscle cells
Overgrowth of uterine lining
Development of uterine fibroid
Degeneration of interior part of the fibroid
4-5 sanitary pads/day

during menstruation Increased blood flow volume
Hyaline degeneration Red or carneous infarction
Smooth muscle cells are replaced by fibrous connective

tissue
Continued growth of fibroid (leiomyomas)
Myoma (2009)
Fibroid breaks away from the uterus and develops in other locations Hyperstimulation of ovaries
Hormonal imbalance
s/p EL, adhesiolysis, omentectomy, biopsy of mesenteric mass, Left salphingo-oophorectomy
nated Peritoneal Leiomyomatosis (spreads to the abdominal wall)
Abnormal proliferation of follicle
T/C mesenteric lymphoma Follicles fail to ovulate and fail to undergo atresia and continue
Palpable mass at left hypogastric

Cyst grow in size
region: 24 x 10 x 14 cm
Abdominal girth of 79 cm
Abdominal pain
IX. Nursing Care Plans
Ineffective airway clearance related to increased sputum production

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Objective: Ineffective airway After 8 hours of nursing 1. Monitor ital signs 1. Tachycardia, After 15 minutes of
 With clearance related to interventions the client dysrhythmias ad nursing interventions:
Endotracheal tube excessive mucus will be able to have a changes in BP can
hooked to production and presence patent airway free from reflect effect of  The client clears
of endotracheal tube secretions. systemic hypoxemia airway using
mechanical
on cardiac function controlled coughing
ventilator with the
following techniques and
2. Maintain ET-MV 2. To assist client in
settings: FiO2 of settings as indicated. respiration. suctioning
40%, tidal volume
of 400 mL, BUR 3. Assist client to 3. Semi-fowler’s  The client’s sputum
of 12, PEEP of assume position of position facilitates is thin, white,
comfort (semi respiratory function to odorless and
4cm/H20, AC
fowlers) aid breathing, chest moderate in quantity
Mode. expansion and
 With clear to ventilate lung fields.
yellow copious
amount of 4. Coughing is a natural
secretions when 4. Demonstrate and help self cleaning
client to perform mechanism, assisting
suctioned
effective coughing the cilia to maintain
 (+) crackles upon while in fowler’s patent airways.
auscultation on position
both lung fields 5. To help client reduce
 RR= 20bpm 5. Suction secretions as secretions and clear
needed. airway
6. For drainage of
6. Reposition client secretions
every 2 hours
7. Promotes optimal
7. Encourage deep chest expansion
breathing exercise
Objective: Risk for thromboembolic After 8 hours of nursing 1. Perform passive 1. Leg exercises After 15 minutes of
 s/p: exploratory and hemorrhagic interventions the client Range of motion promote blood flow in nursing interventions:
laparotomy, complications related to will be able to show no exercises(leg the legs. Muscle
adhesiolysis, immobility, signs or thromboembolic exercises) hourly. contraction compress  The client clears
dehydration,and possible or hemorrhagic the veins and help airway using
omentectomy,
fat particle escape and complications. prevent venous stasis, controlled coughing
and biopsy of the aggregation a mjor cause of clot
mesenteric mass, techniques
2. formation.
and Left
salphingo-  The client’s sputum
oophorectomy. is thin, white,
odorless and
 Post operative
moderate in quantity
Incision at the left
hypogastic
region, dry and
intact
 With platelet
count of: 91 K/uL
(140-400)
 PT of 12.3
(8/12/10)
Risk for Impaired Skin Integrity related to limited movements
Date: January 27, 2010

Subjective: Risk for impaired skin After 8 hours of nursing 1.Implement and post a 1. To promote After 8 hours of nursing
“Minsan inuupo ko integrity related to intervention the client turning schedule circulation and to reduce care the client maintained
yan baka kasi magka limited movements will be able to maintain restricting time in one tissue pressure; 2 hours is intact skin and prevented
bed sores” as intact skin and prevent position for two hours the maximum time for skin breakdown
verbalized by the skin breakdown the cells to withstand
client’s eldest son pressure
Objective: 2.Keep nails short, 2. To reduce risk of

 pronounced squared and filed dermal injury when
bony scratching
prominences
 Immobility 3.Provide preventive skin 3. To minimize contact
 Extreme age care: Change of diapers with irritants
 Presence of frequently
type 2 diabetes
mellitus 4. Assist client with ROM 4. To enhance
 Dry skin exercises circulation and
improve/maintain joint
mobility
5. Recommend elevating 5. To promote venous

lower extremities return
6.Keep linens dry and 6. To prevent moisture

free of wrinkles that would increase risk
of skin breakdown and
also to prevent skin
irritation

7. Bathe with mild soap 7.To maintain
cleanliness without
irritating the skin
8. Use skin cream or 8.To relieve dry skin

lotion after bathing
9. Massage skin gently 9.To improve circulation

to the skin and to
enhance skin tone
10.Emphasize the
importance of good 10.Hygiene prevents
hygiene and proper accumulation of bacteria
grooming thus preventing diseases
Drug Study
Dose, Route and Action/

Drug Classification Side Effects Nursing Responsibilities
Frequency Indication
Salbutamol + 2cc nebulizer bronchodilators Action:  hypokalemia Assess respiratory status
Ipratropium every 6 hours Salbutamol stimulates beta-2  headache before initiation of therapy and
nebule PRN for difficulty receptorsof bronchioles by  dizziness monitor for inhalation of
of breathing increasing levels of cAMP  fatigue ipratropium
which relaxes smooth muscles  hypertension
to produce bronchodilation. Give client frequent sips of
 bronchospasm
waste and sugar less hard
 cough
Ipratropium antagonizes the candy or gum to relieve dry
effect of acetylcholine. It mouth
causes a local and site specific
brnchodilation by preventing
the increase in intracellular
cyclic guanosine
monophosphate which is
produced by the interaction of
acetylcholine with the
muscarinic receptors of the
bronchial smooth muscles.
Indication:
Chronic obstructive pulmonary
disease

Drug Frequency Classification Side Effects Nursing Responsibilities
Indication
Piperacillin/ 4.5mg IV every 8 Antibacterial Action:  headache Obtain client hertory of
Tazobactam hours ANST -Penicillin Inhibits the action of bacterial  fever hypersensitivity to penicillin,
betalactamases. It has the  dizziness cephalosporin or other drugs
potential to enhance the  weakness prior to administration
activity of beta lactam  anxiety
antibacterials against  hypokalemia Monitor if bleeding occurs
betalactamase producing
bacteria. Assess client for the signs and
symptoms of infection
Indication: including characteristic of
Treatment of severe bacterial wound, sputum, urine, stool,
infection, urinary tract fever and WBC > 10,000
infection, nosocomial and
community acquired Assess for overgrowth of
pneumonia infection which indicate fever,
malaise, cough, sputum,
redness
Assess urine output, if

decreasing, notify physician,
also check for BUN,
creatinine as it indicate
nephrotoxicity
Monitor electrolytes such as

potassium, sodium, chloride
Monitor client carefully

during first 30minutes after
infusion for signs of
hypersensitivity
Action/
Dose, Route and Nursing
Drugs Classification Indication Side Effects
Frequency Responsibilities
Metformin 500mg/tab 2 tabs Antidiabetic/: Action:  Urinary tract Assess for hypoglycemic and
per orem OD Biguanide Decrease intestinal infection hyperglycemic reactions
absorption of glucose and  Back pain
hepatic glucose production.  Headache Assess client’s renal status
It also improves insulin  Fatigue
sensitivity(increase Monitor for possible drug induced
peripheral glucose uptake adverse reactions
and utilization)
Assess client’s and family knowledge
Indication: on drug therap
Non-insulin dependent Inform client that drug must be
diabetes mellitus type 2 continued on daily basis to control
symptoms and prevent complications
Encourage client to take drug in the

morning to prevent hypoglycemic at
night
Aspirin 80mg 1 tab per Anticoagulants Action:  dizziness Administer after meals, with food or
orem after meal Relieves pain and antacid to minimize gastric irritation
OD reduces inflammation by
inhibition of peripheral Do not crush or have client chew
prostalglandin synthesis. enteric-coated or time-release caplets
It also inhibits the
synthesis or action of Ensure that bleeding time and
other mediators of prothrombin time have been
inflammation. It acts on evaluated before beginning large
the hypothalamic heat dose long-term therapy
regulating center to
relieve fever, by If signs of bleeding, black tarry
promoting sweating and stools, or tinnitus occurwithhold
vasodilation, leading to medication and notify health care
heat loss and cooling by provider
evaporation. Also
decreases platelet Advise client to take medicine after
aggregation by meals and with full glass of water
preventing formation of
thromboxane A, a
platelet aggregating
substance.
Indication:
Treatment of mild to
moderate pain; fever,
prophylaxis of
myocardial infarction
Action
Dose, Route and Nursing
Drugs Classification Indication Side Effects
Frequency Responsibilities
70 u SQ 6am Antidiabetic Action:  Hypoglycemia Obtain client’s hertory and any known
Insulin 10 u SQ 4pm Decrease blood glucose by  Insulin resistant allergies
transport of glucose into  Visual
cells and the conversion of impairment
glucose to glycogen
indirectly increases blood Monitor fasting blood glucose, 2
pyruvate and lactate, hours after meals: assess client for
decreases phosphate and signs and symptoms of hypoglycemia
potassium.
Monitor body weight periodically
Indication:
Management of type 2 Explain technique of administration
diabetes mellitus or non
insulin dependent diabetes Observe injected sites for signs and
mellitus which cannot be symptoms of local hypersensitivity
controlled by diet and
exercise or weight reduction Assess for adverse effects
alone.
75mg/tab NGT Anti platelet, Action:  abdominal Advise client that each dose may be
Clopidogrel OD anti coagulant Blocks ADP receptors pain taken without regard to meals but to
which prevent fibrinogen  headache take with food if stomach upset occurs
binding at that site and  dizziness
thereby reduce the Advise client that if a dose is missed to
possibility of platelet skip that dose and take the next dose at
adhesion and aggregation. the regularly scheduled time
Indication:
Reduction of
atherosclerosis events (MI,
stroke, vascular death) in
clients with atherosclerosis
documented by recent MI
Dose, Route
Action/
Drug and Classification Side Effects Nursing Responsibilities
Indication
Frequency
Isosorbide 30mg/tab Anti-Anginal Action:  headache Assess for pain: duration, time
mononitrate Per orem Drugs Increases supply of oxygen to the  dizziness started, activity being
OD heartby dilating both the arterties and  weakness performed, character and
veins which supply th heart itself.  fatigue intensity
Indication: Monitor vital signs

Prevention of angina pectoris and
treatment of myocardial infarction Give one hour before or two
hours after meal with 8 oz of
water
Tablet should not be crushed or

chewed and should be
swallowed together
Monitor for headache,

hypotension and tachycardia
Caution client to avoid sudden

position changes to prevent
orthostatic hypertension
Dose, Route
Action
Drug and Classification Side Effects Nursing Responsibilities
Indication
Frequency
Amlodipine 50mg/tab Calcium Action:  Headache Assess cardiorespiratory status
Per orem Antagonists, Inhibits influx of calcium ion across cell  dizziness
OD Anti-Anginal membranes to produce relaxation of  weakness Assess hydration and fluid
Drugs coronary vascular smooth muscle  somnolence volume status
(dilatation of coronary arteries), decrease  shortness of breath
peripheral vascular resistance of smooth Monitor platelet count
 dyspnea
muscle (decrease blood pressure) and
 pallor
increases myocardial oxygen delivery in
clients with vasospastic angina.
Indication:
Hypertension
Drug Classification Side Effects Nursing Responsibility
Captopril 25mg per tab; ¼ angiotensin- Action:  dyspnea Monitor blood pressure
tab converting Selectively suppresses rennin angiotensin  cough
Per orem enzyme (ACE) aldosterone system; inhibits ACE; prevents  fatigue Monitor blood studies:
TID inhibitor conversion Angiotensin1 to Angiotensin2.  dizziness decreased platelets and
 headache renal studies
Indication:
 weakness
Hypertension, diabetic nephropathy Check potassium levels
Store in airtight
container
Caution client about side

effects
Generic: 60g/tab + 100cc Mucokinetic/ Action:  headache Assess patients hertory of

N- water NGT OD Expectorant Decreases the viscosity of  chest tightness underlying condition like
Acetylcysteine secretions by splitting of  dizziness cough: type, frequency,
disulphide bonds in  mild fever character
mucoproteins. It also promotes  dyspnea
the detoxification of an Assess patient in
intermediate paracetamol respiration and pulmonary
metabolite which is used in the secretions, exercise caution
management of paracetamol
overdosage
Indication:
Treatment of respiratory
affections characterized by thick
and viscous hypersecretions: acute
and chronic bronchits and its
exacerbation
Tiotropium 1 cap PRN NGT Anticholinergic Action:  cough Monitor patient’s
lurdiplate x dob Tiotropium bromide, a long-  headache respiratory status during
acting quaternary ammonium  dizziness each treatment.
antimuscarinic, is structurally  fatigue
related to ipratropium. It is a  hypertension If bronchospasm worsens
nonselective competitive during or shortly after
 bronchospasm
antagonist of muscarinic (M1-M5) treatment, discontinue the
receptors and causes treatment and notify health
bronchodilation by inhibiting the care provider immediately
actions of acetylcholine and other
cholinergic stimuli at Assess patient for
M<290>3<>190> receptors in respiratory, gastrointestinal
the smooth muscle of the genitourinary and general
respiratory tract. body side effects.
Indication: Inform health provider if

Maintenance therapy of COPD. noted and significant
Dose, Route
Classificatio Action
Drugs and Side Effects Nursing Responsibilities
n Indication
Frequency
Simvastatin 40mg/tab Lipid- Action:  Dizziness Assess client’s nutrition
1 tab lowering Inhibit an enzyme, 3 hydroxy 3  headache
PO agents methylglutarylcoenzyme A (HMG-CoA)
OD at HS reductase, which is responsible for catalyzing Monitor creatinine phosphokinase
and an early step in the synthesis of cholesterol levels due to possibility of myopathy
Lowering of total and LDL cholesterol and serum cholesterol
Indication: Monitor triglycerides, cholesterol

To reduce low density lipoprotein cholesterol, baseline and throughout treatment
apolipoprotein beta, and triglycerides. To
increase high density lipoprotein cholesterol in Evaluate therapeutic response and
the treatment of hyperlipidemia adverse reactions on a regular basis
Dose, Route Action/
and Frequency Indication
Lactulose 30cc Laxatives Action:  Diarrhoea Assess client’s condition
PO Causes an influx of fluid in the intestinal  Nausea before therapy and reassess
OD at HS tract but increasing the osmotic pressure  Vomiting regularly to monitor drug
within the intestinal lumen. Bacterial  Hypokalaemia effectiveness
metabolism of the drug to lactate and  bloating
other acids which are only partially Monitor fluid and
 abdominal cramps
absorbed in the distal ileum and colon electrolyte status
augments the osmotic effect of
(none of these were
lactulose. The distention of the colon Monitor for increased
manifested by the client)
due to increased fluid enhances glucose level in diabetic
intestinal motility and secretion. Ther client
result to the passage of soft stools.
Decreased in luminal pH (due to Mix with fruit juice, water
bacterial metabolism) further increased or milk to make more
motility and secretion. It also lowers palatable
intentional absorption of ammonia
presumably due to increased utilization Teach client that normal
of ammonia by intestinal bacteria. bowel movements do not
always occur daily and that
Indication: adequate fluid consumption
Constipation is necessary
Dose, Route Action/
and Frequency Indication
Hydrocortisone 100mg IV every Corticosteroid Action:  pallor Assess patient’s condition
6 hours Gluco-corticoid with anti-  weakness before starting therapy and
inflammatory effect because of  delayed wound re-assess regularly
its ability to inhibit prostaglandin healing
synthesis, inhibit migration of  headache Monitor for possible drug
macrophages, leukocytes and  hypertension induced adverse reactions
fibroblasts at sites of  blurred vision
inflammation, phagocytosis and Monitor intake and output,
lysosomal enzyme release. It can signs of infection especially
also cause the reversal of fever and WBC count
increased caplliary permeability.
Indication:
Treatment of primary or
secondary adrenal cortex
insufficiency, respiratory disease
X. HEALTH TEACHING
Topic: Hygiene
Time allotment: 10 minutes
Objectives Content Teaching strategy Evaluation
Discuss to the client the importance of proper hygiene.

After 10 minutes of lecture- Lecture / discussion Through re-
discussion, the client will be  Proper hygiene is done to prevent spread of bacteria. demonstration and
able to:  To feel comfortable and to feel relaxed. question and answer, the
 To look presentable. client was able to met the
1. Identify and verbalize goal for he was able to:
the importance of
proper hygiene. Demonstrate ways on how to perform proper hygiene. -Verbalize the
Lecture/demonstration importance of proper
2. Demonstrate and  Oral hygiene: Gargle mouth wash or use Bactidol every hygiene.
identify ways on how morning and at night to avoid halitosis and mouth sores.
to perform proper  Hand hygiene: Wash hands with water and soap. Dry hands -Demonstrate ways on
hygiene. with towel to prevent contamination of bacteria. how to perform proper
 Ear care: Clean the ears every other day using cotton buds and hygiene.
discard properly after use.
 Perineal care: Clean the area using soap and water and dry the
area with clean cloth before putting another clean diaper.
 Explain to the client the importance of changing catheter
every 3 days to prevent any infection.
 Body hygiene: Perform bed bath with the help of the
significant other, use deodorant to prevent body odor.
Topic: Drug Compliance
Time allotment: 30 minutes
After 30 minutes of lecture- Discuss to the client and to the significant other, the importance of Lecture / discussion Through re-
discussion, the client will be drug compliance: demonstration and
able to:  Drug compliance is important to prevent resistance to the question and answer, the
drugs. client was able to met the
1. Identify importance of  To prevent further complications and recurrence of the disease. goal for he was able to:
drug compliance.  To promote fast recovery.
 It is better to have a pill box so to be organized with the - Identify importance of
2. Verbalize medications that is to be taken every day. drug compliance.
understanding of the  Taking medications as ordered/instructed to attain the desired
actions and side effects therapeutic effect. -Verbalize understanding
of the drugs. of the actions and side
Discuss to the client and to the significant other, the actions and effects of the drugs.
common side effects of the drugs: Lecture/discussion
 Bronchodilators- to dilate the bronchioles for easy breathing.
 Palpitations
 Hypertension
 Headache
 Dizziness
 Cough
 Anti-diabetic- to decrease sugar level in the blood.
 Abdominal bloating
 Antipyretic- to lower down temperature.
 Visual disturbance
 Bronchoconstriction

 Antihypertensive- to lower down blood temperature.
 Headache
 Dizziness
 Fatigue
 Palpitation Mucolytic- to decrease the viscosity of secretions.
 Dyspnea
 Anti-bacterial
 Nausea
 Vomiting
 Rash
 Laxatives- to increase bowel movement.
 Distention hyperglycemia
 Calcium antagonist- decrease glucose level.
XI. References
 Allen, M., Lewis, A., Metcalf, W. et al (2002): Mosby’s Pocket Dictionary of Medicine,
Nursing and Allied Health Sciences, 4th Ed. Elsevier Science, Singapore
 Beare P., Myers J. (1990): Principles and Practice of Adult Health Nursing. C.V. Mosby
Co., Missouri
 Brunner and Suddarth (2008). Textbook of Medical Surgical Nursing 11th Edition;
Lippincott Williams and Wilkins, a Wolters Kluwer business, Philippines
 Brunner and Suddarth’s textbook of Medical Surgical Nursing – 11th Edition [edited by]
Suzanne C. Smeltxer..et.al
 Essentials of Human Anatomy and Physiology, 8th edition by Marieb, Elaine N (2006).
Pearson Education Inc., Publishing as Benjamin Cummings
 Kneisl CR, and AMES, SW (1986). Adult Health Nursing: A biopsychosocial Approach.
Addison – Wesky Publishing, California
 Kneisl CR, and AMES, SW (1986). Adult Health Nursing: A biopsychosocial Approach
(The text whose time has come!). previous Edition: Addison – Wesky Publishing
company Inc., California
 Manual of Laboratory Diagnostic Exam by Nenita Gonzales UERMMMC
 Medical Surgical Nursing Clinical Management for Positive Outcomes by Joyce M.

Black and Jane Hawks
 Medical Surgical Nursing: A Nursing Process Approach, 3rd Edition by Alison Miller
 PPD Nursing Drug Guide, 2nd Edition Phil. (2008). Malan Press Inc.
 Principles of Anatomy and Physiology: Maintenance and Continuity of the Human Body,
12th Edition Volume 2 by Gerard J. Tortora and Bryan H. Derrickson (2009)
 Principles of Anatomy and Physiology: Organization, Support and Movement and

Control Systems of the Human Body, 12th Edition Volume 1 by Gerard J. Tortora and
Bryan H. Derrickson (2009)
 Stegman, J. (2005): Stedman’s Medical Dictionary for the Health Professions and
Nursing 5th Edition by Wolters, Khiwer Health Co., USA

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St.

Paul University Manila

College of Nursing and Allied Health Sciences

Nursing Care Study

3 days prior to confinement, the client experienced pallor, weakness, difficulty of

On August 11, 2010, the client underwent exploratory laparotomy, adhesiolysis,

The client’s final diagnosis is Abdomino-Pelvic Mass, Ovarian New Growth

B. Nursing History (Based on the Functional Health Pattern by Gordon)

Sigmund Freud’s Psychosexual Theory

Erik Erikson’s Eight Stages of Development

According to Erikson’s eight stages of development, the client is in the late

Jean Piaget’s Cognitive Theory

In Jean Piaget’s Cognitive Development theory, the client is in the Formal

Lawrence Kohlberg’s Moral Development Theory

In Lawrence Kohlberg’s Moral Development Theory, the client is at the

The client was not able to

Client’s tonsils are pink in color,

Round, overted, and equal in size; similar

Inspection and palpation

Normal findings upon

Anterior Inspection Anteroposterior to transverse diameter in Normal findings of the

Trachea has bronchial and tubular breath

Skin intact; uniform in temperature.

Skin intact; uniform in temperature.

Percussion Tympany over the stomach and gas-filled

Muscle is thin but with smooth

Lower extremities’ muscles

skin is intact. Appears slightly wrinkled

To maintain effective airway of the client:

To ensure condition, progress and response to treatment, continuous monitoring of the

To maintain adequate nutrition and hydration:

a. Metronidazole 500g IV every 8 hours

To prevent spread of infection and further complications:

To prevent recurrence of the disease:

a. Compliance of medications as prescribed by the physician

To prevent further injuries:

a. Observe safety precaution by raising side rails.

A. Arterial Blood Gas

D. URINALYSIS ( August 11, 2010 )

Symptoms of Uterine Myoma may include:

OVARIAN NEW GROWTH/CYST

Primary factors that cause ovarian cysts:

Genetic predisposition: Genetic predisposition is often considered the leading cause of

Diagnosis of Ovarian Cysts

Anatomy of the Mesentery

Constitutional Symptoms of Lymphoma

Symptoms of Mesenteric Lymphoma

The Sandwich Sign

A particular finding on an abdominal CAT scan is highly suggestive of a mesenteric lymphoma.

Finding Mesenteric Lymphoma

FEMALE REPRODUCTIVE SYSTEM

Dry Skin- presence of poor skin There is an increase urine output

Predisposing Factors: Precipitating Factors:

Increase hormonal production of estrogen and luteinizing hormone

Proliferation of smooth muscle cells

Overgrowth of uterine lining

Development of uterine fibroid

Degeneration of interior part of the fibroid