VELEZ COLLEGE – COLLEGE OF NURSING

F. RAMOS STREET, CEBU CITY

WARD II-PPA

A CASE STUDY ON PATIENT J.D, 34 YEARS OLD FEMALE, DIAGNOSED WITH LEFT PARATUBAL CYST, TWISTED, S/P OPERATIVE LAPAROSCOPY, LEFT PARATUBAL
CYSTECTOMY, LEFT SALPINGECTOMY, RIGHT FALLOPIAN TUBE STERILIZATION BY ELECTROCAUTERY, ADHESIOLYSIS

Submitted by:
 BSN-2A BSN-3A BSN-3B BSN-4A BSN-4B
Baste, Regine C. Balingit, Regina Angela N. Fermo, Valerie Claise R. Cabatino, Mikee Cheayanne Aviles, Eunice
Lipae, Alyssa-Mae T. Cedillo, Francis Jay P. Pacheco, Cinderella L. Coronel, Danika Marie Reoma, Era Kesiya
Robles, Robert Angelo I. Garate, Normaine Nilaine B. Pacres, Edralyn P. King, Joren Sesante, Janielle Blythe
Miñoza, Alissandra C. Tantug, Desiree Mae A. Wong-Marcon, Marie Christelle T.
Morillo, Gladys Meiji E. Tomandao, Yroll
Siguan, Maria Katrina T.
Tiu, William C. Jr.
 Submitted to:
Ms. Ivy Marie R. Rico, RN, MN
Ms. Mildred Karaan, RN, MN
Ms. Lhara Mae Pigano, RN, MN

February 15, 2013

CHAPTER 1
INTRODUCTION
PARATUBAL (PARAOVARIAN) CYST

Definition:
A paraovarian cyst is defined as a closed fluid-filled sac that grows beside or near to ovary and fallopian tube, but it is never attached to them. It is located with broad connection (ligament) between the
uterus and ovary and is found on only one side (unilateral) of uterus. It develops from embryological vestiges (Wolffian structures), external covering of the Fallopian tubes (tubal epithelium) or smooth
serous membrane that lines the cavity of abdomen (peritoneum). Paraovarian cysts are very small ranges from 2 to 20 cm. Incidence and prevalence of paraovarian cysts are relatively common and
account for 10% of all pelvic masses.

Etiology:
1. Genetic predisposition: Genetic predisposition is often considered to be the primary cause of ovarian cyst as 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.
2. Poor dietary choices: Different types of food including the ones rich in carbohydrates, junk food, toxic food and acidic food can bring about hormonal imbalance and can weaken your immune
system making you more vulnerable to ovarian cyst. Similarly diets rich in sugar and low on fresh vegetables can make the task of flushing out toxins difficult thereby aggravating ovarian cyst
problem.
3. Weak immune system: A weak immune system invites 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.
4. 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.
5. 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 ovarian cysts. What is important to point out is the common factor in each of these possible causes, as
each one is perceived as stress by the body.  When the body senses stress the sympathetic nervous system is immediately stimulated, placing the body into a state of “fight or flight.”  Anytime this
happens the body’s endocrine system releases a slue of hormones. Over time, this can create severe hormonal imbalances, which are shown to be one of the common factors in all ovarian cyst.

Risk Factors:
The smaller cysts are most commonly found in middle-aged women (in the 30 to 40 years of age group), and are often indistinguishable from simple ovarian cysts. Larger paraovarian cysts tend to
develop in younger women, quite often during a pregnancy, at which time they have a tendency to grow rapidly.

Signs and Symptoms:

Many individuals with small paraovarian cysts will report no symptoms. However, individuals with larger paraovarian cysts will show some symptoms:
o Frequent complain of pelvic pain usually on one side (unilateral)
o Irregular periods
o Abnormal uterine bleeding
o Pain during sexual intercourse (dyspareunia).

Complication:
- Infection
- Bleeding
- Rupture of Cyst
- twisting is also severe as it is painful and leads to stoppage of blood supply to that ovary [torsion]
- Infertility
- Dystocia during pregnancy
- Formation of pus and its discharge from the cyst

Diagnostic Tests:
 Physical exam: Paraovarian cysts are discovered when physician presses with his hands (palpation) on the lower abdomen or when she inserts one or two fingers into vagina while pressing with
other hand on the abdomen.
 Tests needed includes:
 Diagnostic ultrasound (sonography) is a noninvasive diagnostic imaging technique which uses high-frequency sound waves to produce images of structures within the body. The sound waves
are passed through the body tissues with a device called transducer. Objects inside the body will reflect a part of sound waves back to the sensor, where the waves are recorded, analyzed and
displayed for viewing on a screen. Modern sonographic equipment will display live images of moving tissues (real-time viewing) and will also provide 3-dimensional reconstruction information
about different structures. The area covered by the ultrasound beam will depends on equipment design.
 Doppler sonography (duplex Doppler sonography) will enable the visualization of blood flow in both arteries and veins (vascular systems) as well as in organs. It reveals changes in the pitch of
sound waves (Doppler effect) as they bounce off circulating blood cells. When combined with the technology of advanced data processing, color Doppler can acquire data fast enough to study
the complex flow of blood in the heart and other organs. A computer image will represents the speed and direction of blood flow is then generated from the data. Power Doppler sonography is
a new technique is about 5 times more sensitive than color Doppler. It is useful in measuring the blood flow in blood vessels traversing solid organs.
 Visual exam by using a thin, lighted microscope inserted into the abdomen or by a laparoscopic process used to confirm diagnosis, size and location of a paraovarian cyst.

Nursing Considerations:
Carefully explain the nature of the cyst, the type of discomfort the patient is apt to experience and how long the condition is expected to last. Teach the patient to watch for signs and symptoms of cyst
rupture such as increasing abdominal pain, distention and rigidity.

Medical Intervention:
- Most paraovarian cysts that are small and asymptomatic will not require any treatment as they disappear on their own.
- Operative laparoscopy and cystectomy

Operative laparoscopy has become the standard approach for most common surgeries, including tubal ligation, cholecystectomy, appendectomy, and ovarian cystectomy
Advantages:
 Usually can be performed in the outpatient setting
 Shorter hospitalization when admission is necessary
 Better cosmetics
 Faster recovery and earlier return to normal activity
 Less risk of postoperative adhesion formation and infection
 Small punctures instead of one long incision
 Reduced post-operative pain

Preparation:
The day prior to the procedure
1. Liquids only
2. Liquids may include fruit juices, soups etc.
3. No milk and milk products
4. Laxatives as prescribed
5. Patient may consume clear liquids up to 10 pm
6. Fasting from 10 pm onwards

Morning of the surgery

o Nothing to be taken by mouth
o Site is shaved

Duration: Usually 1-3 hours but varies depending on the complexity that is required.

Risks:
 The most common complication is bleeding inside the pelvis during the surgery.
 Damage to the bowel, the bladder, or other vital organs inside the abdomen can also occur, since many patients have a significant amount of scar tissue around these organs. If damage
to bowel, bladder or a major blood vessel were to occur, you would require an immediate laparotomy (major incision and surgery) for repair. Sometimes, the injury to the organs or
bladder is not noticed until a few days after Operative Laparoscopy.
 Rarely, large hematomas (blood clots) of the abdominal wall can occur near the areas where the small incisions were created.
 Infection can also occur, particularly when dye is injected into the tubes to test whether they are open. The dye, because it is injected through the cervix and vagina, can carry bacteria
into the tubes and thus cause an infection.
 Allergic reactions to medications can also arise, and this is unpredictable. Certain conditions may increase the risk of serious complications.

Post-operative problems may include:

 Constipation
 Wound, pelvic or bladder infection
  Pelvic or wound hematoma
 Thrombosis
 Infection

FALLOPIAN TUBE STERILIZATION or TUBAL LIGATION

Definition
 A tubal ligation, also known as having your tubes tied or tubal sterilization is a type of permanent birth control. During a
tubal ligation, the fallopian tubes are cut or blocked to permanently prevent pregnancy.
 A tubal ligation disrupts the movement of the egg to the uterus for fertilization and blocks sperm from traveling up the
fallopian tubes to the egg. A tubal ligation doesn't affect your menstrual cycle.
 A tubal ligation can be done at any time, including after childbirth or in combination with another abdominal surgical
procedure, such as a C-section. It's possible to reverse a tubal ligation — but reversal requires major surgery and isn't
always effective.

Purpose
 Tubal ligation is performed in women who want to prevent future pregnancies. It is frequently chosen by women who
do not want more children, but who are still sexually active and potentially fertile, and want to be free of the
limitations of other types of birth control.
 Women who should not become pregnant for health concerns or other reasons may also choose this birth control
method.

Procedure
 While under anesthesia, one or two small incisions are made in the abdomen, usually near the navel and a device
similar to a small telescope on a flexible tube, called a laparoscope is inserted.
 Using instruments that are inserted through the laparoscope, the tubes (Fallopian tubes) are coagulated (burned),
sealed shut with cautery, or a small clip is placed on the tube.
 The skin incision is then closed with a few stitches. You are usually feeling well enough to go home from the outpatient surgery center in a few hours.

Indications
 Tubal ligation permanently prevents pregnancy, ending the need for any type of contraception.
 A tubal ligation may also decrease the risk of ovarian cancer.
 Medical conditions that prohibit further pregnancy.

Contraindications
 There is an unstable medical condition postpartum (eg, hemorrhage, infection, uncontrolled hypertension, HELLP [hemolysis, elevated liver enzymes, and low platelets] syndrome)
  The patient is ambivalent regarding the procedure
 The patient has known or suspected significant abnormalities of the uterus, fallopian tubes, or intra-abdominal cavity
 The patient consent is not mature according to state/local regulations
 The status of the newborn is unclear

Complications
 Nausea and vomiting
 Minor infections
 Minor bleeding
 Bruising or a collection of blood at the incision site
 Burns on the skin
 Abnormal or painful scar formation
 Allergic skin reaction to tape, dressings, or latex
 Delayed return of bowel and/or bladder function

Risks
 Damage to the bowel, bladder or major blood vessels
 Adverse reaction to anesthesia
 Wound doesn't heal properly or becomes infected
 Prolonged pelvic or abdominal pain

Pre-operative Measures
 Review the risks and benefits of reversible and permanent methods of contraception
 Ask about your reasons for choosing sterilization and discuss factors that could lead to regret, such as a young age or marital discord
 Explain the details of the procedure
 Discuss the causes and probability of sterilization failure
 Share information about tubal ligation reversal
 Help you choose the best time to do the procedure, such as shortly after childbirth or in combination with another abdominal surgical procedure, such as a C-section

Post-operative Care
 Eating: Drink liquids and eat lightly for the first one to two days after surgery. After that you should be able to eat normally.
 Activity/Bathing/Driving: Get plenty of rest. LISTEN TO YOUR BODY. You will be sore the first few days after surgery. If you had extensive surgery, the soreness may last for a week or more.   You
may drive a car in one week.
 Wound Care: Your stitches are underneath your skin and will dissolve. You may see a knot at the end. If it is still there at your post-op appointment, the physician or nurse will pull it out for
you. Any staples on your incision will be removed in the office within 7 days. Keep your incisions clean and dry. On the second day after surgery, you may remove your outer tape and gauze or
Band-Aid. Leave the plastic strips on top of your wound for one week unless they are bothering you. If the strips haven't fallen off after one week, you may gently pull them off.
  Vaginal Bleeding: You may notice a bloody vaginal discharge for the next few days after surgery, especially if you had a dilation and curettage (D & C) as well. If any special dyes were used
during the case to check to see if your fallopian tubes are open for fertility purposes, you may notice the discharge is bluish-red or purple and your urine may be green. This will disappear after
a couple of days. Please use pads and avoid using tampons.
 Pain Medications: Pain medications will be prescribed for you either before your surgery or before you are discharged home. Do not exceed the dosages written. If you find that the medication
prescribed does not control your pain, call your physician. Please refrain from having intercourse until your post-op appointment.
 Follow-Up: You should have a follow-up appointment with the physician who performed your surgery 1 week following your surgery.

Nursing Considerations
 Immediate rapid assessment, then review all systems
 VS and assessments every 15 minutes x4, q30m x 4, q1hrx4, q4h until 24 hrs has elapsed.
 Temperature/Infection. Don’t change first dressing, that’s the surgeon’s prerogative. Reinforce only.
 Fluid intake/output (usually until oral intake reestablished)
 Safety: ready equipment, raise side rails, call bell, assist OOB, etc.
 Comfort and rest
 Early ambulation

SALPINGECTOMY

Definition
Salpingectomy is the removal of one or both of a woman's fallopian tubes, the tubes through which an egg travels from the ovary to the uterus.

Purpose
 Removal of one tube (unilateral salpingectomy) is usually performed if the tube has become infected, a condition
known as Salpingitis.
 Salpingectomy is also used to treat an ectopic pregnancy, a condition in which a fertilized egg has implanted in
the tube instead of inside the uterus. In most cases, the tube is removed only after drug treatments designed to
save the structure have failed.
 A bilateral salpingectomy (removal of both the tubes) is usually done if the ovaries and uterus are also going to
be removed. If the fallopian tubes and the ovaries are both removed at the same time, this is called a Salpingo-
oophorectomy.

Procedure
 Regional or general anesthesia may be used.
 Often a laparoscope is used in this type of operation, which means that the incision can be much smaller and the
recovery time much shorter.
 The surgeon makes a small incision just beneath the navel.
 The surgeon inserts a short hollow tube into the abdomen and, if necessary, pumps in carbon dioxide gas in
order to move intestines out of the way and better view the organs.
 After a wider double tube is inserted on one side for the laparoscope, another small incision is made on the
 other side through which other instruments can be inserted.
 After the operation is completed, the tubes and instruments are withdrawn. The tiny incisions are sutured and there is very little scarring.
 In the case of a pelvic infection, the surgeon makes a horizontal (bikini) incision 4-6 in long in the abdomen right above the pubic hairline. This allows the doctor to remove the scar tissue.

Indications
 If patient is not a suitable candidate for medical therapy.
 Medical therapy has failed.
 The patient has a heterotopic pregnancy with a viable intrauterine pregnancy.
 The patient is hemodynamically unstable and needs immediate treatment.
 The ectopic pregnancy has ruptured.
 Future fertility is not desired.
 The ectopic pregnancy represents a failure of sterilization.
 The tube has previously been reconstructed.
 Sterilization is requested.
 Hemorrhage continues after Salpingotomy.
 The ectopic pregnancy is in the blind-ending distal segment after a previous partial salpingectomy.
 The current pregnancy represents a chronic tubal pregnancy.

Contraindications
• The patient has a medically treatable ectopic pregnancy.
• The patient has other medical conditions that would make the risks associated with surgery unacceptable.

Risks
• All surgery, especially under general anesthesia, carries certain risks, such as the risk of scarring, hemorrhaging, infection, and reactions to the anesthesia.
• Pelvic surgery can also cause internal scarring which can lead to discomfort years afterward.

Pre-operative Measures
 Obtain large-bore venous access and start fluid resuscitation.
 Make sure blood is available.
 Do not delay the operation; the patient has an active bleeding site, and it must be stopped as soon as possible.
 Place a Foley catheter before starting the procedure.
 Insertion of either a Hulka tenaculum or a Harris-Kronner uterine manipulator/injector (HUMI) device into the uterus may facilitate manipulation of the tube during surgery.
 The patient is given an injection an hour before surgery to encourage drowsiness.

Post-operative Care
 Proper pain control and hemodynamic stability are important postoperative considerations.
 Most often, patients treated with laparoscopy are discharged on the same day of surgery; however, overnight admission may be necessary for some patients to monitor postoperative bleeding
and achieve adequate pain control.
 Patients treated by laparotomy are usually hospitalized for a few days.
 Patients who were in shock or had to receive blood transfusions generally require a longer postoperative observation period, which should include observation that the kidneys are functioning
 normally and the patient has regained normal hemodynamics.
 Even when major surgery is performed, most women are out of bed and walking around within three days. Within a month or two, a woman can slowly return to normal activities such as
driving, exercising, and working.

Nursing Considerations
1. Monitor the following for signs of infection:
 Redness, swelling, increased pain, or purulent drainage at incisions, injured sites, exit sites of tubes, drains, or catheters any suspicious drainage should be cultured; antibiotic therapy is
determined by pathogens identified at culture.
 Elevated temperature Fever of up to 38° C (100.4° F) for 48 hours after surgery is related to surgical stress; after 48 hours, fever above 37.7° C (99.8° F) suggests infection; fever spikes
that occur and subside are indicative of wound infection; very high fever accompanied by sweating and chills may indicate septicemia.
 Color of respiratory secretions Yellow or yellow-green sputum is indicative of respiratory infection.
 Appearance of urine Cloudy, foul-smelling urine with visible sediment is indicative of urinary tract or bladder infection.
2. Monitor white blood count (WBC). Rising WBC indicates body’s efforts to combat pathogens; normal values: 4000 to 11,000 mm3. Very low WBC (neutropenia <1000 mm3) indicates severe
risk for infection because patient does not have sufficient WBCs to fight infection.
3. Assess for presence, existence of, and history of risk factors such as open wounds and abrasions; in-dwelling catheters (Foley, peritoneal); wound drainage tubes (T-tubes, Penrose, Jackson-
Pratt); endotracheal or tracheostomy tubes; venous or arterial access devices; and orthopedic fixator pins. Each of these examples represent a break in the body’s normal first lines of
defense.
4. Assess for history of drug use or treatment modalities that may cause immunosuppression.
5. Assess immunization status. Elderly patients and those not raised in the United States may not have completed immunizations, and therefore not have sufficient acquired
immunocompetence.
6. Assess nutritional status, including weight, history of weight loss, and serum albumin. Patients with poor nutritional status may be anergic, or unable to muster a cellular immune response
to pathogens and are therefore more susceptible to infection.
7. Assess patient’s signs and symptoms of pain and administer pain medications as prescribed. Monitor and record effectiveness and adverse effects.

ADHESIOLYSIS
Definition
Adhesiolysis is the name of a procedure used to remove scar tissue inside the uterus and in the reproductive tract. This procedure is generally used when scar tissue becomes problematic due
to pain symptoms or interference with fertility.

Procedure
 Abdominal Fascia – the abdomen fascia is grasped with two clamps and incised.  The fascia is
Injecting Incision Site - incision site prior to the incision theoretically reduces the the tissue that holds the abdominal wall together and along with the abdomen muscles gives
postoperative pain the patient feels the abdomen strength

Suture Tags of Fascia -  sutures are placed on the edges of the fascia so the surgeon can
Incision – the incision is made in the inferior border of the belly button better identify the fascia at the end of the case.  Meticulous closure of the fascia helps to
prevent hernia formation.
Hasson trocar placement – the trocar is the tube, which allows the surgeon to access the
inside of the abdomen.  This particular tube will allow the surgeon to place the laparoscope Interceed is an absorbable cellulose mesh that prevents
(camera scope) into the belly thus permitting visualization of the procedure and adhesions. adhesion formation at the surgical site as seen above

Indications
 Patients with a complete obstruction or partial obstruction not resolving with nonoperative therapy
 Patients with resolved obstruction but with history of recurrent, chronic obstruction demonstrated by contrast study

Contraindications
 Hemodynamic instability
 Uncorrected coagulopathy
 Severe cardiopulmonary disease
 Abdominal wall infection
 Multiple previous upper abdominal procedures

Risks
  New pelvic scarring as a result of the surgery.
 External scarring.
 Infection, which may require the use of antibiotics.
 Complications resulting from the use of anesthesia.
 Excessive bleeding or swelling, especially if the patient is under the influence of blood thinners such as Aspirin.
 Excessive postoperative pain, which may be aided by the use of pain medication.

Complications
■    Neck and shoulder pain
■    Infection of the incision site
■    Hematoma
■    Headache (caused by dural puncture or induced by hydrostatic pressure) 
■    Chronic adhesive arachnoiditis
■    Retinal hemorrhage and temporal blindness can occur when the sudden increase in epidural pressure is transmitted to the subarachnoid space.
■    Other vision changes
■    Confusion

Pre-operative Measures
 The history and physical examination of a patient to undergo epiduroscopic adhesiolysis should include the following assessments:
 Presence of infection or distorted anatomy at the skin entry site
 Straight-leg raising test for documentation of radiculopathy
 Magnetic resonance imaging or computed tomography of the lumbar and sacral spine should be consideredto assess the contents of spinal canal and seek spinal stenosis.
 The following studies should also be performed in a patient being considered for epiduroscopic adhesiolysis:
 Nerve conduction study and electromyography
 Baseline ophthalmologic examination using funduscopy
 Complete blood count, coagulation battery, and urinalysis
 Nonsteroidal anti-inflammatory drugs, aspirin, and anticoagulants should be discontinued for 3 to 7 days before and after the procedure.

Post-operative Care
 A postoperative neurologic examination should be performed. If any new neurologic deficits are detected, magnetic resonance imaging and neurologic consultation should be
considered.
 The patient is instructed not to bathe for 5 days
 The appropriate analgesics are prescribed.
 Prophylactic antibiotics are given for 3 days.
 First Day
1500 to 3000IU of hyaluronidase in 4mL and then followed by 9mL of 0.125% ropivacaine
30-min neurologic observation
  Second Day
1500IU of hyaluronidase in 2mL and then followed by 40mg of triamcinolone in 9mL of 0.125% ropivacaine

Nursing Considerations
 Activity: You may need to walk around the same day of surgery, or the day after. Movement will help prevent blood clots. You may also be given exercises to do in bed. Do not get out of
bed on your own until your caregiver says you can. Talk to caregivers before you get up the first time. They may need to help you stand up safely. When you are able to get up on your
own, sit or lie down right away if you feel weak or dizzy. Then press the call light button to let caregivers know you need help.
 Food and drink after surgery: You will be able to drink liquids and eat certain foods once your stomach function returns after surgery. You may be given ice chips at first. Then you will get
liquids such as water, broth, juice, and clear soft drinks. If your stomach does not become upset, you may then be given soft foods, such as ice cream and applesauce. Once you can eat
soft foods easily, you may slowly begin to eat solid foods.
 Medicines: You may need any of the following:
 Antibiotics: This medicine is given to help treat or prevent an infection caused by bacteria.
 Anti-nausea medicine: This medicine may be given to calm your stomach and to help prevent vomiting.
 Pain medicine: Caregivers may give you medicine to take away or decrease your pain.
 Do not wait until the pain is severe to ask for your medicine. Tell caregivers if your pain does not decrease. The medicine may not work as well at controlling your pain if you wait too long
to take it. Pain medicine can make you dizzy or sleepy. Prevent falls by calling a caregiver when you want to get out of bed or if you need help.
 Neurologic exam: This is also called neuro signs, neuro checks, or neuro status. A neurologic exam can show caregivers how well your brain works after an injury or illness. Caregivers will
check how your pupils (black dots in the center of each eye) react to light. They may check your memory and how easily you wake up. Your hand grasp and balance may also be tested.
 Physical therapy: You may need to see a physical therapist to teach you special exercises. These exercises help improve movement and decrease pain. Physical therapy can also help
improve strength and decrease your risk for loss of function.

ANATOMY AND PHYSIOLOGY

Female Reproductive System

The reproductive system or genital system is a system of organs within an organism which work together for the purpose of reproduction. Many non-living substances such as fluids, hormones,
and pheromones are also important accessories to the reproductive system. Unlike most organ systems, the sexes of differentiated species often have significant differences. These differences
allow for a combination of genetic material between two individuals, which allows for the possibility of greater genetic fitness of the offspring.
The major organs of the reproductive system include the external genitalia (penis and vulva) as well as a number of internal organs including the gamete producing gonads (testicles and ovaries).
Diseases of the human reproductive system are very common and widespread, particularly communicable sexually transmitted diseases.
Organs of the Reproductive System
Ovaries
The ovary is an ovum-producing reproductive organ, often found in pairs as part of
the vertebrate female reproductive system. Ovaries in female individuals are analogous to testes in male
individuals, in that they are both gonads and endocrine glands. Ovaries secrete
both estrogen and progesterone. Estrogen is responsible for the appearance of secondary sex
characteristics for females at puberty and for the maturation and maintenance of the reproductive organs in
their mature functional state. Progesterone prepares uterus for pregnancy, and mammary gland for lactation.
Progesterone functions with estrogen by promoting menstrual cycle changes in the endometrium.
Fallopian tubes
The uterine or fallopian form the initial part of the duct system. They receive the ovulated oocyte and
provide the site where fertilization can occur. Each of the uterine tubes is about 10 cm long and extends
medially from an ovary to empty into the superior region of the uterus. Like the ovaries, the uterine tubes are
enclosed and supported by the broad ligament. The distal end of each uterine tube expands as the funnel-
shaped infundibulum, which has finger-like projections called fimbriae that partially surround the ovary.
Uterus
The uterus is located in the pelvis between the urinary bladder and rectum, is a hollow organ that
functions to receive, retain, and nourish a fertilized egg. In a woman who has never been pregnant, it is about
the size and shape of a pear. During pregnancy, the uterus increases tremendously in size and can be felt well
above the umbilicus during the latter part of pregnancy. The uterus is suspended in the pelvis by the broad
ligament and anchored anteriorly and posteriorly by the round and uterosacral ligaments.
The major portion of the uterus is referred to as the body. Its superior rounded region above the
entrance of the uterine tubes is the fundus, and its narrow outlet, which protrudes into the vagina below, is the cervix. The wall of the uterus is thick and composed of three layers. The inner layer
or mucosa is the endometrium. If fertilization occurs, the fertilized egg burrows into the endometrium and resides there for the rest of its development. When a woman is not pregnant, the
endometrial lining sloughs off periodically, usually about every 28 days, in response to changes in the levels of ovarian hormones in the blood. This process is called menstruation. The
myometrium, composed of interlacing bundles of smooth muscle, is the bulky middle layer of the uterus. The myometrium plays an active role during the delivery of a baby, when it contracts
rhythmically to force the baby out of the mother’s body. The outermost serous layer of the uterus is the perimetrium, or the visceral peritoneum.

Vagina
The vagina is a thin walled tube 8 to 10 cm long. It lies between the bladder and rectum and extends from the cervix to the body exterior. Often called the birth canal, the vagina provides
a passageway for the delivery of an infant and for the menstrual flow to leave the body. Because it receives the penis during sexual intercourse, it is the female organ of copulation.
The distal end of the vagina is partially closed by a thin fold of the mucosa called the hymen. The hymen is very vascular and tends to bleed when it is ruptured during the first sexual
intercourse. However, its durability varies. In some women, it is torn during a sports activity, tampon insertion, or pelvic examination. Occasionally, it is so tough that it must be ruptured surgically
if intercourse is to occur.
Mons pubis
The mons pubis is a fatty, rounded area overlying the pubic symphysis. After puberty, this area is covered with pubic hair.
Labia majora
 The labia majora (singular: labium majus) are two prominent longitudinal cutaneous folds that extend downward and backward from the mons pubis to the perineum. It is hair-covered
skin folds that enclose two delicate, hair-free folds, the labia minora. The labia majora enclose the region called the vestibule.
Labia minora
The labia minora are two flaps of skin on either side of the human vaginal opening, situated between the labia majora (outer labia, or outer lips). Inner lips vary widely in size, colour, and
shape from woman to woman.
The inner lips extend from the clitoris obliquely downward, laterally, and backward on either side of the vulval vestibule, ending between the bottom of the vulval vestibule and the outer lips.
The posterior ends (bottom) of the inner lips are usually joined across the middle line by a fold of skin, named the frenulum labiorum pudendi or fourchette.
On the front, each lip divides into two portions. The upper part of each lip passes above the clitoris to meet the upper part of the other lip—which will often be a little larger or smaller—forming a
fold which overhangs the glans clitoridis; this fold is named the preputium clitoridis. The lower part passes beneath the glans clitoridis and becomes united to its under surface, forming, with the
inner lip of the opposite side, the frenulum clitoridis. On the opposed surfaces of the labia minora are numerous sebaceous glands not associated with hair follicles.
Vestibule
The Vulval vestibule (or "Vulvar vestibule") is a part of the vulva between the labia minora into which the urethral
opening and the vaginal opening open. Its edge is marked by Hart's Line. The external urethral orifice is placed about
2.5 cm behind the glans clitoridis and immediately in front of that of the vagina. It usually assumes the form of a short,
sagittal cleft with slightly raised margins. Nearby are the openings of the  Skene's ducts. A pair of mucus-producing glands,
the greater vestibular glands, flank the vagina, one on each side. Their secretion lubricates the distal end of the vagina
during intercourse.
Clitoris
The clitoris is located anterior to the vestibule. It is a small, protruding structure that corresponds to the male
penis. Like the penis, it is hooded by a prepuce and is composed of sensitive erectile tissue that becomes swollen with
blood during sexual excitement. The clitoris differs from the penis in that it lacks a reproductive duct.

Lymphatic System
  The lymph system is not a closed system. The circulatory system processes an average of 20 liters of  blood per day
through capillary filtration which removes plasma while leaving the blood cells. Roughly 17 liters of the filtered plasma
actually get reabsorbed directly into the blood vessels, while the remaining 3 liters are left behind in the interstitial fluid.
The primary function of the lymph system is to provide an accessory route for these excess 3 liters per day to get returned
to the blood. Lymph is essentially recycled blood plasma.
Lymphatic organs play an important part in the immune system, having a considerable overlap with the  lymphoid system.
Lymphoid tissue is found in many organs, particularly the lymph nodes, and in the lymphoid follicles associated with
the digestive system such as the tonsils. Lymphoid tissues contain lymphocytes, but they also contain other types of cells
for support. The system also includes all the structures dedicated to the circulation and production of  lymphocytes (the
primary cellular component of lymph), which includes the spleen, thymus, bone marrow, and the lymphoid tissue
associated with the digestive system.
The blood does not directly come in contact with the parenchymal cells and tissues in the body, but constituents of the
blood first exit the microvascular exchange blood vessels to become interstitial fluid, which comes into contact with the
parenchymal cells of the body. Lymph is the fluid that is formed when interstitial fluid enters the initial lymphatic vessels of
the lymphatic system. The lymph is then moved along the lymphatic vessel network by either intrinsic contractions of the
lymphatic passages or by extrinsic compression of the lymphatic vessels via external tissue forces (e.g. the contractions of  skeletal muscles). The organization of lymph nodes and drainage follows
the organization of the body into external and internal regions; therefore, the lymphatic drainage of the head, limbs, and body cavity walls follows an external route, and the lymphatic drainage
of the thorax, abdomen, and pelvic cavities follows an internal route. Eventually, the lymph vessels empty into the lymphatic ducts, which drain into one of the two subclavian veins (near the
junctions of the subclavian veins with the internal jugular veins).

Functions of the Lymphatic System

The lymphatic system has multiple interrelated functions:
 it is responsible for the removal of interstitial fluid from tissues
 it absorbs and transports fatty acids and fats as chyle from the digestive system
 it transports white blood cells to and from the lymph nodes into the bones
 The lymph transports antigen-presenting cells (APCs), such as dendritic cells, to the lymph nodes where an immune response is stimulated.

Organs of the Lymphatic System

Lymph Nodes
A lymph node is an oval-shaped organ of the immune system, distributed widely throughout the body including the armpit and stomach and linked by lymphatic vessels. Lymph nodes are
garrisons of B, T, and other immune cells. Lymph nodes act as filters or traps for foreign particles and are important in the proper functioning of the immune system. They are packed tightly with
the white blood cells called lymphocytes and macrophages.
Lymph nodes also have clinical significance. They become inflamed or enlarged in various conditions, which may range from trivial, such as a  throat infection, to life-threatening such as cancers. In
the latter, the condition of lymph nodes is so significant that it is used for cancer staging, which decides the treatment to be employed, and for determining the prognosis. When swollen, inflamed
or enlarged, lymph nodes can be hard, firm or tender.

Spleen
The spleen is a soft, blood-rich organ that filters blood. It is located in the left side of the abdominal cavity, just beneath the diaphragm, and curls around the anterior aspect of the stomach.
Instead of filtering lymph, the spleen filters and cleanses blood of bacteria, viruses, and other debris. As with the other lymphoid organs, the spleen provides a site for lymphocyte proliferation
and immune surveillance, but its most important function is to destroy worn-out blood cells and return some of their breakdown products to the liver. Other functions of the spleen include
storing platelets and acting as a blood reservoir.

Thymus
The thymus gland, which functions at peak levels only during youth, is a lymphoid mass found low in the throat overlying the heart. The thymus produces hormones, thymosin and others, that
function in the programming the certain lymphocytes so they can carry out their protective roles in the body.

Tonsils
The tonsils are small masses of lymphoid tissue that ring the pharynx, where they are found in the mucosa. Their job is to trap and remove any bacteria or other foreign pathogens entering the
throat. They carry out this function so efficiently that sometimes they become congested with bacteria and become red, swollen, and sore, a condition called tonsillitis.

Peyer’s Patches
Peyer’s patches, which resemble tonsils, are found in the wall of the small intestine. The macrophages of Peyer’s patches are in an ideal position to capture and destroy bacteria (always present in
tremendous numbers in the intestines), thereby preventing them from penetrating the intestinal wall. Peyer’s patches and the tonsils are part of the collection of small lymphoid tissues referred
to as mucosa-associated lymphatic tissue (MALT). Collectively, MALT acts as a sentinel to protect the upper respiratory and digestive tracts from the never-ending attacks of foreign matter
entering those cavities.

CLIENT IN CONTEXT PRESENT STATE INTERVENTION EVALUATION

J.G., 34 years old, female, married, with an
obstetrical score of G3P3003, Roman Catholic,
currently residing at Capitol Site, Cebu City, was
admitted for the first time at Cebu Velez General
Hospital (CVGH) last January 30, 2013 at 12:30pm
due to Paraovarian Cyst, Left Ovary, scheduled for
a Laparoscopy, Cystectomy, and Bilateral Tubal
Ligation. The patient was admitted per taxi. Under
the service of Dr. Pherdes Galbo, under the
Department of Obstetrics/Gynecology, with a case
number of 11973/13-30714.
History of present illness:
1 month PTA, patient experienced headache and
PHYSICAL EXAMINATION
DAY 1
Thursday, January 31, 2013 @ 1:30 pm
GENERAL IMPRESSION
Seen patient lying on bed, awake, afebrile, not in
respiratory distress, looks anxious and in pain,
appears clean and dresses appropriately to
weather and occasion, has the ff V/S:
BP 120/80 mmHg; PR: 27 bpm; RR 18cpm; Temp.:
36.5/axilla; Pain 8/10 as 1 as the lowest and 10 as
the highest
ANTHROPOMETIC MEASUREMENTS
DOCTOR’S ORDER
On January 30, 2013, the patient was
admitted to the ward and was placed on
NPO on 6am. She was then scheduled for
Operative Laparoscopy, Cystectomy, and
Bilateral Tubal ligation possible open on
January 31, 2013 at 2pm. She was given
Cefazalin one gram IV after a negative skin
test, Bisacodyl (Dulcolax) 1 tab at six pm
and a mineral oil was place @ HS at the
umbilical area.
On January 30, 2013 3:40pm venoclysis
sudden onset of constant gnawing pain at the left
lower quadrant of the abdomen, radiating to the
left thigh and left iliac region, with a pain score of
8/10, with 1 as the lowest and 10 as the highest,
lasted for 7 days, relieved by taking Mefenamic
Acid 500mg/tab three times a day without
prescription. There were no other interventions
done.
27 days PTA, patient sought consult to a private
gynaecologist at Cebu Doctor’s University –
Hospital. Constant gnawing pain at the left lower
quadrant of the abdomen, radiating to the left
thigh and left iliac region, with a pain score of
8/10, with 1 as the lowest and 10 as the highest,
were still noted. Patient was advised to continue
Mefenamic Acid 500mg/tab by physician.
Transvaginal ultrasound revealed presence of Left
paraovarian cyst with morphology of Right Ovary
sonographically compatible with a multicystic
ovary and a left ovary sonographically compatible
with PCD.
On the day of the admission, patient went to
Cebu Velez General Hospital for scheduled
Laparoscopy, Cystectomy, and Bilateral Tubal
Ligation. Patient was then admitted to PPA Room
222 Bed B.
Past Health History
Patient only experienced hospitalizations for
labor and delivery purposes.
Last 2008, During her first pregnancy, patient
experienced Urinary Tract Infection. Treatment
was done at home. Unrecalled Antibiotic
Medications were prescribed for 7 days.
Patient has no problems at birth. Childhood
illnesses include a typical fever, cough and colds as
claimed by the patient. She is a non-hypertensive,
non-diabetic, non-smoker and a non-alcoholic
Height: 165 cm / 1.65 m / 5'4''
Weight: 60 kg / 132.2 lbs
BMI: 22 (normal) wt(kg)/ht(m)2
IBW: 120 lbs
Head circumference: 56 cm
Abdominal girth: 90 cm
Mid-arm circumference: 28 cm
Chest circumference: 91 cm
SKIN
evenly colored skin tone, tan complexion , intact,
smooth and, warm to touch
SCALP AND HAIR
black hair, evenly distributed, scalp is clean and
dry, dandruff was noted, alopecia not noted
NAILS
clean, pink nail beds, smooth and firm, nail plate is
firmly attached to nail bed, (CRT)pink tone returns
immediately to blanched nail beds when pressure
is released, nail clubbing and infection not noted
HEAD AND FACE
head is symmetric, round, erect, upright and in
midline, no lesions noted, face is symmetric with a
oval appearance, no abnormal movements noted
ABDOMEN
asymmetric and report pain in left lower quadrant
EYES
px can read students' nameplate at 2 feet distance,
+PERRLA, (accommodation of pupils) constriction
and convergence of the pupils noted appropriately,
sclerae are white and free from lesions
EARS
auricles/pinna is align with the lateral canthus of
both eyes, smooth without lesions, mastoid is not
tender, small amount of cerumen noted on both
ears
NOSE AND SINUSES
nasal structure is smooth, and symmetric, without
tenderness, a red glow transilluminate the frontal
D5LR one liter at 30 microdrops/minute
was started and Cefazalin 1gm IVTT was
given ANST an hour prior to OR. At 4:50pm
she was rescheduled for OR at 3pm the
following day instead of 2pm. She was then
placed on a general liquid diet for dinner
and NPO by 7am.
At 9:30pm she was given Midazolam 15mg,
one tab @ 10pm and was NPO after 6am,
and D5LR one liter was infused at 30
drops/minute.
On January 31, 2012, her vital signs were
monitored every 4 hours and she was
placed in the recovery room. Her FBC—CDU
was removed at 6am and was monitored if
she was unable to void for 4—6 hours.
Regular IVF was returned to 30
drops/minute to follow D5LR one liter with
the same drops and was terminated when
consumed. The specimen from the left
fallopian tube and left paratubal cyst was
sent to Histopath for biopsy. On 8:05pm
she was given Chlorehexidine (Orahex) as
gargle for three times/day.
On 5:30pm she was given Tramadol 5mg
every 6 hours 3 times a days, Keratolac
30mg every 6 hours for three days, Zetran
30mg every 6 hours, three times/ day,
Eterocoxib 120mg one tab PO once a day
at 10am for five days, and Tramadol +
paracetamol (ALGESIA) one tab three times
a day for breakthrough.
On February 1, 2013, at 7:50am, she may go
home with the following take-home
medications:
1. Eterocoxib 120mg/tab, one tab
beverage drinker.
Gordon’s Functional Pattern
1.    Health Perception - Health Management
Pattern
Patient has a positive outlook in life. She
views health as something of importance with
verbalization of, "Importante jud ang health kay
mao imong puhunan ug kung wa’y health kay
wala jud ka". She rates her health before
hospitalization with 9 and during hospitalization
with 6, with 10 as the highest and 1 as the lowest.
When asked the reason for giving such rating,
patient stated “Ang-ang dili pa man gyud fully
conditioned ang lawas.”Patient claims to practice
self-medication with Mefenamic acid PO PRN for
pain relief and Paracetamol for fever. . Patient
took Marbelon (2011) for relief of headache,
Nardet (2011), Althea (2012) for sleepiness, Soffia
(2012). Patient claims to know Breast Self-
Examination but fails to practice it. Patient could
not recall her immunization status with
verbalization of "Wala na nako na hinumdom dai,
nakalimot najud ko pero murag kumpleto man
cguro”. She claims to take prescribed medications
with good compliance.
Environmental History
Patient is a graduate of University of
Cebu. She is working as a Production operator of
lens in MEPZA, Lapu-Lapu City. Her working
environment is near from chemicals, radiation and
toxic fumes. She is greatly exposed to chemical
substances such as Acetate and Ethanol. There
were no recorded work-related injuries. Patient
claims to be satisfied with her job because of good
salary and having a lot of friends at work.
and maxillary sinuses once a day PO before eating
MOUTH AND THROAT 2. Tramadol + Paracetamol (algesia),
lips are smooth and moist without one tab three times a day PO as
lesions/swelling, 32 whitish-yellow teeth noted, no
needed for pain.
dentures pink buccal mucosa without lesions,
3. Chlorhexidine (Corahex) 30 mL for
tongue is pink, moist, and papillae noted without
fissure or lesions, frenulum is midline, uvula hangs gargle, three times a day after
freely in the midline and free from swelling eating.
NECK
neck is symmetric with head centered and without Follow—up check-upAP after 1 week of
bulging masses biopsy results
UPPER EXTREMITIES
skin is warm to touch, radial pulse have equal
strength bilaterally 2+
LOWER EXTREMITIES
legs are free from lesions/ulcerations, identical in
size and shape bilaterally, no edema present in the
legs
NEUROLOGICAL SYSTEM
CRANIAL NERVE TESTING
CN I / OLFACTORY (S). not assessed
CN II / OPTIC (S). px can read newsprints at 12
inches distance
CN III / OCULOMOTOR (M). eyes move in a
smooth, coordinated motion in all directions(six
cardinal gaze), +PERRLA
CN IV / THROCLEAR (M). same to CN III
CN V / TRIGEMINAL (B). temporal and masseter
muscle contract bilaterally, px correctly identify
sharp and dull stimuli an light touch to forehead,
cheeks and chin, eyelids blink bilaterally
CN VI / ABDUCENS (M). same to CN III and IV
CN VII / FACIAL (B). px frown, wrinkles forehead,
shows teeth, raises eyebrows, and closes eyes
against resistance, movements are symmetrical
CN VIII / VESTIBULOCOCHLEAR (S). AC>BC,
vibrations heard equally well in both ears
 Patient lives with her mother, husband,
children, and cousin in a ten-storey house in
Capitol but stayed at the second floor with 2 doors
and 2 windows. One bed room for her family. The
kitchen, living room, dining room, and bathroom
room are distinct to each other as claimed. House
is composed of mixed constructional materials
such as wood and cement. Water is supplied by
MCWD with a flushed-type toilet and electricity by
VECO. They use mineral water for drinking and
water from MCWD for other uses. Water in their
house is stored in a water container. Waste
disposal is collected by a garbage collector once or
twice a week. Cleaning in her house is practiced
every day and cleaning materials are placed just
behind the door. Crowing index is 2.33. They have
no pets. The nearest grocery store and fire station
is 10mins. away when travelling by motor vehicle
or jeepney. The drug store, health center, and
barangay hall are 10-15mins. away from their
house. The nearest hospital and church are 15-
20mis. away by motor vehicle.Household
recreational facilities include the television, DVD
player, and radio. Patient claimed that their place
is sometimes visited with thieves but without that,
their place is safe and peaceful.
CN IX / GLOSSOPHARYNGEAL (B). uvula and soft
palate rise bilaterally and symmetrically on
phonation, gag reflex intact, px swallows without
difficulty, no hoarseness noted
CN X / VAGUS (B). uvula and soft palate rise
bilaterally and symmetrically on phonation, gag
reflex intact, px swallows without difficulty, no
hoarseness noted
CN XI / SPINAL ACCESSORIES (M). not assessed
CN XII / HYPOGLOSSAL (M). tongue movement is
symmetric and smooth
DAY 2
Friday, February 1, 2013 @ 10:00 am
GENERAL IMPRESSION
Seen patient lying on bed, awake, afebrile, not in
respiratory distress, looks tired and sleepy,
appears to be her stated chronologic age, appears
clean and dresses appropriately to weather and
occasion, body built-mesomorph, cooperative and
affect is appropriate, smiles and frown
appropriately, speech is clear and moderately
pace, has the ff V/S: BP 130/90 mmHg; PR: 70 bpm;
RR 17cpm; Temp 36.6/axilla;
ANTHROPOMETIC MEASUREMENTS
Height: 165 cm / 1.65 m / 5'4''
Weight: 60 kg / 132.2 lbs.
BMI: 22 (normal) wt(kg)/ht(m)2
IBW: 120 lbs
Head circumference: 56 cm
Abdominal girth: 89 cm
Mid-arm circumference: 28 cm
Chest circumference: 91 cm
SKIN
evenly colored skin tone, tan complexion , intact,
2.    Nutrition -  Metabolic Pattern smooth and, warm to touch, pinches easily and
Patients’ weight is 60 kg / 132.2 lbs. Height: 165 immediately returns to its original position, edema
cm / 1.65 m / 5'4'' Her BMI is 22. She eats three not noted, presence of lesions on the abdomen
times a day with snacks in the morning. She eats SCALP AND HAIR
all kinds of foods as long as it is tasty. She has no black hair, evenly distributed, scalp is clean and
difficulty in chewing or swallowing. dry, dandruff was noted, alopecia not noted
NAILS
Patient does not have regular dental check-ups clean, pink nail beds, smooth and firm, nail plate is
but only seeks one if she experiences severe firmly attached to nail bed, (CRT)pink tone returns
immediately to blanched nail beds when pressure
Client’s Usual Diet 24-hour recall is released, nail clubbing and infection not noted
Diet HEAD AND FACE
Breakfast 7:00 AM 7: 00 AM head is symmetric, round, erect, upright and in
- ½ - 1 cup or rice - 1 cup of rice midline, no lesions noted, face is symmetric with a
- 1 serving of fish - 1 serving beef oval appearance, no abnormal movements noted,
- 1 glass of milk steak temporal artery is elastic and nontender, TMJ-
- 1 glass of milk mouth opens and closes fully, lower jaw moves
laterally 1-2 cm in each direction
Lunch 12: 00 NN 12:00 NN EYES
-1 cup of rice - 1 cup noodles distant visual acuity is 20/20 without corrective
-1 piece of chicken - 1 glass of lenses, px can read students' nameplate at 2 feet
-1 piece banana water distance, (confrontation test)px is able to see the
-1 glass of examiners' finger at the same time the examiner
water/salabat sees it, (corneal light reflex) reflection of light on
the corneas are exactly same spot on each eye,
Dinner 6: 30 PM 6:30 PM (cover test) uncovered eye remains fixed straight
-1 cup of rice -1 cup of rice ahead and the covered eye remains fixed straight
- 1 serving of -1 serving of fish ahead after being uncovered, (position test) eye
vegetable viand -1 pc banana movement is smooth and symmetric throughout
- 1 serving of -1 glass of water all six directions, upper and lower lids closes easily
vegetable soup and meet completely when closed, lower lid is
- 1 glass of water/ upright with no inward and outward turning,
salabat eyelashes are black, short, and evenly distributed,
Snacks 10 AM 9:30 AM no lesions noted eyeballs are symmetrically align in
- 1 piece of bread - 1 piece of sockets without protruding or sinking, bulbar and
- 1 glass of water bread palpebral conjunctiva is clear, moist, smooth, and
- 1 glass of free from swelling/lesions, +PERRLA,
water (accommodation of pupils) constriction and
toothache and took Mefenamic Acid for relief.
Before hospitalization she drinks only 4-5
glasses/day. During hospitalization, fluid intake
was still 4-5 glasses/day. Patient’s diet during
hospitalization is NPO pre-op and post-op; and
diet as tolerated a day after the operation.
3.    Elimination Pattern
Before hospitalization, patient urinates
regularly 2-3 times a day with clear and yellow
urine amounting to 120 - 240 mL per episode. She
takes 4-5 glasses of water a day. She defecates
once a day with formed, soft, semisolid and
cylindrical stools. She claimed not to practice
Kegel’s exercises. She does not use laxatives, has
no difficulty in defecating.
During hospitalization, patient claimed
that she cannot urinate and defecate easily.
4.   Activity - Exercise Pattern
Before hospitalization, patient usually
wakes up at around 4:00 AM - 5:00 AM, fixes their
bed and eats her breakfast. After eating her
breakfast, she then takes a bath and prepares
herself to work. She goes to work with her
husband via motorcycle or jeepney if they are not
on the same shift with her husband. She then
takes her lunch at 12 PM. At around 5 PM, she
goes home.
During hospitalization, she usually wakes
up at around 6 AM, eats breakfast at 7 AM. She
can’t easily change position in bed, needs
assistance like going to the comfort room. She
sleeps at around 7:30 PM. Patient has a slight
difficulty in doing ADL's.
5. Cognitive- Perceptual Pattern
convergence of the pupils noted appropriately,
sclerae are white and free from lesions
EARS
auricles/pinna is align with the lateral canthus of
both eyes, smooth without lesions, mastoid is not
tender, small amount of cerumen noted on both
ears, tympanic membrane is intact, (weber's test)
vibrations are heard equally well in both ears,
(rinne test) AC>BC, (romberg test) px maintains
position for 20 seconds with minimal swaying,
(whisper test) px was not able to repeat assesors
whispered word 'good morning'
NOSE AND SINUSES
nasal structure is smooth, and symmetric, without
tenderness, px is able to sniff through each nostrils
while other is occluded, nasal mucosa is moist and
free of exudates, nasal septum is intact without
perforations, frontal and maxillary sinuses are non-
tender to palpation, no crepitus is evident,
nontender on percussion, a red glow
transilluminate the frontal and maxillary sinuses
MOUTH AND THROAT
lips are smooth and moist without
lesions/swelling, 32 whitish-yellow teeth noted, no
dentures pink buccal mucosa without lesions,
tongue is pink, moist, and papillae noted without
fissure or lesions, frenulum is midline, px can
distinguish between sweet and salty, hard palate is
firm with transverse rugae, varicose veins on
ventral surface of the tongue not noted, uvula
hangs freely in the midline and free from swelling,
tonsils is pink, symmetric, enlarge to 1+ without
lesions
NECK
neck is symmetric with head centered and without
bulging masses; thyroid gland, thyroid, cricoid
cartilages moves upward symmetrically as the
client swallows, neck movements are smooth and
 Patient is aware and oriented to time,
place and people as proven by the ability to recall
the time that she’ll take her prescribed
medications. Patient knows her name and how old
she is. Patient can speak, write and understand in
English, Tagalog and Visayan. She is a Bachelor of
Science in Computer Secretarial graduate. Patient
claims not to have any problems with vision. She
can hear well modulated voices; can distinguish
the smell of orange. She can recall recent (24-hour
food recall), intermediate (significant events
during her day of admission) and past events (date
of her previous prenatal check-up). She usually
makes decisions with her husband’s approval.
Current condition has not affected cognition and
perception.
6. Sleep – Rest Pattern
Before hospitalization, patient usually
sleeps at 7:30 PM and wakes up at 6:00 AM. She
claims to typically have 8 – 10 hours of sleep.
During hospitalization, her sleeping pattern did
change because of uneasiness as claimed.
Patient’s nap before hospitalization is usually 1-2
hours in the afternoon. During hospitalization, she
takes a nap for 1 hour in the afternoon. She only
drinks milk to aid her sleep but doesn’t takes
drugs or sedatives to facilitate sleep and does not
have any problems or disturbances in sleeping.
Bedtime rituals include washing her face and
brushing her teeth. She sleeps with 1 blanket and
2 pillows, one at the head part and the other at
her side. She usually sleeps in left side lying
position. Sleep is usually restful as claimed by
patient.
7.Self- Perception and Self-Concept Pattern
controlled (flexion, extension, lateral abduction
and rotation), trachea is midline, lymph nodes are
not palpable, no lesions noted
UPPER EXTREMITIES
skin is warm to touch, radial pulse have equal
strength bilaterally 2+, ulnar pulses are not
detectable, brachial pulses have equal strength
bilaterally, epitrochlear lymph nodes are not
palpable, (allen test) radial and ulnar arteries are
patent
POSTERIOR, ANTERIOR THORAX, AND LUNGS
scapulae are symmetric and non-protruding,
shoulders are equally horizontal positions, px does
not use accessory muscles to assist breathing, no
palpable crepitus, (chest expansion) as px takes a
deep breath, examiners' thumbs moves 5cm apart
symmetrically, (diaphragmatic excursion) equally
bilateral and measure approximately 3-5 cm, no
adventitious sounds such as crackles, wheezes are
auscultated, (bronchophony) voice transmission is
soft, muffled, and indistinct, (egophony) letter 'E' is
distinguishable, voice transmission is soft and
muffled, (whispered pectoriloquy) numbers '1-2-3'
are inaudible, very faint and muffled, sternum is
position at midline, retractions not noted,
respirations are relax, effortless, and quite
HEART
apical pulse is palpated in mitral area, S1 is best
heard at the apex and S2 follows which is best
heard at the base of the heart, no murmurs heard
using the bell of the diaphragm,
FEMALE BREAST
breast are symmetric, no lesions and mass
palpated by the px, no tenderness and lymph
nodes felt by the px
JUGULAR VEINS
jugular venous pulse not noted in upright position,
carotid pulse is 2+, jugular veins are distended 45
 Patient identifies herself as a strong and degree while px is lying down
independent woman. She claims that her strength ABDOMEN
is her family and sees herself as someone who is presence of dry, clean, intact dressing in left upper
self-worthy. When asked to describe patient, S.O. quadrant, left lower quadrant, right upper
verbalized “Responsable ug buotan.” Major quadrant, and right lower quadrant of the
accomplishment includes being able to finish abdomen, incision site is approximately 1-2cm,
college, was able to work and now has a family of incision site is free from swelling, inflammation
her own. and pain, striae not noted, umbilicus is midline and
clean, abdomen is round and symmetric, 10-15
Rosenberg’s self –esteem scale gurgling sounds noted or borborymi in 1 full
ITEMS SA A DA SD minute in each quadrant, deep palpation and
A percussion not assessed because px refuses
On the whole, I am √ LOWER EXTREMITIES
satisfied with legs are free from lesions/ulcerations, identical in
myself. size and shape bilaterally, no edema present in the
At times I think I’m √ legs; toes, feet and legs are equally warm
no good at all. bilaterally, inguinal lymph nodes not palpated by
I feel that I have a √ the px, posterior tibial and dorsalis pedis pulses are
number of goods bilaterally strong, varicosities not noted, (- homan
qualities. sign) no pain and tenderness elicited
I am able to do √
things as most NEUROLOGICAL SYSTEM
other people. CRANIAL NERVE TESTING
I feel I don’t have √ CN I / OLFACTORY (S). px able to identify scent of
much to be proud alcohol, coffee presented to each nostrils
of. CN II / OPTIC (S). px has a 20/20 vision OD and OS,
I certainly feel √ px can read newsprints at 12 inches distance,
useless at times. peripheral vision is intact/full
I feel that I √ CN III / OCULOMOTOR (M). eyes move in a
am a person of smooth, coordinated motion in all directions(six
worth, at least as cardinal gaze), +PERRLA
an equal plane CN IV / THROCLEAR (M). eyes move in a smooth,
with others. coordinated motion in all directions(six cardinal
I wish I could have √ gaze), +PERRLA
more respect for CN V / TRIGEMINAL (B). temporal and masseter
myself. muscle contract bilaterally, px correctly identify
sharp and dull stimuli an light touch to forehead,
All in all, I am √
cheeks and chin, eyelids blink bilaterally
 inclined to feel
that I am a failure.
I take a positive √ gaze), +PERRLA
attitude toward
myself.
8. Role Relationship Pattern
Patient is the second child among five
children. Patient described her role as a good
daughter to her mother-in-law and a loving wife
to her husband. When it comes to decision-
making, everyone in the family has a say. Patient
can easily talk to her family members.
9. Sexuality Reproductive Pattern
Patient had her menarche at the age of 14.
Patient’s menstrual cycle was irregular before
having a baby which only lasts for 3 days
maximum as claimed. After giving birth of her first
child, she was then having regular periods lasting
for 4 days, consuming 2-3 sanitary napkins a day.
Patient claimed that she had only one sexual
partner and that is her husband.
10. Coping-Stress Tolerance
Patient described stress as “Kanang mga
problema sa kinabuhi”. Patient claimed that she
does not get stressed easily. Patient usually talks
to her husband when she has problems. When she
gets stressed, she prays, listens to music, talks
with her husband and relaxes. She claimed that
she does not have a poor appetite when she gets
stressed.
11. Value-Belief Pattern
Patient is Roman Catholic. She goes to
CN VI / ABDUCENS (M). eyes move in a smooth,
coordinated motion in all directions(six cardinal
CN VII / FACIAL (B). px smiles, frown, wrinkles
forehead, shows teeth, puffs out cheeks, purse
lips, raises eyebrows, and closes eyes against
resistance, movements are symmetrical, px
identifies correct flavor
CN VIII / VESTIBULOCOCHLEAR (S). client cannot
hear whispered words 'good morning' from 1-2
feet, AC>BC, vibrations heard equally well in both
ears, (-Romberg sign)slight sway
CN IX / GLOSSOPHARYNGEAL (B). uvula and soft
palate rise bilaterally and symmetrically on
phonation, gag reflex intact, px swallows without
difficulty, no hoarseness noted
CN X / VAGUS (B). uvula and soft palate rise
bilaterally and symmetrically on phonation, gag
reflex intact, px swallows without difficulty, no
hoarseness noted
CN XI / SPINAL ACCESSORIES (M). there is
symmetric, strong contractions of the trapezius
muscles, sternocleidomastoid muscle
CN XII / HYPOGLOSSAL (M). tongue movement is
symmetric and smooth
MUSCULOSSKELETAL SYSTEM
no edema noted, able to ambulate in the room and
ward, full ROM in upper and lower extremities, no
pain noted on joints
FEMALE GENITALIA, ANUS & RECTUM
grossly female, no lesions and swelling noted on
genitalia, anus, and rectum as verbalize by the
patient.
LABORATORIES
URINALYSIS
A routine urinalysis (UA) has two major
their church every Sunday or whenever she has
time. Religious practices include praying and going
to their church.
Genogram:
components: (1) macroscopic analysis and (2)
microscopic analysis. Macroscopic analysis includes
examining the urine for overall physical and
chemical characteristics. The microscopic
component of a UA involves examining the sample
for formed elements, also termed urinary
sediment

Ecomap:
Purpose: One of the most useful indicators of
health and disease, helpful in detection of renal or
metabolic disorders, an aid in diagnosing and
following the course of treatment in diseases of
the kidney and urinary system and in detecting
disorders in other parts of the body such as
metabolic or endocrine abnormalities in which the
kidneys function normally .
INTERPRETATION and IMPLICATIONS: Results are
U/A 01/7/13 NORMAL
within normal range.
Macroscopic

Yellow
Color Light Yellow

Appearance clear Clear

4.5 – 7.5
pH 6.0

1.005 – 1.035
Sp. Gravity 1.010

Protein Negative Negative

Glucose Negative Negative

Ketone Negative Negative

Microscopic

RBC/hpf 0-2 /hpf 0-3/hpf Independent:

1. Assessed skin status such as color,
WBC/ hpf 0-2 /hpf 0-3/hpf temperature and sensation Desired Outcome:
R: for adequacy of blood supply and nerve Within 8 hours of student nurse- patient
Epithelial Negative innervations interaction, incision will remain intact
Rare
Cells 2. Assessed and monitored changes around and dry with no signs of evisceration or
incision site dehiscence and skin surrounding incision
Blood Negative Negative R: Promotes timely intervention will not show signs of inadequate blood
3. Assessed pain and Noted episodes of supply such as pallor, cyanosis and
Bilirubin Negative Negative
vomiting coolness. Patient will be able to
R: The evisceration causes pain and can be demonstrate how to splint wound.
Urobilinogen Negative Negative associated with vomiting.
4. Instructed to splint wound when Actual Outcome:
Nitrite Negative Negative coughing and avoid straining February 1, 2013
R: These complications result from sutures After 8 hours of student nurse-patient
giving way, from infection, and, more
frequently, after marked distention or
strenuous cough
5. Kept incision clean and dry
R: moist skin is at risk for impaired skin
integrity
6. Report feeling of “something giving way”
R: may suggest evisceration
Independent Interventions
1. Monitored vital signs
R: to identify responses associated with
both medical and emotional conditions
2. Assessed factors contributing to anxiety
R: these factors can cause/exacerbate
anxiety
interaction, incision remained intact and
dry with no signs of evisceration or
dehiscence and showed no signs of
inadequate blood supply such as pallor,
cyanosis, and coolness. Patient was able
to demonstrate how to splint wound.
Desired Outcome
Within 8 hours of student nurse-patient
interaction, the patient will be able to
express better understanding of her
condition and reduction of anxiety.
 3. Observed behaviors
Complete Blood Count R: which can point to the client’s level of Actual Outcome
A CBC includes (1) enumeration of the cellular anxiety After 8 hours of nursing interventions,
elements of the blood, (2) evaluation of RBC 4. Established rapport the patient was able to verbalized, “wa
indices, and (3) determination of cell morphology R: to avoid the contagious na ko na-kulbaan, mas okay na karon
by means of stained smears. Counting is effect/transmission of anxiety after naka-tog nako.”
performed by automated electronic devices 5. Provided accurate information about the
capable of rapid analysis of blood samples with a situation
measurement error of less than 2 percent. R: helps client to identify what is reality
based
Purpose: This test helps in determining certain 6. Encouraged patient to verbalize feelings
blood disorders, inflammation and infection. It regarding her condition and the upcoming
evaluates the three main types of blood cells: the operation
RBCs, WBCs and platelet. It is frequently ordered R: to determine those that might be helpful
to provide information about the hematologic in current circumstances
system and other systems. It consists of a series of 7. Identify client’s perception about the
tests that determine the number, variety, upcoming surgery
percentage, concentrations and quality of blood R: it can point to the client’s level of anxiety
cells. It is also used in monitoring routine physical 8. Taught relaxation techniques such as
exam and diagnosis of a wide range of conditions DBE, talking with SO, or have diversional
and diseases. activities such as listening to music or radio,
RESULT reading newspaper to reduce anxiety
TEST AS OF Normal values R: to decrease the level of anxiety
01/18/13
WBC 7.3k/uL 4.10-10.9 Interventions:
RBC 4.93M/uL 4.20-5.40 1. Determined presence of physical or
psychological stressor, including pain, Desired outcome:
advance age, current condition. Within 8 hours of nursing intervention,
HGB 139g/L 125-160 R: To assess causative/contributing factors. the patient will be able to rest and sleep
2. Noted environmental factors affecting for 2-3 hours with no interruptions.
sleep.
HTC 0.41% 0.37-0.47
R: To assess causative/contributing factors. Actual outcome:
3. Ascertained duration of current problem After 8 hours of nursing intervention, the
MCV 82fl 78-100 and effect on life/functional ability. patient was able to take a rest but have
R: To assess degree of impairment. not slept and is still disturbed due to
MCH 28pg 27-31 4. Determined patient’s expectations of feeling of anxiousness and constant
adequate sleep and listened to subjective monitoring of her condition.
reports of sleep.
MCHC 0.34g/dl 0.32-0.34
RDW 11.3% 11.60-16.0
PLT 351k/uL 150-450
Differential
count
Segmenters 52.7 50.0-70.0
 Monocytes 5.1%M 2.0-11.0
Eosinophils 3.2%E 0.0-6.0
Basophils 0.6%B 0.0-2.0

APPENDIX A
DRUGS

Chlorohexidine(orahex)

C: Oral antiseptic
A:This medication is used along with regular tooth brushing/flossing to treat gingivitis, a gum disease that causes red, swollen, and easily bleeding gums. Chlorhexidine belongs to a class of drugs
known as antimicrobials. It works by decreasing the amount of bacteria in the mouth, helping to reduce swelling and redness of the gums and bleeding when you brush. OTHER This section
contains uses of this drug that are not listed in the approved professional labeling for the drug but that may be prescribed by your health care professional. Use this drug for a condition that is
listed in this section only if it has been so prescribed by your health care professional. This drug may also be used to help prevent tooth decay in those who are not able to brush their teeth.
I: weakened immune systems, patients breathing through a ventilator.
C: Chlorhexidine Gluconate Oral Rinse, 0.12% should not be used by persons who are known to be hypersensitive to chlorhexidine gluconate or other formula ingredients.
A: Nausea, stomach upset, skin rash, acute toxicity.
N: gargle it in the mouth and not to swallow
Gargle thrice a day to promote wellness
 Put away from children’s reach

Tramadol
C: Analgesics (centrally acting)
A:Binds to mu-opioid receptors and inhibits reuptake of serotonin which decreases pain
I:Moderate to moderately severe pain
C: not be administered to patients who have previously demonstrated hypersensitivity to tramadol, any other component of this product or opioids. Tramadol hydrochloride is contraindicated in
any situation where opioids are contraindicated, including acute intoxication with any of the following: alcohol, hypnotics, narcotics, centrally acting analgesics, opioids or psychotropic drugs.
Tramadol may worsen central nervous system and respiratory depression in these patients.
N: Assess type, location, and intensity of pain before and 2-3 hr (peak) after administration.
• Assess BP & RR before and periodically during administration. Respiratory depression has not occurred with recommended doses.
• Assess bowel function routinely. Prevention of constipation should be instituted with increased intake of fluids and bulk and with laxatives to minimize constipating effects.
• Assess previous analgesic history. Tramadol is not recommended for patients dependent on opioids or who have previously received opioids for more than 1 wk; may cause opioid withdrawal
symptoms.
• Prolonged use may lead to physical and psychological dependence and tolerance, although these may be milder than with opioids. This should not prevent patient from receiving adequate
analgesia. Most patients who receive tramadol for pain d not develop psychological dependence. If tolerance develops, changing to an opioid agonist may be required to relieve pain.
• Tramadol is considered to provide more analgesia than codeine 60 mg but less than combined aspirin 650mg/codeine 60 mg for acute postoperative pain.
• Monitor patient for seizures. May occur within recommended dose range. Risk increased with higher doses and inpatients taking antidepressants (SSRIs, tricyclics, or Mao inhibitors), opioid
analgesics, or other durgs that decrese the seizure threshold.
• Overdose may cause respiratory depression and seizures. Naloxone (Narcan) may reverse some, but not all, of the symptoms of overdose. Treatment should be symptomatic and supportive.
Maintain adequate respiratory exchange.
• Encourage patient to cough and breathe deeply every 2 hr to prevent atelactasis and pneumonia.

Ketorolac
C: NSAID
A: Interfers with prostaglandin biosynthesis by inhibiting cyclooxygenase path-way of arachidonic acid metabolism; also acts as potent inhibitor of platelet aggregation
I: Moderately sever acute pain
C: hypersensitivity to drugs, concurrent use of aspirin, peptic ulcer disease, I bleeding or perforation, advance renal impairment, prophylactic use before major surgery
A: drowsiness, headache, dizziness, hypertension, rash, pruritus, diaphoresis, excessive thirst, edema, injection site pain, nausea, vomiting
N: Inform px that drug is only for short term pain management
Tell px to minimize GI upset by eating small frequent servings
Advise px to avoid drinking and avoid hazardous activities
Tell px report adverse cns reactions

Enterocoxib
C:CoX 2 inhibitor
A: selective cox 2 inhibitor which inhibits arachidonic acid then inhibits prostaglandin synthesis which reduces pain.
I: CS, pregnancy
C: hypersensitivity, px suffering from stomach ulcer, liver or kidney disease
 A: Weakness
 Fatigue
 Dizziness
 Headache
 Flu-like illness
 Diarrhoea
 Wind
 Nausea
 Indigestion (dyspepsia)
 Stomach pain or discomfort
 Heartburn
 Changes in blood tests related to your liver
 Swelling of the legs and/or feet due to fluid retention (oedema)
 Increased blood pressure
 Palpitations (unpleasant sensations of irregular and/or forceful beating of the heart)
 Bruising
N:Take full course of medication

Bisacodyl
C:Laxative
A: Thought to stimulate colonic mucosa, producing parasympathetic reflexes that enhance peristalsis and increase water and electrolyte secretion, herby causing evacuation of colon.
I: Constipation; bowel cleansing for childbirth, surgery and endoscopic examination
C: hypersensitivity to drug, Intestinal Obstruction, Gastroenteritis, Appendicitis
A: CNS: dizziness, syncope
GI: nausea and vomiting
Metabolic: hypokalemia, fluid and electrolyte imbalances, tetany, alkalosis
Musculoskeletal: muscle weakness
N: Instruct patient to swallow (not chew) enteric coated tablets no sooner than 1 hour before or after ingesting antacids or dairy product
Advise px not to use bisacodyl or other laxatives habitually
Suggest other ways TO PREVENT CONSTIPATION, such as by eating fruits, vegetables, and whole grain to increase dietary bulk and by dinking 8 to 10 glasses of water daily

Midazolam
C:Therapeutic: 
Anti-anxiety agents, sedative/hypnotics
Pharmacologic:
benzodiazepines
A: • Acts at many levels of the CNS to produce generalized CNS depression.
• Effects may be mediated by GABA, an inhibitory neurotransmitter.
I: Preprocedural sedation.
• Aids in the induction of anesthesia and as part of balanced anesthesia.
C:hypersensitivity, Closed Angle Glaucoma, Instability of the Heart or Circulation, Chronic Heart Failure, Constriction of Blood Vessels of the Extremities, Obstructive Pulmonary Disease, Hardening
of the Liver, Long-Term Kidney Problems, Coma, Shock, Pregnancy
A: cough, wheezing, trouble breathing, weak or shallow breathing;
Slow heart rate;
Seizure (convulsions);
Feeling like you might pass out;
agitation, hostility; or
confusion, hallucinations, unusual thoughts or behavior.

Less serious side effects of midazolam may include:

drowsiness, dizziness;
blurred vision;
nausea, vomiting;
nose, sneezing;
mild rash; or
amnesia or forgetfulness after your procedure.
N: Monitor BP, pulse and respiration continuously during IV administration. Oxygen and resuscitative equipment should be immediately available.
• If overdose occurs, monitor pulse, respiration, and BP continuously. Maintain patent airway and assist ventilation as needed. If hypotension occurs, treatment includes IV fluids, repositioning
and vasopressors.
• The effects of midazolam can be reversed with flumazenil (Romazicon).

Esomeprazole
C: Proton pump inhibitor
A: reduces gastric production by inhibiting enzyme activity in gastric parietal cells, preventing transport of hydrogen ions in gastric lumen
I: treatment of gastroesophageal reflux disease (GERD); healing of erosive esophagitis
C: hypersensitivity to drug or its components
A;CNS:headache,dizziness,asthenia,vertigo,apathy,anxiety,paresthesia,insomnia,abnormal dreams
EENT: sinusitis, epistaxis
GI: nausea, vomiting, diarrhea, constipation, abdominal pain
Respi: URTI, cough
Skin: rash, inflammation, urticaria, pruritis, alopecia, dry skin
N: Instruct px to take drug 1 hour before or 2 hours after meal
If px has trouble swallowing capsule instruct to open it, sprinkle pellets into soft food and take right away
Caution to avoid driving and other hazardous activities
Advise female px to tell prescriber if she’s pregnant or breast feeding

Ondanosetron
C: serotonin type 3 (5-HT3) antagonist; antiemetic
A: blocks serotonin 5-ht3 receptor sites in vagal nerve terminals by disrupting CNS chemoreceptor trigger zone
I: to prevent nausea and vomiting caused by moderately emetogenic chemotherapy
C: CNS: headache, dizziness, malaise, drowsiness, fatigue, weakness, extrapyramidal reactions
CV: chest pain, hypotension
GI: constipation, diarrhea, abdominal pain, dry mouth
GU: urinary retention
Respi: bronchospasm
Skin: rash
Other: pain at injection site, shivering anaphylaxis
N: tell px to remove orally disintergrationg tablet
Tell px to instantly report extrapyramidal symptoms
Inform px with phenylketonuria that powder contains phenylalanine
Caution patient to avoid drinking

APPENDIX B
DISCHARGE PLAN
 H health Teachings
• Advised not to do strenuous activity that may re-open catheter site
• Instructed to maintain therapeutic dietary regimen.
• Advised patient to maintain ideal body weight
• Encouraged to do hand washing prior to and after eating and especially every after defecation or urination
• Encouraged to have adequate sleep and rest
• Encouraged to limit going to crowded places to prevent risk of having infection
• Advised to have adequate rest and sleep
• Advised to wear mask in interacting with people with active infection
• Encouraged to sterilize kitchen utensils
 Anticipatory guidance
 Reminded to go to physician after 2 weeks for follow up check up.
 Instructed to report any signs of infection such as foul-smelling discharges, pain, redness, swelling, warmth
 Instructed to report immediately to the physician any signs of bleeding on the site
 Advised to report to the attending physician any side effects and adverse effects of the prescribed medications occur
 Advised S.O. to report any sign of decrease in patient’s mental status
 Advised patient and so to report to the nearest hospital or health care facility when the ff. Signs and symptoms are observed:
o Headache
o Dizziness
o Nausea
o Blurred vision
o Chest pain
o Numbness of extremities
o Difficulty in breathing
o Fatigue
o Fever

 Spirituality, Security & Safety

• Instructed significant others not to leave patient’s side.
 • Instructed significant others to provide time to listen to patient’s concerns and worries.
• Encouraged verbalization of feelings.
• Instructed significant others to assist and provide emotional support to patient to achieve successful coping.
• Encouraged significant others to be available in supporting the patient from his therapy and worries to facilitate her coping.
• Instructed significant others to assist patient with care and hygiene while encouraging the patient to participate activities within her tolerance.
• Instructed significant others to modify arrangement of furniture at home convenient to patient’s situation.
• Advised to make sure that the floor is not slippery to prevent injury.
• Encouraged not to put unnecessary pressure on the wound site.
• Instructed to keep sharp objects away from the affected area.
• Instructed to keep personal belongings within patient's reach by placing them on a bedside table to avoid falls.
• Encouraged to continue strengthening her faith in God in everything that she does and to rediscover herself to know her capabilities and limitations in order to become more productive
and mature
• Encouraged to continue to attend masses and thank the Lord for all the blessings and to ask for His constant guidance.
• Encouraged to surrender worries, anxieties and fear to God.
• Encouraged to continue attending religious organizations and activities.
• Encouraged to keep his faith in God strong through prayer and reading the bible.
• Encouraged to continue attending masses to strengthen his relationship with God.
• Instructed to have adequate lighting and ventilation in her home.
• Instructed to keep away sharp or hazardous materials from patient.

 Medications
 instructed patient to take medication at the right dosage, right time, right route and right frequency
 informed patient about the indication, contraindications and adverse effect of the medication
 advised to comply to his take-home-medications
 Explained the importance of religiously completing the course of pharmacologic therapy
 Encouraged strict compliance to medication therapy advised by the physician.
 Instructed to check the expiry of the drug before purchasing it or taking it.
 Instructed not take any OTC medications without consulting the physician
 Instructed not to overdose antibiotic meds because it can cause superinfections
 Taught about the signs and symptoms of superinfection such as black hairy tongue, cheesy mass on the tongue, anorectal itching, vaginal itching and a high grade fever.
 Encouraged to eat probiotic foods such as yogurt and Yakult to prevent superinfection

 Incision Care
• Practice proper hand washing before and after handling the affected area.
• Instructed to minimize contact of site to any surface.
• Instructed to keep incision clean and dry.
 • Drink plenty of fluids and increase your fiber intake so your bowels are soft and easy to move.
 Avoid touching the site with bare hands.
 Advised not to exert too much pressure on the catheter site to prevent any complications

 Nutrition
• Instructed to adhere with the type of diet prescribed by the doctor
• Encouraged to eat foods rich in protein such as meat and fish.
• Encouraged to take food rich in Vitamin C such as guava, orange, and other citrus fruits to promote wound healing.
• Encouraged the patient to eat low salt, low fat, low cholesterol diets.
• Maintained a well balanced diet and not to skip meals.
• Instructed to avoid foods rich in fats, salt and sugar such as processed foods, canned goods, salted fish, carbonated drinks, oily foods.
• Instructed to avoid eating carcinogenic foods like grilled foods
• Encouraged to maintain established diet in the hospital
• Encouraged that calories must be supplied by carbohydrates and fats to prevent wasting.
• Taught patient about sources of dietary fiber such as raw fruits, vegetables and whole grain breads and cereals.
• Instructed to avoid caffeine, alcohol and tobacco intake.

 Environment
• Instructed to keep surrounding clean and safe.
• Encouraged to have a quiet and calm environment conducive for sleep and rest, and relaxation to promote faster healing process.
• Instructed SO to provide environment in which client can talk freely about feelings, fears and sensation to provide psychological support.
• Instructed to rearrange furniture in the house that may block the client’s pathway to prevent falls and injury.
• Instructed significant others to transfer patient to a room away from dust and allergen, if in case the patient's room is facing the public road.
• Encouraged significant others to provide a calm and quiet environment conducive for rest and sleep.
• Advised so to lessen stimuli by dimming the room and avoiding noise to facilitate proper rest of the patient.
• Instructed significant others to provide patient room with proper lightning.
• Instructed SO to provide patient a well-ventilated room.