Angeles University Foundation

Mac Arthur Highway, Angeles City, Pampanga

First Semester, AY 2022-2023

Case Analysis:

Pelvic Organ Prolapse and Its Repair

Submitted by:
CORDOVA, Louisa Ann
DEL ROSARIO, Catherine Joy
DELA PEÑA, Merson
FLORES, Lakisha
MACAPAGAL, Denzel Matthew
PAMINTUAN, Jenica Mei

October 1, 2022

1
 Table of Contents

Introduction 3

Personal History 4

Family health illness history 6

History of past illness 8

History of present illness 9

Physical examination 9

Diagnostics and Laboratory Procedures 11

Anatomy and Physiology 21

The patient and her illness 23

Synthesis of the disease 26

Nursing Care Plans 29

Medical managements 39

Surgic see al managements 53

Nursing managements 55

Client’s daily progress chart 58

Discharge planning 63

Summary of findings 65

Conclusion 65

Recommendation 66

Learnings derived 66

Appendices 67

References 70

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● INTRODUCTION
Pelvic Organ Prolapse (POP) is a condition where there is a protrusion of pelvic
organs into or out of the vaginal canal. These organs usually include the uterus, rectum, or
the bladder (Women’s Health, 2021). Currently, there are different ways to classify pelvic
organ prolapse. One way is classifying them based on the prolapsed organ. This
classification includes: Cystocele (prolapsed bladder), Rectocele (prolapsed rectum),
Enterocele (prolapsed intestines), Uterine (prolapsed uterus), and Vaginal vault (prolapsed
vagina). Another is classifying them based on severity: Stage 1 means that organs are still
supported by the pelvic floor, however, prolapse is very mild; Stage 2 means that the organs
have began to fall but are all still inside the vaginal canal; Stage 3 means that pelvic floor
organs are visible outside the vaginal canal; Lastly, Stage 4 means that the organs have
compLely fallen through the vagina. According to the National Association For Continence
(n.d), the medical management for POP varies depending on its severity. Individuals who
have Stage 1 or Stage 2 POP, and whose daily activities are not affected by the symptoms
of their condition, medical management such as surgeries are usually considered elective.
Rather, individuals who are in this stage are instructed to change their diet or lifestyle to help
them manage their symptoms. On the other hand, individuals who are in the later stages of
POP, surgeries are usually deemed necessary. This is because Stage 3 and Stage 4 POP
comes with debilitating symptoms that may disrupt an individual’s activities of daily living.

According to the Association of Pelvic Organ Prolapse Support (n.d), statistics

regarding the global prevalence of POP in women ranges from 3% to 68%. However, the
majority of statistics available today often estimate a 50% prevalence in women, which
usually peaks at ages 60-69 years old. In the US, 300,000 surgeries take place annually,
and 1/3 of women who are diagnosed with pelvic organ prolapse are said to undergo
multiple surgeries. While there is available data on the global prevalence of Pelvic Organ
Prolapse, most researchers recognize the undeniable inaccuracy and scarcity of statistical
data regarding this disease. Lack of routine Pelvic Organ Prolapse screening, and stigma
that comes with the often considered embarrassing symptoms of Pelvic Organ Prolapse are
said to be two of the major contributing factors why accurate and abundant data regarding
POP is still lacking up to this day. On the other hand, national and local data regarding
Pelvic Organ Prolapse in the Philippines is not readily available.

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 The conduct of this study shall only be for the sole purpose of achieving the following
objectives mentioned below:
To advance the knowledge and understanding of the student nurses about the stage
III pelvic organ prolapse and to compare text-book drawn ideas and concepts with real-life
situations.
To develop better understanding and awareness on the needs and condition of
patients with the same condition and enhance the appropriate nursing interventions that
could be carried out as appropriate to the condition in focus.
To identify key issues presented by the subject’s case which could be further studied
and reinforced by future progressions and breakthroughs in the nursing practice.

● PERSONAL HISTORY
Patient L is a 73 year old married female and natural born Filipino citizen. She was
born on December 12, 1948. She is currently living in Mactan st. Claro M. Recto, Angeles
City, Pampanga with her husband along with her daughter and grandchild. She was
admitted on September 13, 2022 in a private tertiary health facility in Angeles City with chief
complaint of introital mass. After four days of confinement, she was discharged on
September 16, 2022 with a final diagnosis of G3P3 (3003) Pelvic organ prolapse stage III,
S/P anterior and posterior colporrhaphy under spinal anesthesia, Hypertension St2,
DMT2, Dyslipidemia.

Patient L is the older child among the two children of mr. and mrs. M. Her father
being the breadwinner of the family had tried many jobs from being a laborer, helper, ice
drop vendor and security guard while her mother was a housewife. She was born in San
Fernando, Pampanga but grew up in Angeles City where they permanently held residence
since 1958. Patient L attended her elementary education in one of the public elementary
schools in Angeles City along with her other sibling. After graduating, she received a
one-year scholarship in high school. She finished her secondary education in 1969 in one of
the universities in Angeles City with the help of her uncle who was a businessman.

In 1971, she worked as a sub-teacher in one public school in Angeles City. But
according to her, a year later, she decided to resign because her salary was not enough for
her and she really doesn't want to pursue teaching. While looking for another job, Patient L
helped her mother, who at that time accepted laundry from their neighbors. In 1972, she

4
found a job at a furniture shop where she worked as a bookkeeper for a year before
deciding to look for another job. And in 1973, she worked as a cashier in a restaurant. In that
same year, she met her first boyfriend, the restaurant manager and the restaurant owner's
son. After being in a relationship for 3 years, they decided to get married on April 26, 1976.
The couple started to build their family and lived in the house of her husband’s parents. After
getting married, patient L stopped working and took care of their children. Her husband
continued working in the family-owned restaurant. The couple was blessed with three
children. Her eldest daughter was born in 1977. She is a graduate of BS Biology in a
well-known private university in Angeles City. In 1979, their second child was born and
finished BS Metallurgical Engineering at the University of the Philippines. Their youngest
son was born in 1982. He graduated in University of Santo Tomas, BS Computer Science.

It was in 1996 when Patient L’s husband found a job in a well-known industrial
company where he worked as a welder for 12 years until he decided to retire at the age of
63 in 2010. Patient L, on the other hand, found a job in 1998 in a publishing house where
she initially worked as a secretary until she got promoted as the production manager in
2002. She continued to work for the company for 16 years until she decided to retire last
2014 at the age of 65. Her husband retired earlier than Patient L and received a retirement
pay which he saved for their personal expenses. When Patient L retired in 2014, she
received a lump sum of money which was deposited in the bank. In addition, the couple are
both members of the Social Security System, and received a pension monthly.

The family's daily expenses are mostly taken care of by their children since they live
with them. According to Patient L, their children divide the expenses incurred among them.
Both Patient L and her husband have their senior citizen's cards which are used when
purchasing their maintenance medications. In terms of expenses in the hospital or
medications, they are entitled for discounts with their PhilHealth membership. According to
Patient L, her expenses for her medications and hospitalizations are not a problem since her
second and third children send her money to support their finances for her medical
management.

According to Patient L, since she lives near school and the barangay health center,
she built a little sari-sari store to also help her to get past her boredom. She stated that she
has a monthly income of 15,000 pesos from her sari-sari store and also receiving a pension

5
of 9,000 pesos as a retired high school teacher. Also, their average monthly household
expenses are close to the following estimates. Their monthly electricity bill is around Php
3,000-4,500, Water bill is around Php 500-1000. Food is budgeted at Php 5,000-7,000 per
month.

They also pay for their internet connection for Php 1300 per month. Whatever
amount they have in excess every month is deposited in the bank and is used for medical
emergencies and unexpected expenses. Patient L was born to a family affiliated with the
Roman Catholic Church. She practices the same faith inculcated in her by her parents. She
attends mass every Sunday with her family and follows the system of belief of the Catholic
Church. But due to the pandemic, Patient L now attends mass on television. Up to this time,
the family is still guided by the teachings of the Catholic Church.

Although Patient L and her husband were born and raised in the province, they did
not frequently visit traditional healers ("mananawas", "manghihilot", "herbolarios*). They only
sought the assistance of "manghihilot" in cases of simple strains or sprains and “naipitan ng
ugat”. They frequently wanted the advice of a medical doctor in the management of illnesses
especially those not resolved by home treatment and over-the-counter medications. The
family also uses over-the-counter (OTC) medications for common illnesses like paracetamol
(Biogesic) for fever and headache, loperamide for diarrhea, nasal decongestants like
Neozep. Ibuprofen as a pain reliever and lagundi for cough. When it comes to antibiotic use,
they consult the doctor first. For illnesses they cannot manage at home, they seek medical
treatment at a doctor's clinic but if the medical need is perceived as an emergency by the
family, they go straight to the hospital. They are aware of the presence of a barangay health
center within their community but opt to seek medical help directly from a doctor.

Patient L’s diet is usually composed mainly of vegetables and chicken, sometimes
she still eats pork and beef. Patient L did not engage in any vices such as smoking and
drinking. She stated that she doesn’t like the smell of cigarette smoke. She stated that
although her husband is a smoker, she has always reminded him to smoke outside the
house to prevent the other family members from being exposed to secondhand smoking.
When it comes to household chores, they do not have a house helper. Patient L still does
simple chores like sweeping their yard in the morning, cooking meals and washing the
dishes. On the other hand, they have an automatic type of washing machine so they do not

6
have any problems when it comes to laundry. As for most married couples who are
advancing in age, Patient L and her husband rise up early in the morning as early as 5:30
am. At 6:00 am the couple would usually have breakfast together with their children who
have to be early for work. She then watches television for most hours of the day. She is very
fond of watching the news and gets to know about all the issues concerning not only our
country but also that of the world. She said that watching and listening to the news sharpen
her thinking abilities. After resting for a while after lunch, she takes her afternoon nap until
about 2 o'clock in the afternoon. Upon waking up, she watches television shows and news
reports again since according to her, she avoids straining her feet. At 6:00 pm, she eats
dinner with her husband since their children usually arrive at around 7:00 in the evening.
They watch a couple of television series before going to bed at around 8:00 in the evening.
As a pastime, Patient L would usually talk to her sibling who is in Taiwan via video call with
the use of the internet.

With the help of her husband’s parents they were able to buy a lot in Claro M. Recto,
Angeles City where they first built their house made of wood. The family has resided there
since 1983. In 2000, with the help of her siblings, they were able to make renovations with
their house and as described by Patient L, the family's humble house is a bungalow made of
concrete and wood having three bedrooms, a living room, dining room, a kitchen and a two
toiL facility. The house has a total lot area of 160 square meters. The house has wide
windows which provide for adequate light and ventilation. During the night, the house is also
well-lighted since they utilize fluorescent bulbs. The house is also located near a health
center, barangay hall, a chapel, and a public school. The nearest health care facility aside
from the health center, however, is a tertiary private hospital along McArthur Hi-way roughly
10-15 minutes walk from their house. The family's water source comes from nawasa while
the electricity is supplied by the local electric company.

7
● FAMILY HEALTH

Figure 1. Family Health Genogram of Patient L

In the genogram presented, you can see that Patient L is in the center connected to her
husband. With the legend above, you can interpret that Patient L has Hypertension and
Diabetes Mellitus while her husband doesn't have any. Patient L’s Hypertension and
Diabetes Mellitus is a genetic condition that she inherited from her late father and was also
diagnosed with colon cancer which is the cause of his death, alongside with this it was also
from her late Grandfather. Along with Patient L’s father, her uncle was also diagnosed with
hypertension which he passed into his only son. Patient L’s only brother is recently
diagnosed with colon cancer. Patient L and her husband have three children, (eldest to
youngest is from left to right respectively). Patient L’s eldest daughter is also diagnosed with
hypertension while her husband is diagnosed with Diabetes Mellitus. Patient L’s second
child inherited both Hypertension and Diabetes Mellitus. Patient L’s youngest son is
diagnosed with Lupus and only Patient L’s grandson from her second child inherited
Hypertension.

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● HISTORY OF PAST ILLNESS
Patient L was diagnosed with Diabetes Mellitus Type 2 when she was 64 years old in
1958. In 1961, she was diagnosed with dyslipidemia, she was 67 yrs old at the time, in the
same year, she was also diagnosed as hypertensive. When she turned 72, she was diagnosed
with hypertension stage 2. She also had bronchial asthma when she was 54 years old. Her
previous hospitalizations were when she gave birth to her children. She delivered her first baby
through Normal Spontaneous Delivery with the help of forceps. Her second child was also
through NSD. Then her last born was delivered through Cesarean delivery.

● HISTORY OF PRESENT ILLNESS

3 year prior to consultation, the patient palpated introital mass (size of a calamansi or a 5
peso coin). No other signs or symptoms since then, so the patient did not seek consultation. 1
month prior to consultation, the patient noted an increase in introital mass, spontaneously
reducible. Now with associated symptoms of incomplete voiding, dripping of urine, but still with
good bowel movement, no abdominal pain, dysuria, and no increase in urinary frequency, no
vaginal bleeding. Persistence Of symptoms prompted consultation. Physical exam and pelvic
ultrasound was done, advising surgery. Hence admission.

● PHYSICAL EXAMINATION
September 15, 2022
The physical examination of our patient is done as part of nursing practice. This
procedure is typically carried out to assess the client's general health (Krans, 2020). Moreover,
it encompasses a thorough head-to-toe assessment that also incorporates the IPPA (inspection,
palpation, percussion, and auscultation) approach and the taking of vital signs (blood pressure,
respiratory rate, pulse rate, and temperature) (Dignity Health, 2017). A thorough physical
examination was performed during the initial visit last September 15, 2022 in the case of patient
L, a 73-year-old woman who was diagnosed with pelvic organ prolapse. The patient was
observed to be awake, alert, and coherent while eating in bed during the initial nurse-patient
interaction. She was also able to give detailed responses to questions that were addressed to
her. At 8 AM, vital signs including temperature (35.3C), BP of 130/90 mmHg, RR of 20 bpm, and
PR of 76 bpm were also recorded. At 12 PM, her vital signs are as follows: temperature of
35.9C , RR of 20 bpm, PR of 70bpm, and BP of 130/90 mmHg. Meanwhile, other data was
gathered such as the head, eyes, ears, nose, and throat (HEENT) assessment, which showed
normal findings other than the patient's gray hair and her ability to read close-up text with the aid

9
of reading glasses. Exams of the chest, lungs, and neck are unremarkable. The results of the
cardiac examination are normal, with the exception of the 130/90 mmHg blood pressure. Patient
L's abdominal examination reveals a decrease in bowel movements, yet her examination of her
female genitalia, including the anus, rectum, and prostate, reveals unremarkable results.
Whereas her extremities assessment revealed 2+ pitting edema in both of her lower limbs, the
back/spine assessment revealed normal results. And lastly, the results of her neurological
examination are normal.

September 16, 2022

The patient's health must continue to be closely monitored on the second day of care in
order to identify any improvements or deteriorations and to be prepared to intervene
immediately if necessary. Hence , the student nurses assigned to her the day before her
discharge on September 16, 2022, saw that she could now stand and walk independently from
her bed to the comfort room. Along with the vital signs, a physical examination of the patient
was also performed. To further elaborate, the patient's vital signs, including temperature, BP,
RR, and PR, were also recorded at 8 AM. The patient's BP was 130/90 mmHg, a temperature of
36 Celsius, RR of 20 bpm, and a PR of 76 bpm. Her vital signs were once again taken at 12
PM; they were as follows: BP of 120/80 mmHg, RR of 20 bpm, PR of 74 bpm, and temperature
of 36.6 °C. With the exception of needing reading glasses to read text that was close to her, the
patient's head, eyes, ears, nose, and throat (HEENT) were normal. Examinations of the chest,
lungs, and neck are unremarkable. The results of the cardiac examination are normal, with the
exception of the patient's blood pressure reading of 130/90 mmHg taken at 8 am. Patient L
reported that she hasn't defecated yet during her abdominal exam, which indicates a decrease
in bowel movement; nevertheless, an assessment of her female genitalia, as well as the anus,
rectum, and prostate, revealed no notable abnormalities. The evaluation of her back and spine
reveals normal results, however the evaluation of her lower limbs still reveals 2+ pitting edema
in both of them. And lastly, the results of her neurological examination are also normal.

10
● DIAGNOSTIC AND LABORATORY PROCEDURE

DATE ANALYSIS AND

NURSING
DIAGNOSTIC/ ORDERED / INDICATIONS INTERPRETATIO
NORMAL INTERVENTIONS
LABORATORY DATE OR RESULTS N OF RESULTS
VALUES (BEFORE, DURING,
PROCEDURES RESULTS PURPOSES (CLIENT-CENTE
AND AFTER)
IN RED)

1. COVID-19 Antigen 09/08/2022 Detects the Negative Negative Not infectious 1. Practice
(Nasopharyngeal presence of a precautionary
Swab) specific viral measures by doing
antigen, which proper
indicates handwashing,
current viral wearing appropriate
infection. PPE, and disposing
infectious materials
properly.
2. Instruct the patient
about what to
expect during
obtaining the
sample.
3. Monitor the patient
for possible adverse
reactions to the

11
 nasal swab.
4. Evaluate the
patient’s vital signs.

2. Clinical Chemistry 09/08/2022 To perform Potassium: Potassium: Potassium: 1. Inform the patient
quantitative 4.60 mmol/L 3.6 - 5.2 Normal about the purpose
and qualitative Glucose: mmol/L Glucose: High and procedure of
analyses on 6.31 mmol/L Glucose: Creatinine: the test to be done.
body fluids Creatinine: 3.9 - 5.6 Normal 2. Inform the patient
specifically on 74.20 µmol/L mmol/L that he will feel a bit
the blood, Creatinine: of pain when the
urine, spinal 53 to 97.2 needle is inserted.
fluid, feaces, µmol/L 3. Advice the patient
and tissue. not to pull his hands
during the
procedure.
4. Clean the site where
the needle will be
pricked.
5. Provide comfort
measures to divert
her attention from
pain or discomfort
6. Apply pressure

12
 dressing to the
puncture site.
7. Observe the vein
puncture site for
bleeding.
8. Remind the patient
that she can have
her meal right after
the procedure.

3. Urinalysis 09/08/2022 Identify and Color: Light Specific Color: Normal 1. Instruct the patient
treat a variety yellow gravity: 1.005 Appearance: to void directly into a
of illnesses, Appearance: - 1.030 Normal clean, dry container
including Clear pH: Acidic provided by the
diabetes, renal pH: 5.0 Specific gravity: hospital laboratory.
disease, and Specific Normal Sterile, disposable
urethral gravity: 1.015 containers are
infections. A recommended.
urinalysis 2. Instruct the patient
involves to throw away the
examining the first stream of urine
color, that comes out and
consistency, catch the remaining
and urine into the

13
 composition of container.
urine. 3. Cover all specimens
tightly, label properly
and send
immediately to the
laboratory.
4. Observe standard
precautions when
handling urine
specimens.

4. Microscopic 09/08/2022 Detecting and Pus: 1 - 2/hpf Pus: 0 - 5/hpf Pus: Normal 1. Inform the patient
Exam evaluating Red: 0 - 1/hpf Red: <4/hpf Red: Normal about the
renal and Mucus Mucus threads: procedure.
urinary tract threads: Rare Normal 2. Prepare the things
disorders as needed for the
well as other procedure in a safe
systemic and clean way.
diseases. 3. Collect the
specimen at the
best time possible.
4. Collect the
specimen from the
actual site of

14
 infection without
contaminating
adjacent tissues and
secretions.
5. Collect an amount of
samples.
6. Label the specimen
properly and fill out
the test request form
completely.
7. Lessen transport
time and maintain
an appropriate
environment
between collection
of specimens and
delivery to the
laboratory.

5. Chemical Exam 09/08/2022 Reveals the Sugar: Sugar: Normal 1. State the specific
existence of Negative Albumin: Normal purpose of the test.
particular Albumin: 2. Discuss the process
impurities, and Negative of the test to be
the producer Others: None done.

15
 can utilize this 3. Monitor the patient.
knowledge to 4. Assist the patient for
locate and her needs.
eliminate 5. Provide therapeutic
contamination measures to lessen
sources. the anxiety.
6. Observe the patient
for after effects.
7. Continue to monitor
and assess the
patient.

6. Immunology Responsible for HBA1C: High 1. Explain the

9/8/2022 HBA1C: 5.9 <5.7%
Section laboratory procedure.
testing and 2. Provide therapeutic
clinical measures.
consultation in 3. Monitor the patient.
several broad 4. Assess for the need.
areas including 5. Continue to provide
the evaluation comfort.
of autoimmune
disease,
immunodeficie
ncies,

16
 immunoprolifer
ative disorders,
and allergy, as
well as having
responsibility
for some
aspects of
infectious
disease
serology.

7. Hematology Responsible for Hemoglobin: 1.Explain test

9/8/2022 Hemoglobin: Hemoglobin:
the diagnosis Normal procedure. Explain that
11.6g/dl 11.6 to 15g/dl
and Hematocrit: Low slight discomfort may be
management of Hematocrit: Hematocrit: RBC: Normal felt when the skin is
a wide range of 0.35 .36 to .48 MCV: Normal punctured.
benign and MCH: Normal 2. Encourage her to
malignant RBC: 3.77 RBC: 3.8 to MCHC: Normal relax and avoid stress if
disorders of the 5.2 (x WBC: Normal possible.
MCV:92.8
red and white 10*12/L.) Neutrophils: 3. Apply manual
blood cells, MCH: 30.8 Normal pressure and dressings
MCV:
platelets and Lymphocytes: over the puncture site
the coagulation MCHC:33.1 High on removal of dinner.
80–100 fl
system of the Monocytes: 4. Monitor the puncture

17
patients. WBC: 7.17 MCH: Normal site for oozing or
Eosinophils: hematoma formation.
Neutrophils: 27.5 and 33.2
Normal 5. Instruct the patient to
0.56
MCHC: Platelet: Normal resume normal activities

Lymphocytes: and diet.

31-37 grams
0.34

WBC:
Monocytes:
0.04 4.5 to 11.0

Eosinophils: Neutrophils:
0.01
.54 - .62
Platelet:
265,000/mcL Lymphocytes:

.02 - .04

Monocytes:

.02 - .08

Eosinophils:

.01 - .04

Platelet:

18
 150,000 to
450,000. mcL

8. Imaging (Chest PA) 09/08/2022 To evaluate the 1. Inform the patient to

Both Lungs
lungs, heart Remove all metallic
are clear.
and chest wall objects.
and may be Heart is 2. Ensure the patient is
used to help enlarged with not pregnant or
diagnose left ventricle suspected to be
shortness of configuration. pregnant.
breath, 3. Assess the patient’s
persistent Tortuous and ability to hold his or her
cough, fever, calcified. breath.
chest pain or 4. Provide appropriate
Other
injury. clothing.
structures not
5. Instruct the patient to
remarkable
cooperate in the

Impression: procedure especially

when holding her breath
1.Clear lungs during the procedure.
6. Assess the patient's
2.
needs.
Cardiomegaly
7. Provide comfort.

19
3.
Arteriosclerotic
aorta

20
● ANATOMY AND PHYSIOLOGY
Muscular system
Pelvic floor muscle

Source: General anatomy of the female pelvic floor- side view (Peter Lamb as cited in Yates,
2019)
The pelvic floor muscle has a "hammock" shape (Yates, 2019) that allows it to
function as an organ that holds and protects the major organs, such as the large intestine,
bladder, and internal reproductive organs. The pelvic organ is made up of muscles and
connective tissues that are required to hold these aforementioned organs in place, —
particularly from activities and pressures put on humans such as lifting (Cleveland Clinic,
2022), which is associated with the case of a 73-year-old woman named Patient L, who is
diagnosed with stage 3 pelvic (uterine) organ prolapse. She has three children, two of whom
were born NSD (one was delivered using forceps), and the third was delivered through
c-section, which was suspected of being one of the factors contributing to prolapse. More
so, her physician informed her that because of her being "masipag", which generates
pressure during her activities, her pelvic floor has compromised. Furthermore, given the
patient's age and medical history, especially her NSD and C-section, strenuous activity
should already be forbidden. However, she is compelled to perform all the responsibilities,
including staff lifting, every day because her family is too occupied and one of them has
lupus. Because of the strain and excessive pressure, her pelvic muscle was unable to keep
her uterus in place, weakening it and causing it to slide out past the vaginal opening.

21
Reproductive system
Uterus

Source: (Medline plus, 2022)

The uterus, a hollow, pear-shaped organ that is accounted for in growing fetuses and
is a component of the female reproductive system (Ameer, et. al., 2022), has a relevance to
the patient's condition in this study. Patient L , a 73-year-old woman with a uterus measuring
90.5 mm x 51.5 mm x 43.0 mm in size, was admitted to the hospital due to stage 3 uterine
prolapse. During assessment, the patient mentioned that her oldest child was born through
forceps under NSD when she was 25 years old. Her second-to-eldest was born when she
was 29 years old under NSD, and her youngest child was delivered through C-section when
she was 31 years old. They are all full-term. The patient reported that during her
consultation with her physician, it was discovered during the assessment that she had
already felt a mass (calamansi/five pesos in size) on her genitalia during the year 2020. This
prompts her physician to perform further assessment, which eventually reveals that the
patient has stage 3 pelvic organ prolapse, specifically that her uterus protrudes outside of
the vaginal opening. Moreover, the doctor told her during the assessment that in contrast to
lifting heavy objects, one of the things that set off her condition was the fact that she was
already going menopaused, which caused her estrogen levels to decrease and caused her
uterus to prolapse.

22
● THE PATIENT AND HER ILLNESS

Fig.2. Book-based schematic diagram of the pathophysiology of pelvic organ prolapse stage
III

There are different factors why pelvic organ prolapse occurs in women, but mainly it
results from when the pelvic floor muscles and ligaments stretch and weaken until they no
longer provide enough support. To further understand this, the diagram above exhibits the
pathophysiology of this condition. The initial manifestation that the patient will notice is an
increase in the intra abdominal size. Because of this there will be an increase in mass of the
endopelvic fascia and the levator will stretch and tear that will lead to a decrease in the tone
of the perineal muscle. After that, further stretching of the perineum occurs which results in

23
the descent of the part/s of the woman’s reproductive system out to the introitus. Because of
the descent of the organ/s, the patient may exhibit any of the following, first vaginal fullness
or pressure, ulceration due to the protruding pelvic organ, and the displacement of pelvic
organs.

The occurrence of ulceration on the protruding organs the patient might experience
vaginal spotting. On the other hand, the displacement of pelvic organs the patient might feel
urinary elimination difficulties like incontinence and/or increased frequency due to the
displacement of the bladder.

24
 Fig.3. Patient-based schematic diagram of the pathophysiology of pelvic organ prolapse
stage III

As seen in Fig.2, the patient has had 3 childbirths. Her first and eldest child was born
through forceps-assisted delivery, her second child was born through normal spontaneous
delivery, and her third and youngest child was born through cesarean section delivery. The
patient stated that all of her children were born at term with normal weight for a newborn.

25
 During the interview, Patient L stated that she still does some of her family’s laundry even at
her old age. In the year 2019, Patient L felt a protruding mass out of her vaginal canal with
the size of a 5 peso coin. This incident was not accompanied by any signs and symptoms,
which was why the patient did not seek medical aid. 3 years later, the patient noticed that
the protruding mass increased in size and felt alerted by it. Together with this, the patient
experienced impaired urine elimination. She described feeling like she does not void
compLely every time she tries and feels some amount of urine leakage. Due to these signs
and symptoms, Patient L decided to seek a consultation. This consultation lead to the
diagnosis of stage III pelvic organ prolapse.

● SYNTHESIS OF THE DISEASE

Pelvic organ prolapse, stage III
Most women with significant pelvic organ prolapse (POP) have evidence of damage
to the pelvic diaphragm, weakness of the levator ani and enlargement of the levator hiatus
place tension on the pelvic fascial support system, excessive tension results in breaks,
separations, and attenuation of the pelvic fascial support system. When there are multiple
support defects, it is not unusual to find several organs protruding into the vaginal canal.
When there are isolated support defects and little or no evidence of damage to the pelvic
diaphragm, fewer organs are involved (Pubmed, 2021). Damage to the pelvic support
system is thought to be the result of a combination of factors, including childbirth, connective
tissue disorders, pelvic neuropathies, congenital factors, pelvic surgery, and miscellaneous
factors such as obesity, respiratory disorders, occupational and recreational stress, and
hypoestrogenism.

The pelvic floor provides support to the pelvic viscera and consists of the levator ani
muscles, urogenital diaphragm, perineal body and endopelvic fascia. The levator ani, when
considered with its associated fascia, is termed the pelvic diaphragm. The muscle fibers of
the pelvic diaphragm are arranged to form a broad U-shaped layer of muscle with a defect
anteriorly. This physiological defect is the urogenital hiatus and allows the passage of the
urethra, vagina and rectum through the pelvic floor (Indian journal of urology, 2020).

The muscles of the pelvic floor are composed of the levator ani and coccygeus,
which form a cradle within the bony pelvis supporting the pelvic organs. The levator ani
originates on each side from the pelvic sidewall, arising anteriorly just above the arcus

26
tendineus fasciae pelvis and inserting posteriorly into the arcus tendineus levator ani. The
arcus tendineus fasciae pelvis and arcus tendineus levator ani fuse near the ischial spine.
The levator ani has three divisions: the pubococcygeus, iliococcygeus and puborectalis
muscles. Ileococcygeus and pubococcygeus arise from the arcus tendineus levator ani
fascia overlying obturator internus and insert into the midline anococcygeal raphe and the
coccyx. Posteriorly, the coccygeus arises from the ischial spine and sacrospinous ligament
and inserts into the coccyx and sacrum. The striated muscle of the pelvic floor is composed
of both slow and fast twitch muscle fibers. The slow twitch fibers provide muscle tone over a
long period of time, thus supporting the pelvic viscera while the fast twitch fibers react to
sudden increases in intra abdominal pressure. The urogenital diaphragm or the perineal
membrane is a triangular sheet of dense fibrous tissue spanning the anterior half of the
pelvic outL, which is pierced by the vagina and urethra. It arises from the inferior ischiopubic
rami and attaches medially to the urethra, vagina and perineal body, thus supporting the
pelvic floor. The perineal body lies between the vagina and the rectum and provides a point
of insertion for the muscles of the pelvic floor. It is attached to the inferior pubic rami and
ischial tuberosities through the urogenital diaphragm and superficial transverse perineal
muscles. Laterally it is attached to the fibers of the pelvic diaphragm while posteriorly it
inserts into the external anal sphincter and coccyx. The endopelvic fascia is a meshwork of
collagen and elastin which represents the fused adventitial layers of the visceral structures
and pelvic wall musculature. Condensations of the pelvic fascia are termed ligaments and
these play an important part in the supportive role of the pelvic floor. The natural variation
that exists in the inherent mechanical properties of these and other supportive tissues in the
pelvis has been emphasized in recent studies.

To conclude, uterine prolapse occurs when pelvic floor muscles and ligaments
stretch and weaken until they no longer provide enough support for the uterus due to the
mentioned different factors. As a result, the uterus slips down into or protrudes out of the
vagina (Lubna, 2021).

Due to the different factors seen on the patient, she palpated introital mass 3 years
prior to consultation specifically size of 5 pesos and calamansi and because of no pain
experienced the patient did not seek consult. On the other hand, 1 month Prior to
consultation The patient noted an increase in introital mass, spontaneously reducible and
with that the uterus protruding out of the vagina.

27
Predisposing/Precipitating Factors
Pelvic organ prolapse has various precipitating factors, which are the following:
having one or more vaginal births, being older when you have your first baby, giving birth to
a large baby, aging, obesity, prior pelvic surgery, chronic constipation or often straining
during bowel movements, family history of weak connective tissue, being Hispanic or white,
chronic coughing, such as from smoking.
Through assessment to the patient different factors have been identified with the
occurrence of the condition and these are, Gravida 3 Para 3, age of 73 years old, lifting
heavy objects, she is already menopause that lead her estrogent level low that cause
prolapse of her uterus, and BMI= 28 (Overweight).
Signs and Symptoms
The following are the signs and symptoms of pelvic organ prolapse: feeling of
heaviness around lower tummy and genitals, dragging discomfort inside vagina, feeling like
there's something coming down into vagina and like sitting on a small ball, feeling or seeing
a bulge or lump in or coming out of vagina, discomfort or numbness during sex, and
problems peeing such as feeling like your bladder is not emptying fully, needing to go to the
toilet more often, or leaking a small amount of pee when you cough, sneeze or exercise.

Among all of the listed signs and symptoms, the patient manifested only 3. She
recalled feeling a 5-peso sized introital mass in the year 2019. 3 years later she noticed an
increase in the size of the introital mass which was also accompanied by urinary
incontinence and a sense of incomplete urination.

28
● NURSING CARE PLAN
Nursing priority #1:

NURSING SCIENTIFIC EXPECTED

ASSESSMENT OBJECTIVES INTERVENTIONS RATIONALE
DIAGNOSIS EXPLANATION OUTCOMES

Subjective: Decreased Hypertension, Short term: Independent: Independent: Short term:

● The patient cardiac also known as After 2 hours 1. Assess the 1. Heart volume and After 2 hours of
verbalized, output high or raised of nursing patient’s vital output can be nursing
“Nararamda related to blood pressure, interventions, signs, focusing accurately interventions,
man ko increased is a condition in the patient will on blood predicted by the patient shall
yung lakas blood which the blood be able to pressure and monitoring blood have exhibited a
ng tibok ng pressure as vessels have exhibit a pulses and pressure and lowered blood
puso ko. evidenced by persistently lowered blood record. pulse rates. Blood pressure on or
Kagabi hindi a blood raised pressure. pressure on pressure below 120/80
ako pressure of Blood is carried or below abnormalities and mmHg.
makatulog 140/80. from the heart to 120/80 a decreased
ng maayos.” all parts of the mmHg. cardiac output Long term:
● The patient body in the may potentially be After 4 days of
verbalized vessels. It Long term: signs of nursing
that she felt occurs when the After 3 days consequences interventions,
markedly body's smaller of nursing from the patient shall
exhausted blood vessels, interventions, hypertension. have
when she which are the the patient will 2. Help the patient 2. This lessens the demonstrated an
first had her arterioles be able to to plan alternate load on the heart increase in

29
 trip to the narrow, causing demonstrate periods of rest and improves activity tolerance
bathroom the blood to an increase in and activity. overall tissue as evidenced by
after her exert excessive activity Help the client perfusion while the ability to go
IFC was pressure against tolerance as in slowly getting preserving to the bathroom
removed. the vessel walls evidenced by back on her feet energy. without feeling
and forcing the the ability to by simply exhausted.
Objective: heart to work go to the ambulating
● The patient harder to bathroom around the room
has been in maintain the without feeling or going to the
bed rest for pressure. exhausted. bathroom with
a few days assistance.
since her 3. Advise the 3. Can aid in
surgical patient to limit controlling and
procedure. intake of food keeping blood
● The patient high in sodium pressure within a
can be seen and cholesterol. healthy range.
catching her 4. Encourage 4. Blood pressure is
breath every patients to be controlled with
now and vigilant in the maintenance
then. intake of his drugs for
● The maintenance hypertension,
patient’s medications. which also
blood improve cardiac
pressure is output and

30
slightly guarantee
above appropriate tissue
normal at perfusion.
140/80 5. Thoroughly 5. Other than
mmHg check the hypertension,
patient’s other illnesses
laboratory can have an
results such as impact on cardiac
blood cell output. Planning
counts, ABGs, better care for the
electrolytes and patient would be
cardiac marker made possible by
studies. carefully
reviewing
laboratory results.

Dependent: Dependent:
1. Follow and 1. For the goal of
administer determining the
medication as patient's required
per doctor's diet and medicine
order. dosage.
additionally to get
the medicine

31
 ready in case of
an emergency.

Collaborative: Collaborative:
1. Refer the 1. To help the patient
patient to a in planning her
dietician as diet as
ordered. appropriate to
decreasing and
maintaining a
normal blood
pressure.

Nursing priority #2:

NURSING SCIENTIFIC EXPECTED

ASSESSMENT OBJECTIVES INTERVENTIONS RATIONALE
DIAGNOSIS EXPLANATION OUTCOMES

Subjective: Impaired Impaired urinary Short term: Independent: Independent

Short term:
● The patient urinary elimination After 1 hour of 1. Assess the 1. Describes bladder
verbalized elimination defined as the nursing voiding pattern function After 1 hour of
pain when related to disturbance in interventions, (frequency and characteristics nursing
she tried to pain around eliminating the patient will amount). (effectiveness of interventions,
void after the incision urine. The be able to Compare urine bladder emptying, the patient shall

32
 her IFC site as common signs verbalize output with fluid renal function, demonstrate
removal. evidenced by of this condition lessened pain intake. Note and fluid balance). behaviors and
● The patient pain during are pain on sensation specific gravity. 2. A healthy amount techniques to
verbalized urination and urination, during 2. Encourage of fluid prevent the said
increased urine output distended urination. adequate fluid encourages urine condition.
urinary of less than bladder, and intake (2–4 L production and
Long term:
urgency that 30ml/hour. urinary Long term: per day), helps fight illness.
wakes her hesitancy. This After 2 days avoiding After 2 days of
up at night. condition is of nursing caffeine and use nursing
common to interventions, of aspartame, interventions,
Objective: patients in the the patient will and limiting the patient shall
● The patient post-op stage as be able to intake during have no report of
urinated analgesic drugs exhibit a urine late evening and her condition.
less than 30 often disrupt the output of at bedtime.
ml/hour neural circuitry 30ml/hour or Recommend
after her that controls the more. use of cranberry
catheter nerves and juice or buko 3. Signs of renal or
was muscles in the juice. urinary tract
removed. urination 3. Observe cloudy infections, which
● The process. or bloody urine, can exacerbate
patient’s foul odor. sepsis Leukocyte
bladder was Dipstick urine as esterase, nitrite,
distended indicated. and pH may all be
upon quickly

33
palpation. determined using
multistrip
dipsticks, which
may indicate the
presence of an
infection.
4. This lowers the
possibility of
4. Promote getting a UTI.
continued 5. The danger of
mobility. skin irritation,
5. Cleanse breakdown, or the
perineal area emergence of an
and keep dry. ascending
Provide catheter infection is
care as reduced by good
appropriate. perineal
cleanliness.

Dependent:
1. To lessen the pain
felt by the patient
Dependent: during urination
1. Administer attempts.

34
 narcotics or
non-steroidal 2. As a precaution
anti-inflammator for the patient’s
y medications risk for infection.
as ordered.
2. Administer
antibiotics as
ordered by the Collaborative:
attending 1. To prevent urine
physician. retention and
urinary tract
Collaborative: infection and to
1. Keep the accurately monitor
bladder deflated the patient’s urine
with the use of output.
an indwelling
catheter
connected to a
urine bag. .

35
Nursing priority #3:

NURSING SCIENTIFIC EXPECTED

ASSESSMENT OBJECTIVES INTERVENTIONS RATIONALE
DIAGNOSIS EXPLANATION OUTCOMES

Subjective: Risk for falls Risk for falls is Short term: Independent: Independent: Short term:
1. The patient related to defined as the After 2 hours 1. Assess the client’s 1. Alterations in After 2 hours
verbalized dizziness susceptibility to of nursing ability to ambulate mobility increase of nursing
weakness and weak increased interventions, and identify the risk the risk of falls. interventions,
around her lower falling, which the patient will of falls. the patient
legs since extremities. may cause be able to 2. Check on the 2. For identifying the shall have
she came physical harm verbalize a environment for possible danger verbalized a
out of the and lessened threats to safety. or injury to the lessened
post-op compromised feeling of client. feeling of
room. health. Spinal dizziness. 3. Validate the 3. Validation Ls the dizziness.
2. The patient anesthesia is a patient’s feelings patient know that
verbalized type of Long term: and concerns the nurse has Long term:
“Medyo neuraxial After 3 days related to heard and After 3 days of
nahihilo pa anesthesia; of nursing environmental understands the nursing
ako siguro local anesthetic interventions, risks. information and interventions,
dahil sa (LA) is injected the patient will concerns. It also the patient
anesthesia.” into be able to helps promote the shall have
cerebrospinal ambulate nurse-patient ambulated

36
Objective: fluid (CSF) in around the relationship. around the
The patient may the lumbar room with 4. Place the patient in 4. Moving the room with
manifest spine to supervision a room near the client’s room supervision
● Lowered anesthetize and nurses’ station. closer to the and
blood nerves that exit assistance. nurse station assistance.
pressure the spinal cord. allows the health
upon sitting Headache and care provider to
up from her lower limb closely observe
lying weakness are patients at high
position. the most risk for injury and
● Impaired common side falls and promptly
mobility or effects of spinal provide
gait. anesthesia. interventions.
● Altered These side 5. Assist the patient in 5. Early ambulation
mental effects may still ambulation around is encouraged
status. manifest even the room and teach after surgery to
on the next day, the patient’s promote effective
when you sit up significant other on blood flow which
or move how to assist as could lessen the
around. well. weakness felt on
the lower
extremities.
6. Ascertain the 6. To immediately
significant other’s reinforce the

37
 level of knowledge significant other’s
about and knowledge and
attendance to teach them the
safety. role that they may
play in the
treatment plan of
the patient.

Dependent: Dependent:
1. Follow the orders 1. For the purpose
as per the doctor in of drug dosage
terms of and what type of
medications food the patient
needed and must eat.
nutritional intake.

Collaborative: Collaborative:
1. Refer to physical 1. To improve the
therapist or client’s balance,
occupational strength, and
therapist as mobility.
ordered and as
appropriate.

38
● MEDICAL MANAGEMENT

IVFs, BT, NGT FEEDING, NEBULIZATION, ETC.

MEDICAL NURSING
DATE ORDERED,
MANAGEMEN GENERAL CLIENT’S INTERVENTIONS
DATE PERFORMED, INDICATIONS
T/ DESCRIPTION RESPONSE (BEFORE, DURING, AND
DATE CHANGED
TREATMENT AFTER)

1. RT-PCR Ordered on: An RT-PCR test Done prior to the The patient was ● Practice precautionary
swab 09/13/2022 detects the nucleic admission of the negative. measures by doing
acid of the patient to ensure proper handwashing,
Performed on: SARS-CoV-2 may be that she is not wearing appropriate
09/13/2022 present in the upper infected by the PPE, and disposing
and/or lower COVID-19 virus. infectious materials
specimens obtained properly.
from an individual. ● Instruct the patient
about what to expect
during obtaining the
sample.
● Monitor the patient for
possible adverse
reactions to the nasal
swab.
● Evaluate the patient’s

39
 vital signs

2. D5NR 1L Ordered on: The patient Administered to The patient was ● Practice aseptic
IV fluid 09/13/2022 consumed 4 bottles keep the patient kept hydrated technique to prevent
throughout her hydrated. throughout her infecting the site of
Performed on: admission. It contains admission. insertion of IV cannula.
09/13/2022 5g of Dextrose ● Choose the right gauge
Monohydrate, 234 size for the patient.
mg of sodium ● Check the IV fluid label
chloride, 128 mg of with the doctor’s order
potassium acetate to ensure that it is the
tetrahydrate and right one.
30mg (approximately ● Insert the IV cannula to
1.6 mmol/L) of the patient’s
sodium Metabisulfite. non-dominant hand.
● Secure the IV cannula
properly with micropore
or with a clear film.
● Regulate the IV fluid
with the regulation
ordered by the
attending physician.
● Monitor the patient’s
vital signs and for

40
 possible allergic
reactions.

3. Indwelling Ordered on: An indwelling It was inserted for The patient’s ● Inform the patient of the
foley 09/13/2022 catheter is inserted immediate and urine volume purpose of the
catheter and works similarly to rapid bladder was within procedure and what to
Performed on: an intermittent decompression and normal limits. expect.
09/14/2022 catheter, but an monitoring of the ● Select the appropriately
indwelling catheter is patient’s urine sized catheter to be
Removed on: left in place and output. used for the patient.
09/15/2022 connected to a urine ● Perform proper perineal
bag until there an care.
Replaced on: order for removal is ● Perform proper hand
09/15/2022 written by the washing and wear
attending physician. clean gloves prior to
insertion.
● Check the balloon for
possible leakage by
inflating it with PNSS.
● Lubricate the catheter
sufficiently.
● Instruct the patient to
breathe in deep just
when you are about to

41
 insert the catheter.
● Check the catheter if it
is patent by checking if
there is urine flow.
● Properly secure the
tube to the inner side of
the patient’s thigh to
keep it in place and to
prevent the patient
tangling it.
● Hook the urine bag to
the side of the bed
below the level of the
patient’s bladder but
not touching the floor.

DRUGS

DATE ORDERED, ROUTE, NURSING

NAME OF DATE DOSAGE, AND SPECIFIC CLIENT’S INTERVENTIONS
INDICATIONS
DRUG PERFORMED, FREQUENCY FOOD TAKEN RESPONSE (BEFORE, DURING, AND
DATE CHANGED OF ADMISSION AFTER)

1. Losartan Ordered on: 50 mg per tab Given to the The patient had The patient’s ● Verify the drug name,

42
09/13/2022 once a day
Administered on:
09/13/2022 until
day of discharge
patient for the her usual meal blood dosage, time, and
treatment of consisting pressure was route for 3 times.
her mostly of controlled. ● Inform the patient
hypertension vegetables about the purpose of
stage II. rather than the drug.
meat. ● Assess the patient’s
vital signs, specifically
her blood pressure,
pulse rate, and
respiratory rate.
● Check the patient’s
blood laboratory
results to ensure that
sodium, potassium,
creatinine, and BUN
levels are within
normal limits.
● Discuss the purpose
of the medication to
be administered and
the side effects that
may come with it.
● Check the patient for
allergic reactions to
43
 the drug.
● Keep monitoring the
patient’s vital signs.

2. Cefuroxi Ordered on: 500 mg per tab Given to the The patient took The patient ● Verify the drug name,
me 09/14/2022 twice a day for 7 patient as a the medication did not dosage, time, and
days precaution for after her meal, manifest any route for 3 times.
Administered on: preventing but did not signs of ● Inform the patient
09/14/2022 until bacterial mention eating infection. about the purpose of
day of discharge infection as any particular the drug.
she is prone to food before or ● Administer the drug
this due to her after taking it. after the patient has
colporrhaphy. taken her meal to
reduce the intensity of
GI upset and to
increase absorption.
● Prepare a dose of
vitamin K incase
hypoprothrombinemia
occurs.
● Monitor the patient for
signs of
hypersensitivity to the
drug such as hives,

44
 rash, or fever.
● Instruct the patient to
swallow the drug
whole and not to chew
on it.

3. Paraceta Ordered on: 900 mg through Given to the The patient took The patient ● Verify the drug name,
mol 09/14/2022 IV every 6 hours patient to the medication verbalized a dosage, time, and
divided into 3 alleviate pain after her meal, reduced route for 3 times.
Administered on: doses after her but did not sense of pain ● Inform the patient
09/14/2022 until surgery. mention eating from 8/10 to about the purpose of
09/15/2022 any particular 4/10. the drug.
food before or ● Assess the patient’s
after taking it. sense of pain.
● Check the patient’s
medication to card to
ensure that she is not
taking other
medications
containing
paracetamol.
● Inform the patient
about the purpose and
possible side effects

45
 of the medication.
● Administer the drug
after the patient has
taken a meal.
● Monitor the patient for
possible allergic
responses to the drug
such as hives, rash, or
fever.
● Evaluate changes in
the patient’s sense of
pain.

4. Celecoxib Ordered on: 200 mg per tab Given to the The patient took The patient ● Verify the drug name,
09/14/2022 twice a day for 3 patient to the medication did not dosage, time, and
days after control her after her meal, manifest any route for 3 times.
Administered on: Ketorolac pain and but did not signs of ● Inform the patient
09/14/2022 until reduce mention eating infection. about the purpose of
09/16/2022 inflammation any particular the drug.
after her food before or ● Assess the patient’s
surgery. after taking it. range of motion and
swelling or pain in her
joints.
● Inform the patient

46
 about the purpose and
possible side effects
of the medication.
● Administer the drug
after the patient has
taken her meal.
● Monitor the client for
any allergic reactions
to the drug
● Instruct the patient to
report immediately if
sore throat, rash,
fever, itching, or
change in vision
occurs.

5. Ketorolac Ordered on: 30 mg through Given to the The patient took ● Verify the drug name,
09/14/2022 IV every 6 hours patient to the medication dosage, time, and
divided into 3 provide pain after her meal, route for 3 times.
Administered on: doses relief after her but did not ● Inform the patient
09/14/2022/ until surgery. mention eating about the purpose of
09/15/2022 any particular the drug.
food before or ● Ask the patient about
after taking it. her pain scale,

47
● Administer the drug
after the patient has
taken her meal to
reduce the chance for
GI upset.
● Administer the drug 2
to 4 hours before or
after antihypertensive
or diuretic drugs.
● Evaluate changes in
the patient’s sense of
pain after
administration.
● Monitor the patient for
signs of
hypersensitivity to the
drug such as hives,
rash, or fever.

48
 DIET

DATE ORDERED, NURSING

SPECIFIC
TYPE OF DATE GENERAL CLIENT’S INTERVENTIONS
INDICATIONS FOOD
DIET PERFORMED, DESCRIPTION RESPONSE (BEFORE, DURING, AND
TAKEN
DATE CHANGED AFTER)

1. Nothing Ordered on: The patient is Promotes None The patient 2. Calculate the time
per orem 09/13/2022 ordered to not pre-operative stopped when the patient is
(NPO) eat or drink fasting as an eating and last allowed to have
Administered on: anything 8 hours approach to drinking at 10 food intake.
09/13/2022 until prior to the reduce the pm on 3. Instruct the patient
09/14/2022 surgery to lower volume and September when she could eat
the risk of acidity of a 13, 2022. and drink.
aspiration of patient's 4. Assist the patient
gastric contents stomach with oral hygiene
during general contents to after her last meal.
anesthesia reduce the risks 5. Administer ordered
of regurgitation medications before
and subsequent surgery with just a
pulmonary sip of water.
aspiration.

6. Diet as Ordered on: The patient may Ordered to Started with The patient ● Instruct the patient to
tolerated 09/14/2022 be able to patients post-op water, moved had only soup start with clear liquids

49
 (DAT) consume foods to decrease on to soup, for almost half to keep herself
Administered on: from one diet nausea, then mashed a day on her hydrated.
09/14/2022 until stage before diarrhea, and foods, and so first day of ● Assess the patient for
09/16/2022 moving to the gas in the bowel on. post-op. signs of GI upset,
next. The that may cause nausea, and vomiting.
patient may start abdominal pain ● Monitor if the patient is
with a clear and discomfort. skipping a diet stage
liquid diet or soft and if the stage she is
diet and at is tolerable.
proceed to the ● Assess the patient’s
next one bowel pattern.
tolerable. ● Assess the patient’s
fecal output for signs of
GI distress.

ACTIVITY/REST

DATE ORDERED, NURSING

TYPE OF SPECIFIC
DATE GENERAL CLIENT’S INTERVENTIONS
ACTIVITY/ INDICATIONS FOOD
PERFORMED, DESCRIPTION RESPONSE (BEFORE, DURING,
EXERCISE TAKEN
DATE CHANGED AND AFTER)

Flat on bed, also ● Usual Position N/A Patient Before:

Flat on bed Ordered on:
known as supine, ● Sleeping remained 1. Check Doctor’s Order.

50
until able to sit September 14, is a position ● Patients stable, with 2. Use different
up. 2022 where the Patient post-surgery no redness, variations to maximize
L lies on her that involves edema, signs comfort, unless
back, head is intracranial, of pressure contraindicated.

Changed on face up, and cardiac, ulcerations, 3. Ensure the bed is

September 15, neck is in a abdominal, and other angled appropriately.

2022 neutral position. endovascular, abnormalities 4. Fix the bed with no

Configurations laparoscopic, . Surgical wrinkling to avoid bed
such as pillows lower dressing is sores.
can be placed for extremity intact, and no
comfort, unless procedures, excessive During:
contraindicated. and ENT, neck bleeding. 1. Help patients position
and face. themselves.
2. Regularly monitor
patients for redness,
edema, signs of
pressure ulcerations,
and other abnormalities.
3. Regularly reposition
patients, every 2 hours
to maintain blood flow
and prevent pressure
ulcerations.

51
After:
1. Examine patients for
pressure ulcerations.
2. Help patients in
ambulation, if tolerated.

52
● SURGICAL MANAGEMENT (Client-Centered)
Colporrhaphy
Colporrhaphy, which was ordered on September 13, 2022 and performed on
September 14, 2022, is a surgery used to fix weaknesses in your vaginal walls. An
incision is made near the entrance of the vagina, extending inward toward the top of
the vaginal canal. This incision gives the surgeon access to repair and restructure the
weakened underlying pelvic floor tissue that caused the prolapse. It's a surgical
treatment for pelvic organ prolapse (POP). Generally, there are two types of
colporrhaphy: anterior colporrhaphy and Posterior colporrhaphy. Anterior
colporrhaphy, also referred to as cystocele repair, is responsible for the tightening of
the muscles and repositioning of the organs in between the bladder and vagina. On
the other hand, Posterior colporrhaphy, also referred to as rectocele, is responsible for
the muscles and organs in between rectum and vagina. In the case of the client, both
Anterior colporrhaphy and Posterior colporrhaphy was done, primarily due to the
severity of the client’s prolapse.

Client’s Response to the operation.

The surgery was considered successful, the anterior and posterior prolapse was
surgically repaired. Three days postoperative, September 16, 2022, the patient was
ordered for discharge as no complications were noted during hospital stay.

53
Nursing responsibilities before, during and after the operation.
Before:
● Re-check the patient’s consent and ensure that it is valid and signed.
● Informed the medical practitioners involved in the surgical management to be
done.
● Assist the patient during her transfer from her room to the operating room.
● Perform perineal hygiene, if ordered.
During:
● Assist in the operation, if ordered.
● Maintain and observe sterility.
● Closely monitor the patient's vital signs, report as necessary.
After:
● Assist the patient during her transfer from the operating room to her room.
● Monitor the patient, including her general condition, vital signs, and signs of
infection or complications.
● Provide health teachings such as limiting activity for 2 weeks postoperative.
● Teach the patient to avoid strenuous activities such as heavy lifting.
● Educate the patient not to engage in sexual intercourse for 6 weeks
postoperative, or as ordered by the physician.
● Educate and monitor the patient’s diet immediately after surgery, such as
avoiding high fiber food to prevent pressure on the suture line near the rectum.

54
● NURSING MANAGEMENT

FDAR

DATE FOCUS DATA - ACTION - RESPONSE

September 14, D> The patient was received day 1 postoperative anterior and posterior surgical
2022 repair of pelvic organ prolapse; patient was seen lying on bed, awake, alert and
8:00 am General Survey coherent; minimal vaginal bleeding was observed; with heplock on right arm, no
redness, inflammation, or signs infection; Vital Signs were as follows: BP:
140/80mmHg, HR:68 cpm, O2 Sat: 100%.--------------------------------------------AUF,SN.

D> The patient reported minimal pain on the incision site; was observed with
guarding behavior; and patient rated pain 8/10. —----------------------------------AUF,SN.
A> Assessed the patient’s reported pain in terms of location, characteristic, onset,
Acute Pain and severity, assessed the incision site for bleeding; Administered paracetamol 900
8:00 am mg through IV every 6 hours divided into 3 doses, Celecoxib200 mg per tab twice a
day, and Ketorolac 30 mg through IV every 6 hours divided into 3 doses; Educated
client that pain on incision site is normal postoperative; Educated client to limit
movement that involves stretching of the surgical site. —-------------------------AUF,SN.
R> The patient reported a decreased pain rating from 8/10 to 4/10. —--------AUF,SN.

D> The patient, at the time of visit, was observed with dizziness and weakness of

55
 lower extremities. The patient’s movement was also limited by pain felt around the
surgical site. —--------------------------------------------------------------------------------AUF,SN.
A> Assessed the patient’s general condition and ability to ambulate or position self
Risk for Falls without help; Assessed patient’s environment; Altered patient’s environment,
10:00 am removed objects that may cause injury; Kept side-rails up; Instructed family to not
leave the patient unattended; Educated family about proper
ambulation.-—---------------------------------------------------------------------------------AUF,SN.
R> The patient did not experience any fall and is free from injury. —-----------AUF,SN.

September 15 D> The patient was seen lying on bed, awake, alert and coherent; no signs of
8:00 am General Survey bleeding on incision site; Heplock attached in right arm, no redness, inflammation, or
signs of infection; Vital Signs stable and were as follows: BP: 110/70 mmHg, HR:
80bpm, RR: 20cpm, T: 36 degrees. —--------------------------------------------—---AUF,SN.

D> The patient manifested lack of knowledge regarding her medications, proper
wound care, and prognosis of her disease after surgery. —----------------------AUF,SN.
A> Assessed patient's current knowledge about her medications and knowledge
about her prognosis of her disease after surgery; Assessed patient’s knowledge and
ability to perform proper wound care; Assessed ability to learn or perform desired
10:00 am Deficient Knowledge health-related care; Considered client’s learning style; Educated patient and family
regarding her medications’ route, dosing, and timing during discharge instruction;
Educated patient and family about her prognosis after surgery; Taught client how to
perform proper wound care and dressing; and Evaluated other learning needs.

56
—-------------------------------------------—---------------------------------------------------AUF,SN.
R> The patient was able to repeat instructions about proper wound care, and
medications; verbalized understanding of her prognosis; and Expressed willingness
to participate in her treatment regiment.------------------------------------------—---AUF,SN.

57
● CLIENT’S DAILY PROGRESS CHART

DAYS ADMISSION 2 3 4 DISCHARGE

Nursing Problems ● Minimal Vaginal ● Risk for Infection ● Altered Comfort ● Hypothermia
Bleeding
● Minor Vaginal
Bleeding

● Constipation

Vital Signs ADMISSION 2 3 4 DISCHARGE

BP 120/80 mmHg 140/80 mmHg 110/70 mmHg 120/60 mmHg 120/80 mmHg

HR 78 bpm 68bpm 80 bpm 72 bpm 74 bpm

RR 20 cpm cpm 20 cpm 20 cpm 19 cpm

T 36°C °C 36°C 36°C 36°C

Diagnostic / Lab
ADMISSION 2 3 4 DISCHARGE
Procedures

X-ray ✓

58
 Complete Blood ✓
Count

PT-PCR Swab ✓

Anterior-Posterior ✓
Repair

None performed. ✓ ✓ ✓

Medical
ADMISSION 2 3 4 DISCHARGE
Management

D5NR 1L IV fluid ✓ ✓

PLRS 1L IV fluid ✓

Removal of IV fluids ✓

Indwelling Foley ✓ ✓
Catheter Insertion

Indwelling Foley ✓
Catheter Removal

Spinal Anesthesia ✓

59
 Colporrhaphy ✓

None performed. ✓

Drugs ADMISSION 2 3 4 DISCHARGE

Losartan (Cozaar) ✓ ✓ ✓ ✓ ✓
50 mg/tab once a
day

Cefuroxime ✓
(Zinacef) 1.5 gm IV

Cefuroxime ✓ ✓ ✓ ✓
(Zinacef) 500 mg
per tab, twice a day

Paracetamol ✓ ✓
(Biogesic) 900 mg
through IV every 6
hours, divided into 3
doses

Ketorolac (Toradol) ✓ ✓
30 mg through IV

60
 every 6 hours
divided into 3 doses

Celecoxib ✓ ✓ ✓ ✓
(Celebrex) 200 mg
per tab, twice a day,
for 3 days after
Ketorolac

None administered.

Type of Diet ADMISSION 2 3 4 DISCHARGE

NPO ✓ ✓

Soft Diet ✓
(Soup)

Diet as tolerated ✓ ✓ ✓

Activity / Exercise ADMISSION 2 3 4 DISCHARGE

Flat on bed ✓

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Flat on bed until ✓
able to sit up

No specific ✓ ✓
activity/exercise
was ordered.

62
● DISCHARGE PLANNING
General of the Client Upon Discharge
During the room visit, the patient was received 3 days post-op. She was wearing a
flowy house dress, had no on-going IV fluid, and was prepared for discharge. Upon the
removal of her foley catheter, her incision was observed to have a slight redness but no
discharge, swelling, nor signs of infection were noted. The patient was also observed to be
active and cooperative during the interview, and was able to ambulate.
M.E.T.H.O.D.S

> Instructed the patient about the continuation of her

take-home medications such as:
Medication ● Fibrosine sachet BID
● Cefuroxime 500 mg/tab 1 tab twice a day
● Celecoxib 500 mg/capsule

> Instructed client about the use of GynePro perineal

Treatment cleanser as protection from bacteria.
> Encourage regular ambulation and provide adequate
fluids and electrolytes to support wound healing and
recovery.

> Educated the client/SO about the purpose of the

Health Education medications and the importance to adhere with the
prescribed regimen.
> Advised the client for the need of follow-up visits
post-confinement to monitor her progress and any potential
complications of her condition.
> Advised the client to report any signs of complications (ex:
infection, excessive bleeding, difficulty in emptying bladder,
adverse effects of prescribed medications) to a health care
provider.

> Encouraged adequate rest periods and to avoid strenuous

Activities activities that can be detrimental to the body’s healing
process.

63
 > Encouraged mobilization or regular ambulation to promote
blood flow and maintain normal breathing functions that
could hasten healing and recovery, without exerting self.

> Encouraged adequate nutrition and hydration to maintain

Diet skin turgor and promote tissue healing.
● Foods rich in vitamin A, C, and zinc.
● Fluid intake of 2000 mL/day unless medically
restricted.

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● SUMMARY OF FINDINGS
Patient L, a 73 year old natural born filipina, a resident of Angeles City,
Pampanga, and a mother of three children. Is a patient of a private tertiary health facility
in Angeles City. Three years ago, the patient palpated an introital mass, a lump located
on the opening of her vagina. The patient did not seek consultation immediately,
however 1 month prior to consultation, she noticed an increase in size, which prompted
her to consult a professional. Upon examination, it was revealed that there is a
protrusion of the pelvic organs in the vaginal opening. She was later diagnosed with
Stage III Pelvic Organ Prolapse. The reason for this diagnosis is mainly due to the fact
that pelvic organs are already visible outside the vaginal canal and have not yet
completely fallen, hence diagnosed as a Stage III Pelvic Organ Prolapse. On September
13, 2022, she was ordered to have a surgery to reposition the pelvic organs, called
Colporrhaphy. In the patient’s case, she was specifically ordered to have Anterior and
Posterior Colporrhaphy, which means the surgeon would tighten and reposition the
organs in between the bladder and vagina (anterior) and organs in between the rectum
and vagina (Posterior). This order was immediately carried out on September 14, 2022.
The surgery was considered successful, no complications were noted during her hospital
stay, and the patient was discharged on September 16, 2022, three days after the
surgery.

● CONCLUSION
Patient L is one of the many aging women diagnosed with Pelvic Organ
Prolapse. As contained in this case analysis, she is 73 years old, a mother of 3 children,
overweight, active even in her old age, and she has undergone menopause. Because of
these factors, the patient was predisposed in developing the said disease. Although
there is not enough evidence to specifically point out what caused Patient L’s condition,
a lot of studies believe that age is a major contributor in its development.

Pelvic Organ Prolapse has become the reality of many aging women, especially
those whose age is 60 years old and above. That is why it is important to recognize the
prevalence of this disease; as well as recognize the problems that it currently faces,
such as the inaccuracy and scarcity of available data and statistics. With more accurate
and abundant data regarding this disease, health care institutions will be able to devise
health programs that aim to not only help the lives of the women who have already

65
 developed POP, but also those women who are bound to develop it. As often stressed
by Association of Pelvic Organ Prolapse Support (APOPS), Pelvic Organ Prolapse may
rarely be life threatening, it still is, without a doubt, always life altering.

● RECOMMENDATIONS
As the subject for this case study belongs to the elderly age group, it is important to
maximize patient-student nurse interaction as they tend to have a decreased attention span
and are more easily irritated compared to the younger generation due to hormonal changes
that occur with aging. It would also be beneficial to the group if they were able to handle the
patient for more than a day as this would result in more data and information collected.
Since the patient has the tendency to forget details and information, at least one of the
patient’s family members should have been involved during the interview either to validate
the patient’s statements or to fill in the gaps that the patient was not able to fill. It is also
important to note that this particular condition being tackled may be considered sensitive by
the patient as it involves the reproductive system, which is why it should also be a priority
during the data gathering stage to use appropriate language and to respect the patient’s
refusal to divulge some information to create a safe environment for the patient.

● LEARNINGS DERIVED
Although one-half of women aged 50-79 are affected by pelvic organ prolapse, there
are various lifestyle changes that could be done to prevent such conditions. Two of the most
prominent lifestyle changes that an aging woman can do as a preventive measure is to
lessen her participation in strenuous activities such as lifting and prolonged standing and
walking and practice doing kegel exercise regularly, especially after her first child birth, to
effectively strengthen the muscles and nerves of her pelvic floor.

66
● APPENDICES

67
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https://www.pelvicorganprolapsesupport.org/pelvic-organ-prolapse-help-and-hope#:%7E:
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