SOUTHVILLE INTERNATIONAL SCHOOL AND COLLEGES

1281 Luxembourg St. corner Tropical Ave., B.F. Homes International Las Piñas City

PATIENT-CENTERED CARE REPORT

A Clinical Ward Case of a Pediatric Patient with Pelvic Inflammatory Disease

In Partial Fulfillment of the Requirements for the course

NCM 118 NURSING CARE OF CLIENTS WITH LIFE-THREATENING CONDITIONS,
ACUTELY ILL/MULTI-ORGAN PROBLEMS, HIGH ACUITY AND EMERGENCY
SITUATION RLE

Submitted by:

Vasquez, Mari Sheanne M.

Section:

BSN 4-A | RLE A3

Submitted to:

Ms. Madonna C. Beler

Date Submitted:

November 7, 2022

Bachelor of Science in Nursing

PART I

A. General Information
Name of Student: Mari Sheanne M. Vasquez
Year Level: BSN 4-A | RLE A3
Clinical Area: Ospital ng Muntinlupa - Ward
Clinical Instructor: Ms. Madonna C. Beler
Date of Rotation: October 24 & 25, 2022

B. Objectives
After working on this PCCR, I was able to:
1. Identify the presenting signs and symptoms of the patient with Pelvic
Inflammatory Disease.
2. Illustrate and understand the pathophysiology of Pelvic Inflammatory
Disease.
3. Develop a comprehensive nursing care plan that is applicable to the
patient diagnosed with Pelvic Inflammatory Disease.

PART II

A. Case Description
Patient J.M.L.P is a 16-year-old female pediatric patient residing at B26 L1 Atis
Street Almanza II, Las Piñas City. Prior to her admission, the patient came in with a
primary complaint of abdominal pain. The patient had 3 days history of fever with
vomiting and hypogastric abdominal pain, Hence, consulted and was given Omeprazole
and Cefuroxime. The patient’s pertinent physical examination findings show that she has
a tender hypogastric abdomen. Her attending physician is Doctor Dory Rustria Buena.
She was admitted on September 27, 2022, with an admitting diagnosis was T/C Acute
Abdomen. After numerous tests, her final diagnosis was Pelvic Inflammatory Disease.
Patient J.M.L.P’s surgical procedures were S/P Exploratory Laparotomy drainage of
intraperitoneal abscess; intraperitoneal lavage under spinal anesthesia

B. Additional Information/Course in the Unit

Since patient J.M.L.P's chief complaints are vomiting and abdominal pain. An
ultrasound of the whole abdomen was done which revealed that there are normal scans of
the liver, gallbladder, pancreas, spleen, and kidneys.

On September 28, 2022, patient J.M.L.P’s chest x-ray findings revealed that there
are hazy densities in the right upper lung (Remarks: PTB, right upper lung). The rest of
the chest structures are unremarkable. On October 7, 2022, patient J.M.L.P’s chest x-ray
preliminary readings are as follows: (1) Follow-up to the 09/28/2022 study shows the
development of left lower lung pneumonia and small left pleural effusion, (2) The right
upper lobe PTB of undetermined activity is unchanged, (3) The rest of the lungs are clear,
and lastly (4) The heart remains unenlarged. That same day, patient J.M.L.P’s urinalysis
test result showed that her urine is color yellow, its appearance is hazy, PH level is 5.0,
protein is +2, ketones is +3, and sugar is found negative. The pus cells are 1-2/HPF, Red
blood cells are 0-1/HPF, Epithelial cells are moderate, Bacteria are rare, and Mucus
threads are none.

On September 30, 2022, patient J.M.L.P's ultrasound of the appendix findings are
as follows: (1) Focused scanning of the right lower abdomen was done, (2) The right
lower abdominal region is partially obscured overlying gas, (3) There is small free fluid
in the right paracolic gutter, (4) A large fluid collection with sediments is also seen in the
pelvis, (5) The appendix was not visualized.

On October 2, 2022, patient J.M.L.P's Complete Blood Count (CBC) results

showed that she has a low hemoglobin count of 8.5. She also has a low Hematocrit count
of 27.8. Her WBC count is 11,900 which is above the normal range. Lastly, she has a low
RBC count of 3.57. Another Complete Blood Count (CBC) test was done last October
15, 2022. Her CBC laboratory results showed that she has a low hemoglobin count of 113
which is below the normal range of 125-160. She also has a low Hematocrit count of 0.36
which is below the normal range of 0.38-0.50. Her RBC count is 4.1 which indicates that
it is below the normal range of 4.5-5.5. Lastly, patient J.M.L.P’s platelet count increased
to 547 which is above the normal range of 15–350.

On October 22, 2022, patient J.M.L.P is scheduled for wound closure of her S/P
Exlap. A surgical safety checklist has been done. The pre-operative checklist indicated
that patient J.M.L.P has been on NPO since 2:00 am. She was also given medications
prior to the procedure such as Omeprazole 40 mg IV and Ondansetron 40 mg IV at 8:00
am. The patient’s blood type is AB+ and the vital signs of the patient were as follows:
BP: 100/60mmHg, Temp: 36.3℃, PR: 70 bpm, and RR: 20bpm. In addition, a Humpty
Dumpty Scale was performed and the total result was 9 which indicates that patient
J.M.L.P is at low risk. Moreover, a morse falls scale assessment tool was also performed
and the total result was 20 which indicated that the patient is at no risk. After the surgery,
an instrument and sponge count sheet was accomplished which indicated that it was all
complete and correct.

On October 2, 2022, patient J.M.L.P was scheduled for an enterolysis and

omental biopsy. The operative diagnosis was pelvic abscess secondary to pelvic
inflammatory disease. General anesthesia was done on her and it was noted that the
sponge and instrument count was complete. The operation started at 9:30 am and ended
at 12:00 pm. The intra-operative findings were as follows: (1) Omental cake overlying
the entire abdomen, (2) Dense adhesions noted in between bowel to omentum and bowel
to bowel, (3) Abscess collection at the pelvis and right paracolic gutter, (4) Interloop
abscess, (5) Cecum and ileocecal junction unremarkable, (6) Dilated right fallopian tube,
and lastly (7) Ruptured right ovary. Moreover, the other following procedures that were
completed were as follows: (1) the patient was in a supine position received from OB
service on the ongoing procedure, (2) IOF noted, (3) Entorolysis was done, (4) Copious
washing done, (5) Hemostasis, (6) JP drain inserted and secure with Silk 2-0, and lastly
(7), the procedure of OB service continued.

On that same day which was on October 2, 2022, patient J.M.L.P also underwent
exploratory laparotomy, evacuation of pelvic abscess; peritoneal lavage. The operative
diagnosis was a pelvic inflammatory disease; T/C pelvic tuberculosis with a secondary
bacterial infection. The operation started at 8:55 am and ended at 12:50 pm. Spinal
anesthesia was done to her and it was noted that the sponge and instrument count was
complete. The intra-operative findings were as follows: Upon opening, evacuated 800cc
purulent, foul-smelling fluid. The bowels and omentum were densely matted together,
with notes of multiple whitish punctate lesions on the surface. On further exploration, the
uterus was seen, its surface exhibited the same whitish purulent material. The left ovary
and fallopian tube were friable and densely adherent to each other and the left pelvic
sidewall. The right ovary and fallopian tube were likewise friable and hardly
distinguishable from each other. There was a 0.5 cm point of rupture from the surface of
the ovary near the uterotubal junction, and it was seen exuding the same purulent
material. The omentum and bowels were likewise densely adherent to the right adnexa.
The right fallopian tube was dilated to approximately 6 x 2cm with a fimbriated end
noted upon adhesiolysis.

Moreover, the other following procedures that were completed were as follows:
(1) Patient was placed in a supine position under spinal anesthesia, (2) Bladder was
catheterized aseptically, (3) Asepsis-antisepsis was done. Sterile drapes were placed, (4)
Midline infraumbilical vertical incision was done and carried down to the peritoneum, (5)
Evacuation of the pelvic abscess was done, (6) Abdominopelvic organs inspected; Uterus
was identified, and both adnexae were visualized but were densely adherent to each other,
(7) Pathologic right ovary and dilated right fallopian tuber were identified, (8) Patient
was referred intraoperatively to Surgery Service for adhesiolysis and Omental Biopsy, (9)
Hemostasis assured, (10) 2 liters of Peritoneal washing was done, (11) Abdomen closed
in anatomic layers after complete sponge, instruments and needle count, (12) Abdomen
closed by layers, Peritoneum: continuous using Novosyn 1-0, Fascia: continuous
interlocking using Novosyn 0, Subcutaneous: continuous using Novosyn 2-0, and Skin:
subcuticar using Novosyn 4-0, and lastly (13) Final asepsis-antisepsis done. Sterile
dressing was applied.

On October 9, 2022, the gram stain test result revealed that the pus cells are many.
While the is no presence of epithelial cells. The test results also showed that
gram-negative bacilli are many while the gram-positive cocci in pairs and in chains are
rare. For the medical nutrition therapy form for pediatrics, it showed that the scoring of
nutrition risk-related risk factors of patient J.M.L.P are depressed albumin (1 pt) and
weight below or above BMI (1 pt) which has a total of 2 points indicating she is at
moderate risk. Her nutritional status is severe malnutrition. Therefore, the dietitian's
recommendations are as follows: BMI - 13.0 severe thinness, Desirable body weight -
49kg, Total energy requirement - 2,000 calories CHO: 300g CHON: 75g, and Fat: 50g,
Add oral nutrition supplement of pediasure plus 75 scoops in 250 ml water TID
equivalent of 952 calories.

On October 11, 2022, an aerobic culture and susceptibility test result showed that
it is positive for Klebsiella pneumoniae. The antibiotics that patient J.M.L.P is susceptible
are as follows: (1) Levofloxacin, (2) Doripenem, (3) Gentamicin, (4)
Piperacillin-Tazobactam, (5) Cefoxitin, (6) Cefepime, (7) Ertapenem, (8) Imipenem, (9)
Meropenem, and lastly (10) Amikacin. On October 18, 2022, the 7th-day antimicrobial
form revealed that the antimicrobial present is Piperacillin and Tazobactam.

On October 13, 2022, the ultrasound report results revealed that there is a
normal-sized anteverted uterus with a thin endometrium, the ovaries are both normal, and
lastly the transabdominal scan of the fascial layer showed no dehiscence throughout the
length of the incision. The final histopathologic diagnosis showed that part of her
omentum pleural fluid there is chronic granulomatous inflammation with langhan’s type
giant cell and caseation necrosis consistent with tuberculosis etiology (omentum) as well
as blood elements. On October 10, 2022, patient J.M.L.P’s bacteriology test result on her
abdomen showed that there is no acid-fast bacilli seen.

Based on the doctor’s order sheet of patient J.M.L.P, her diet was ordered as DAT
once fully awake. On October 22, 2022, the patient's medications ordered were as
follows: Conzace CUP OD, Omina TAB BID (NON-PNR), Diphendyramine 10 mg -
mid + post-NN (ALBUMIN TRANSFUSION), Pediasure Plus 75 scoops in 250 ml H20
TID, Ketorolac 30 mg IV Q8 RTC x 6 dose, Tramadol 25 mg IV for breakthrough pain
Q4 PRN, Celecoxib 100mg cap (TS - 10/25) Q8 RTC x 3 days, Ondansetron 4mg N x N
+ V Q8 PRN, HRZE (Anti-TB meds) 3 tabs ODAC, Piptazin 3 grams IV Q6, and
Amikacin 150 mg IV Q6.
 C. Holistic Nursing Brief and Pathophysiology

Final Diagnosis: Pelvic Inflammatory Disease

Pelvic inflammatory disease (PID) is a polymicrobial infection of the upper genital tract.
It primarily affects young, sexually active women. The diagnosis is made clinically; no single
test or study is sensitive or specific enough for a definitive diagnosis. Pelvic inflammatory
disease should be suspected in at-risk patients who present with pelvic or lower abdominal pain
with no identified etiology, and who have cervical motion, uterine, or adnexal tenderness.
Chlamydia trachomatis and Neisseria gonorrhoeae are the most commonly implicated
microorganisms. However, other microorganisms may be involved such as E. coli, Group B
Strep, H. influenza, S. aureus, and S. pneumoniae which are the rarely implicated
microorganisms. The spectrum of disease ranges from asymptomatic to life-threatening
tubo-ovarian abscess. Patients should be treated empirically, even if they present with few
symptoms. Most women can be treated successfully as outpatients with a single dose of a
parenteral cephalosporin plus oral doxycycline, with or without oral metronidazole. Delay in
treatment may lead to major sequelae, including chronic pelvic pain, ectopic pregnancy,
peritonitis, perihepatitis (Fitz-Hugh-Curtis syndrome) sepsis, and infertility (Gradison, 2012).

D. Nursing Assessment and Observation

Student nurse first encountered patient J.M.L.P on October 24, 2022, at 12 noon
inside her room at station 7 of the ward unit in Ospital ng Muntinlupa (OSMUN).

Vital signs taken (12 noon)

BP: 110/80 mmHg
T: 36.7℃
PR: 80 bpm
RR: 20 bpm
O2: 98%

Upon entering the patient’s room, the student nurse observed that the status of the patient
was at high risk and she was on bed rest. The student nurse noted that the patient was on HL
(Heplock) at her left brachial artery. The student nurse also noted that the patient has a suctioned
JP drain that has blood with a little amount of pus. The patient verbalized that she was unable to
sleep well last night due to the pain and discomfort from her recent wound closure surgery. The
patient stated that her pain score was 8 out of 10. Therefore, she was having difficulty
ambulating and had a limited range of motion. The patient also verbalized that she was having
difficulty defecating for 3 days already due to the pain from her incision site. With this, the
student nurse instructed the patient to do post-operative exercises such as proper body alignment
and mechanics, deep-breathing exercises, moving the feet, dangling the legs, and ambulation.
These physical activities can help promote defecation, minimize pain, and prevent post-operative
complications. The student nurse also assisted the patient in a high backrest position and
observed that the patient showed a facial grimace and a guarding behavior meaning she was in
pain.
On the second day which was on October 25, 2022, the student nurse first performed vital
signs at 8 am.

Vital signs taken (8 AM)

BP: 110/80 mmHg
T: 36.5℃
PR: 100 bpm
RR: 20 bpm
O2: 97%

After performing vital signs, the student nurse interviewed patient J.M.L.P and obtained
 data regarding her disease. Upon follow-up, the student nurse asked the patient if she was able to
perform the post-operative exercises instructed to her. The patient verbalized that she was able to
perform the physical activities but with slow and limited movement. The patient stated that she is
not experiencing any dizziness, nausea, or vomiting. J.M.L.P was awake, alert, and oriented to
person, place, and time. The student nurse noted that the patient has a water limit of 1.5L due to
her pleural effusion in the lungs. The student nurse also noted that the patient has a clear vision,
however, she has weak extremity strength on both her right and left upper and lower extremities.
Moreover, the student nurse auscultated the patient’s heart sounds which showed that she has
normal heart sounds and a regular rhythm. The student nurse also observed that the patient’s skin
color is pale. The student nurse also auscultated for the patient’s breath sounds and respirations
which showed that she has no respiratory distress. However, the patient’s lungs have bilateral
crackles sounds due to her pneumonia. The patient also verbalized that she has no cough but has
little amount of sputum which is color yellow. Lastly, the student nurse auscultated the patient’s
abdomen and noted that her bowel sounds are normal. The student nurse also palpated the
patient’s abdomen and noted that it is soft, non-tender, and non-distended. However, due to the
pain from her post-surgery, she has the inability to defecate, therefore, she is constipated. The
patient verbalized that she was able to urinate normally. However, her urine color is amber due to
her antibiotic medications. In addition, patient J.M.L.P's level of consciousness is normal and has
an intact thought process.

PART III

A. Current Plan of Care

Nursing Diagnosis #1: Acute pain related to three days post-op wound closure as evidenced by
impaired physical mobility

CUES GOALS/PLAN INTERVENTIONS RATIONALE EVALUATION

Subjective: Short term: ● Provide rapport ● To gain Short term:

● “Masakit After the end of my shift of with the patient. trust and Goal partially met.
yung sa may nursing interventions, the full Patient was able to:
tahi ko pag patient will be able to: cooperation ● Gain knowledge
gumagalaw ● Gain knowledge in during the in relieving pain
ako sobrang relieving pain as pain as evidenced by
kumikirot” evidenced by alleviation expected
as expected outcome: periods. outcome:
verbalized ○ Use of ○ Use of
by the relaxation ● Monitor skin ● These are relaxatio
patient. skills color and usually n skills
temperature and altered in
Objective: vital signs. acute pain.
 ● (+) Facial ○ Deep ○ Deep
Grimace breathing ● Determine and ● Acute pain breathing
● (+) exercises document the is that exercises
Discomfort ○ Proper presence of which ○ Proper
● Verbal positionin possible follows an positioni
report of g pathophysiologi injury, ng
acute pain ○ Demonstra cal and trauma, or ○ Demonst
● Pain score tes psychological procedure rates
of 8 out of measure to causes of pain. such as measure
10 due to increase surgery, or to
incision site mobility occurs increase
● (+) ○ Adequate suddenly mobility
Guarding rest with the ○ Adequat
behavior periods onset of a e rest
● Unable to ● Decreased level of painful periods
ambulate pain from 8/10 to condition. ● Decreased level
● Very limited 2/10 of pain from 8/10
and slow ● Instruct patient ● To reduce to 2/10
movement Long-term: to use pain,
● Weak At the end of my rotation of supportive especially Long-term:
extremity nursing interventions, the materials such when Goal not met. Patient was
strength patient will be able to: as abdominal moving. able to:
● Report pain is binder. ● Report pain is
V/S taken as follows: relieved and relieved and
BP: 110/80mmHg controlled with ● Note the ● This can controlled with
T: 36.7℃ positive coping location of influence positive coping
PR: 80 bpm mechanisms surgical the amount mechanisms
RR: 20 bpm ● Move or perform incisions. of ● Move or perform
O2: 98% physical activity postoperati physical activity
independently ve pain independently
● Increase strength experience ● Increase strength
and function of the d (for and function of
affected body part example, the affected body
vertical or part
diagonal
incisions
are more
painful
than
transverse
or
S-shaped)

● Obtain the ● In order to

client’s fully
assessment of understand
pain to include the client’s
location,
 characteristics, pain
onset, duration, symptoms.
frequency,
quality, and
intensity.
Identify
precipitating or
aggravating and
relieving
factors.

● Perform pain
assessment each ● To
time pain demonstrat
occurs. e
improveme
Document and
nt in status
investigate or to
changes from identify
previous reports worsening
and evaluate the of
results of pain underlying
interventions. condition/d
eveloping
complicatio
ns.
● Identify ways to
avoid or ● Splinting
minimize pain. the incision
during
coughing,
performing
post-operat
ive (deep
breathing)
exercises,
keeping the
body in
good
alignment
and using
proper
body
mechanics,
and resting
between
activities
can reduce
the
occurrence
 of muscle
tension or
spasms, or
undue
stress on
the
incision.

● Provide ● Pain
pharmacologic manageme
pain nt using
management as pharmacolo
ordered. gic
methods
involves
using
opioids
(narcotics),
nonopioids
(NSAIDs),
and
analgesic
drugs.

● Promote and ● To
facilitate early stimulate
ambulation contraction
when possible. s of the
Aid with each intestines
initial change: and prevent
dangling legs, post-operat
sitting in a ive
chair, and complicatio
ambulation. ns.

Nursing Diagnosis #2: Constipation related to three days post-op wound closure as evidenced
by hard stools and inability to defecate

CUES GOALS/PLAN INTERVENTIONS RATIONALE EVALUATION

Subjective: Short term: After the end ● Assess mobility ● Reduced Short term:
“Natatae ako pero of my shift of nursing and level of physical Goal not met.
tuwing lalabas na interventions, the patient physical activity. activity can Patient was able to:
papasok ulit kasi will be able to: affect ● Demonstrate
masakit pag umiiri ● Demonstrate peristalsis and improvement
ako dahil sa tahi improvement in promote in bowel
ko” as verbalized by bowel elimination constipation. elimination
the patient. ● Verbalize relief Mobility may ● Verbalize
from the be difficult in relief from the
Objective: discomfort to the first few discomfort to
● (+) Facial defecate days after defecate
Grimace surgery.
● (+) Long-term: Long-term:
Discomfort At the end of my rotation of ● Assist the patient ● Walking and Goal not met. Patient
● Pale skin nursing interventions, the in doing physical mild physical was able to:
color patient will be able to: activity and activity ● Establish or
● Pain score ● Establish or regain exercise. stimulate regain return
of 8 out of return normal peristalsis that normal pattern
10 due to pattern of bowel promotes of bowel
incision functioning as defecation. functioning as
site evidenced by no Allowing evidenced by
● (+) episodes of painful individuals to no episodes of
Guarding defecation be physically painful
behavior ● Patient maintains active defecation
● Unable to soft, formed bowel facilitates ● Patient
ambulate movements free of normal bowel maintains soft,
● Weak in pain and straining function, formed bowel
appearance enhances movements
● Limited appetite, and free of pain
ROM improves the and straining
● Inability to quality of life.
defecate
for 3 days ● Unless ● A sitting
contraindicated, position with
V/S taken as encourage the knees flexed
follows: patient to use the straightens the
BP: 110/80mmHg bathroom. For rectum,
T: 36.5℃ bedridden enhances
PR: 100 bpm patients, assist abdominal
RR: 20 bpm the patient in muscles, and
O2: 97% assuming a facilitates
high-Fowler’s defecation.
position with
knees flexed.

● Administer ● Can be
medications beneficial in
(stool softeners the short term
and laxatives) as to assist with
prescribed. initiating first
bowel
movement
while patient is
 making
lifestyle
choices to aid
in constipation
prevention.

● Administer ● Patient may

painkillers as require
needed. additional pain
management
following
surgery when
planning to do
activities like a
trip to the toilet
to open their
bowels.

● Perform ● Provides the

abdominal nurse with
assessment. objective data
Palpate to check for treatment.
for distention
and auscultate
for bowel
sounds.

PART IV

A. Recommendation for Improvement

Adolescents are highly vulnerable to acquiring Sexually Transmitted Diseases (STDs)
and their complications because of biological and behavioral factors. Therefore, special attention
should be given to adolescents. Before discharge, I would educate my patient about the risks of
acquiring an STD and its relation to Pelvic Inflammatory Disease (PID). Adolescents often fail
to recognize the dangers of high-risk sex behaviors and do not seek medical advice about such
behavior. Age-appropriate and developmentally appropriate counseling strategies are needed.
Moreover, I would educate my client on the use of condoms or other barrier contraceptives. The
use of barrier contraceptives by sexually active teenagers is frequently inconsistent. Early and
effective intervention for adolescents will reduce their likelihood of acquiring STDs and,
consequently, should diminish PID and other complications of STDs. In addition, I would advise
my patient to use a hot water bottle or a heating pad (set on low) on her belly for pain. I would
also encourage her to eat calcium-rich foods including dark green leafy vegetables, and
antioxidant-rich food including fruits and vegetables. It is important to also reduce or eliminate
trans fatty acids and void coffee and other stimulants, alcohol, and tobacco. Lastly, I will remind
her to drink 6 to 8 glasses of filtered water daily and take multivitamins or probiotic supplements
which may help the maintenance of her immune health.
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