A Grand Case Presentation to the College of

Nursing & Allied Health Sciences

In Partial Fulfillment of the Requirements for the

OB Ward

Presented to:
Jerome Sombilla RN, CNN, MAN
Jayvee F. Daracay RN, MAN’c
Desiree Jane S. Umandap, RN
Giovanni D. David, EdD, RN

Presented by:
BSN 2B
Aquino, Merynhol
Costales, Alliana Mari A.
Cruz, Cristian
Cruz, Kate
Dabu, Joanne
Dela Rosa, Lorenzo
Dula, Jeramille
Golocan, Jessa
Lavin, George S.
Macundo, Nicole
Maiso, Jonalyn
Mari, Trisha Ann
Martinez, Hershey V.
Nicolas, Imee
Ongoco, Aiko
Platero, Princess Aira
Ragasa, Raisa B.
Reyes, Irma
Signio, Angelica
Simsuangco, Julie Ann
Vengua, Cristine
Zalamea, Mark Anthony
 Medical Mngt.
- Birth control
pills
-Analgesic
 Asia pacific College of Advanced Studies
College of nursing
A.H. Banzon St. Ibayo, City of Balanga, Bataan

BIOGRAPHIC DATA

PERSONAL DATA

Name: Patient M
Age: 23 years old
Gender: Female
Birthday: June 13, 1996
Religion: Roman Catholic
Marital Status: Single
Address: Zamora St. Poblacion Pilar, Bataan
Nationality: Filipino
Education level: Bachelor’s degree
Weight: 68 kg
Height: 5’4 inches (162.56 cm)
OB History: never have been pregnant

Menarche: 12 years old

Days of menstruation: 5 to 6 days (abnormal vaginal bleeding)
Coitarche: 20 years old
Menopausal age:

CLINICAL DATA
Chief Complaint: “few days with abdominal pain”
Date of Admission: June 11, 2020 AM
Admitting Diagnosis: Dermoid cyst right, exploratory laparotomy right
oophorectomy
Attending Physician: Dr. Flores/Dr.Chan
Ward: Surgical ward/OB ward
Final Diagnosis: Dermoid cyst on right ovary
 NURSING HISTORY
A. History of Dermoid Cyst

GENETIC

B. Past Health Illness

Ms. M is a 23 years old woman with the present history of Dermoid cyst on the right area. She has a past medical

history (on her previous hospitalization) of PCOS or the Polycystic ovary syndrome. And the client has taken the

medication for this like avaprime 1X per day for 6 months, duphaston 3X per day in 10 days per month, folic acid 1X

a day for 6months and ferrous sulphate 1x a day for also 6 months She also has a history of Childhood illness like

cough and colds, fever and no known allergies, she also have the history of chickenpox when she was 16 years old.

Ms. M got her BCG vaccine when she was an infant, because she has a BCG vaccine scar in her right arm. She doesn't

remember if she has a complete immunization.

 June 6, 2020

C. Present Health Illness

While the client is at work client experience

mild pain on her abdomen

Client suffered from mild pain More painful when

on her hips, weakness she's in a cold area

June 11, 2020

Client went to ICMCwith her brotherbecause of

chief complaint of abdominal pain

June 12, 2020

 Activities of Daily Living

ADL BEFORE DURING INTERPRETATI NURSING

HOSPITALIZATI HOSPITALIZATI ON RESPONSIBILITIES
ON ON

Nutrition The patient’s most - Usually tends Ovarian Dermoid Provide information
common intake of to buy foods Cyst regarding individual
foods are grains like outside rather nutritional needs.
rice, bread, pasta than eat Hospitalization
also likes to eat foods served Offer high protein
vegetables. Rarely by the Picky eater supplements based on
eats meats & hospital. individual needs and
seafoods. - Picky eater capabilities.
Imbalanced
nutrition: less than Encourage family
body requirements members to bring
healthy foods from
home to the hospital.

Exercise - Once a week - The patient Establish guidelines and

only. can lift her goals of activity with the
- Riding a arms and patient.
bike every legs.
Saturday. Have the patient perform
- Can slowly the activity more slowly,
move or in a longer time with
change more rest or pauses, or
position on with assistance if
her own. necessary.

Refrain from performing

nonessential activities or
procedures.

Elimination - Urinary - Urinary Urinary retention Encourage adequate

retention and retention and related to ureteral fluid intake.
abdominal abdominal obstruction.
discomfort. pain. Monitor intake and
- Bowel - Often needs output.
eliminating help or
once a day. assistance Observe for cloudy or
- Yellowish when going bloody urine, foul odor.
color of to the Dipstick urine as
urine, rarely bathroom. indicated.
clear in
color. Compare urine output
with fluid intake, Note
specific gravity.

Hygiene - The patient - During Symptoms of body Guide the patient in

takes a bath hospitalizatio weakness accepting the needed
once a day. n, her family amount of dependence.
member Inability to perform
visits her to personal hygiene Implement measures to
ensure that promote independence,
she’s in good Self-care deficit but intervene when the
condition, patient cannot function.
helps her to
clean and Inform family members
groom to allow the patient
herself. perform self-care
- She takes a measures as much as
bath once a possible.
day.
- She brushes
her teeth
twice a day
Sleep and rest Disturbed sleep The patient has Sharp abdominal Identify the causes that
pattern. trouble sleeping at cramps are known to disrupt
night due to the sleep, such as a current
interruption of drug ↓ illness.
administration
during the night.
Decreased energy
Assist the patient with
The patient wakes
up every midnight
↓ setting priorities for
preferred activities and
because of pain in role responsibility
the abdomen.

Provide quite
Distubed sleeping environment.
pattern

Sexual activity Had sexual During her Unable to engage Assess the patient's
intercourse few hospitalization, the sexual activity due sexual desire, the impact
months ago. patient has not to health condition of her health on her
engaged in any sexuality, and the factors
sexual activity. that influence sexual
function.

Substances use Prescription drug

to treat a wide
Duphaston, -profurex Assess patients for signs
variety of bacterial
avaprime, ferrous and symptoms of
infections
sulfate, folic acid. infection prior to and
throughout therapy.

↓
-Ketarolac to relieve
moderately severe
pain, usually after Administer every 6hrs to
surgery maintain serum levels
and control pain.

↓
to treat moderate
to severe pain
Monitor ambulatory
-Nubain patients; nalbuphine
↓ may produce
drowsiness.

to relieve mild to
moderate pain

↓ Assess patients when

-Mefenamic acid develop severe diarrhea
and vomiting for
dehydration and
Laxative that electrolyte imbalance.
stimulates bowel
movements
 Administer at bedtime
-Dulcolax for morning results.

An anti-sickness Obtaining medical

medicine attention if fainting,
dizziness, irregular
↓ heartbeat or pulse, or
other unusual symptoms
-Domperidone occur.

To treat a wide
variety of bacterial
infection Assess patients for signs
and symptoms of
infection prior to and
throughout therapy.

-Cefuroxime

Pathophysiology
 Sexual intercourse The sperm and Fertilization
egg cell meet. occurs

Four cells then divide The two cells divide Fertilized egg divides
into eight cells into four into two cells

Totipotential cell
blastocyte embryo exits the embryo

Enlargement of Totipotential cell got embedded in

dermoid cyst Dermoid Cyst
the ovary
Hair

Teeth
Abdomina
l pain
Brain tissue

Fluids
Mefenamic oophorectomy
Acid Presses the Laboratories
bladder CBC

Difficulty
in
urination

PATTERNS OF FUNCTIONING
Psychological Assessment Interpretation Relevant theory Analysis
Health
Coping Pattern Maraming pagbabago According to the Sister Callista Possible changes and
at epekto tong client, she expected Roy’s Adaptation effect because of her
kondisyon ko ngayon, to have a lot of model of Nursing recent condition
lalo sa work ko changes and effects Theory ⇓
apektado din, yung about her Adapting some changes
sarili ko, pamilya at condition, The client is ⇓
mga kaibigan ko na especially her work adapting to some
nga lang yung that was mostly changes and Coping up with the stress
tumutulong sakin para affected but despite effects in her life ⇓
palakasin ang loob ko it, she still because of her NORMAL
kasi lagi silang managed to try to condition, with the
andyan para tulungan cheer herself up, help of her loved
ako para harapin at also with the help ones to cope up
kayanin ko tong of her family and with the stress.
kalagayan ko. friends to cope up
with her condition.
-as verbalized by the
client

Interaction Maayos ang relasyon According to the Interpersonal Ability to socialize well
Pattern ko sa lahat ng pamilya client she has a relationship ⇓
ko dati pag uwi ko good relationship theory Have good relationship to
galing sa trabaho with her friends, Hildegard family, friends and
sabay sabay kami family and work Peplau workmate
kakain at bonding mates that is why One of the four ⇓
namin manood ng tv. in times like this components of the
Lahat sila she has many theory is person, Good interaction pattern
kasundo ko kaya nga people to rely on. which is a ⇓
nagpapalitan sila sa developing an NORMAL
pagbabantay sakin organism that tries
dito sa hospital at to reduce anxiety
nung nalaman nila na caused by needs.
kailangan ako Peplau went on to
operahan nalungkot form an
din sila at natakot. interpersonal
Ganon din yung mga model
kaibigan at katrabaho emphasizing the
ko maayos din yung need for a
relasyon ko sa kanila partnership
kaya po minsan kung educated to
hindi kaibigan ko recognize and to
yung dumadalaw respond to the
sakin, katrabaho need for help.”
naman.

Cognitive Wala naman akong According to the Theory of Ability to remember things
Pattern problema sa mga client, she has a cognitive easily
senses ko maayos pa good sense and development ⇓
naman lahat, malinaw good memory and Jean Piagets Can easily understand
mata ko di ako she can easily It deals with the things through
nagsasalamin kahit understand things nature of visualization
nung wala pa akong through knowledge itself ⇓
sakit. Malinaw na visualization. and how humans Good sensory
malinaw din pati po gradually come to ⇓
yung memorya ko acquire, construct
Good cognitive
dahil bata papo ako and use it.
development
matandain po ako sa
mga bagay bagay lalo ⇓
sa nakikita ko. NORMAL

Self- Concept “Nung sinabi ni dok According to the Sister Callista Previous ovarian
Pattern na tatanggalin nga client, the patient Roy’s Adaptation cyst(PCOS)
daw ang isa kong got lower self Model Theory ⇓
obaryo, nalungkot esteem because of Sister Callista Low in self-esteem
ako. pakiramdam ko the removal of her Roy ⇓
kulang na yung right ovary and
 pagkatao ko kasi thinks that she The patient opens Accepting the present
syempre ikaw ba cannot get pregnant herself for situation
naman alisin isang anymore but adapting gradual ⇓
ovary, bumaba self despite it, she changes that he Adjustment in perception
esteem ko. Akala ko gradually accepts might experience ⇓
di na magkakaanak. her recent after her surgery Disturb self –concept
Pero wag daw ako condition, as it is Related to changes in her
mawalan ng pagasa for the sake of her
appearance and
kaya unti-unti recovery.
perception
tinatanggap ko yung
sitwasyon ko ngayon
kasi para naman sa
ikagagaling to.

- as verbalized by the
client

Emotional ”Malungkot ako this According to the Self Care Deficit Encouraging herself to
Pattern past few days dahil client she Dorothea Orem’s reduce stress
nga sa condition ko, experiences Theory ⇓
maraming thought sadness, full To reduce the negative
yung pumapasok sa thought in her The patient is feelings
isip ko, halong kaba at mind, a mixed doing something ⇓
takot din, lalo na fear, and a bit of for herself that can Anxiety related to stress
ngayon, pangalawang nervousness be defined as self
surgery ko na ito at because of her care by doing
sana maging maayos condition but something that can
na ako para makabalik despite that, her help her be
na uli sa work kaya mom cheers her up positive after her
tinutulungan ko din to overcome those surgery.
sarili ko na palakasin negative feelings.
ang loob, in a way na
maiiwasan kong mag
isip ng kung ano ano
para hindi ako
mastress.”

- as verbalized by the
client

Sexuality Wala akong boyfriend Accordig to the The Roper- The client is single
pero may active sex client, she still Logan-Tierney ⇓
life ako, mga twice a single and has no Model for But have an active sex life
month lang, boyfriend but she Nursing ⇓
gumagamit ako ng has an active sex Use condom
condom, pero wala pa life. She does it Is a theory of ⇓
po akong asawa at twice a month nursing care based
NORMAL
anak. using a condom. on activities of
daily living, they
Last month nagkaroon She stated also that listed the ADLs
Menstruation
ako, this month wala she had her and they include
pa. Nakakaramdam menstrual cycle last death and ⇓
lang ako ng mild month and sexuality as Constriction of the uterus
cramp kapag experienced mild activities where as ⇓
nagkakaroon. cramps. sex give many Shedding of lining of
benefits in health. uterus
- as verbalized by the ⇓
client Cause of mild cramps
⇓
NORMAL

Socio Cultural Nagdiriwang kami ng According to the Culture care Celebrating of different
Pattern mga okasyon taon client they are able diversity and occasion
Cultural taon nakasanayan na to celebrate universality ⇓
Pattern namin kapag mahal occasion like Madeleine Release stress
na araw nagpapabasa fiesta,christmas and Leininger ⇓
sila nanay meron new year It is a Enhance Makes the family happy
kaming santo sa labas part of their culture individual ⇓
ng bahay kapag fiesta pattern every year. understanding of
Good cultural pattern
 naghahanda kami at different culture ⇓
kapag pasko o kaya values and beliefs. NORMAL
naman bagong taon
nag rereunion kami ng
mga kamag anak
namin bawat side para
naman kahit isang
beses lang nakakapag
bonding kami yung
wala munang
problema saya lang
muna at pamilya.

Significant Wala pa akong asawa According to the

Pattern ayoko pa kasi mag client she doesn’t
asawa, pero dati may have a husband but
boyfriend ako kaya she had a boyfriend
lang naghiwalay din before, then they
kami kasi mas naka broke up because
No husband
focus ako sa trabaho she prioritized her
Behavioral model ⇓
ko at sa pamilya. Sa work and family.
system Right oophorectomy
kondisyon ko ngayon She said that
Dorothy Johnson ⇓
parang ayoko na because of her
“each individual Reduce self esteem
muna talagang mag condition she no
has patterned,
asawa kasi nga longer wants to be ⇓
purposeful,
pakiramdam ko married because Explanation of Doctor
repetitive ways of
nabawasan yung she feels that her ⇓
acting that
pagkababae ko pero femininity has Give her hope and
comprises a
dahil sa paliwanag ng decreased and positivity
behavioral system
doctor na pwede pa because of the ⇓
specific to that
ako magka anak doctor's
individual.” NORMAL
nagkaroon ako ng pag explanation that
asa kaya mag aasawa she can have a
din ako sa future nga baby with one
lang hahaha. ovary she has hope
and decided to
marry in the future.

Recreational “Habang nasa hospital According to the Sister Callista Overcoming the pain and
Pattern ako ang ginagawa ko client, the patient Roy's Adaptation sadness
lang is talks to other Model of Nursing ⇓
nakikipagkwentuhan patients to Interact with other patient
sa ibang pasyente para minimize the pain The theory and still do what she used
hindi ako when it occurs and explained that to do
makaramdam ng her sadness that she adaptation occurs ⇓
sobrang lungkot at is experiencing and when people Good recreational pattern
hindi ko masyadong reads books as her respond positively ⇓
maramdaman yung pastime while she to changes.
NORMAL
sakit sa abdomen ko is admitted in the
kapag sumasakit at hospital. The patient is
nagpapadala ako ng using a coping
libro sa mama ko para mechanism to
may mabasa ako, adapt to her
mahilig din kasi ako environment to
magbasa ng libro.” meet her
interdependence.
- as verbalized by the
client

Environment Hindi ako sanay na According to the Environmental Not used to be in the
nasa hospital ako na client, she is not Theory environment she has now
ganito ang kapaligiran used to being in the Florence ⇓
ko parang ang liit ng environment of the Nightingale Communicate with other
mundo ko sobrang hospital whereas The act of utilizing patient
tahimik at ang lungkot she has no choice, the environment of ⇓
 puro kapwa ko din so she talks with the patient to assist To lessen negative feelings
pasyente ang other patients and him in his and increase positivity
nakapaligid sakin socialises with recovery.” It ⇓
kaya nakikipag them to avoid involves the Good environment
kwentuhan nalang ako extreme sadness nurse's initiative to ⇓
para bawas inip at and build positivity configure NORMAL
lungkot na din parang in her life while she environmental
pakiramdam ko is admitted in the settings
nalang din nasa hospital. appropriate for the
trabaho ko at mga gradual restoration
katrabaho ko lang din of the patient's
kasama ko. Puro health and that
positivity lang din external factors
pinag uusapan namin
kaya mas lalong
lumalakas loob ko na
magiging maayos din
ang lahat.

Economic Kami ni tatay ang According to the The Neuman Have work before
nagtatrabaho sa patient before Systems Model hospitalization
pamilya namin hospitalization she by: Betty Neuman ⇓
pinaghahatian namin and her father are Have savings
yung mga gastusin sa the one who gives It is based on the ⇓
bahay, sumasahod ako money for patient’s Able to support
kada buwan 15,000. household relationship to hospitalization
Ngayon dahil nasa expenses but stress, reaction to ⇓
hospital ako di ako because of her it, and
Feeling sad because of the
nakakapagbigay ng hospitalization she reconstitution
money spend in bills and
pera at yung ibang can’t contribute factors that are
medicine
ipon ko nagagastos na money for dynamic. The
dahil nga sa mga expenses. She Neuman Systems ⇓
bayarin dito sa ospital spent some of her Model is universal Disturbed thought
at savings on hospital in nature, which processes related to
pati na rin sa gamot. bills and medicine allows it to be persistent feeling of guilt
Kahit na natutustusan and even though adapted to a
namin yung gastos sa she can support her variety
ospital bills, she of situations, and
nalulungkot padin feels sad and guilty to be interpreted in
ako at medyo na because instead of many different
kokonsensya kapag spending money on ways.
naiisip ko na sa halip food they spend it
na pangkain nalang on hospital bills
namin yung pera and medicine.
napupunta pa sa
hospital at gamot ko.

Religious belief Roman Catholic,bali According to the Culture care Roman catholic
importante po sakin client she is Roman diversity and ⇓
yung religion kasi catholic and universality Strong faith to God
simula bata palang religion is Madeleine ⇓
ako nagsisimba na important to her Leininger Helps her to have strength
ako kasama pamilya because when she Enhance ⇓
ko. was a child she individual
Give her peace
Natutulungan din po always went to understanding of
ako ng religion isa po church with her different culture ⇓
ito sa nagpapatatag family. Religion values and beliefs. Good religious belief
sakin at nagbibigay ng helps her to be It focuses on the ⇓
lakas ng loob po na strong and have fact that different NORMAL
lumaban sa buhay, eto strength to fight, it cultures have
din po yung also gives her different caring
nagpaparamdam po peace but now that behaviors and
sakin ng katahimikan she’s in the different health
kahit na saglit na oras hospital she cannot and illness values,
po na pagsisimba go to church but beliefs, and
lang. Pero dahil her faith becomes patterns of
ngayon na nasa stronger than behaviors.
hospital ako hindi before.
nako nakakapag
 simba pero mas lalong
lumakas ang
pananalig ko sa
panginoon.

Values and Dati kapag may According to the Culture care Ignoring pain
beliefs masakit sakin pinapag client before, when diversity and ⇓
sa walang bahala ko she feels pain she universality Hospitalization
lang iniisip ko na ignores it, she Madeleine ⇓
mawawala din yan thinks that it will Leininger Changes perspective
agad na mas mahalaga immediately Enhance ⇓
yung trabaho ko, pero disappear that her individual
Realization
ngayon na nasa work is more understanding of
hospital ako nagbago important, but now different culture ⇓
ang pananaw ko that she is in the values and beliefs. Good values and beliefs
ngayon na realize ko hospital she It focuses on the ⇓
na sa susunod kapag changed her fact that different NORMAL
may masakit sakin o perspective and cultures have
sa pamilya ko wag ko realized that next different caring
na ipagsawalang time if they feel behaviors and
bahala punta na agad something they will different health
sa doctor at naisip ko not ignore it they and illness values,
din na pinaka immediately go to beliefs, and
importante pala ang the hospital. patterns of
kalusugan kesa sa behaviors.
ibang bagay.
Physical Assessment (General Assessment)

Normal Findings Actual Findings Analysis

Initial Assessment Final Assessment

1.Posture -Relaxed, erect -unrelaxed due to -Thoracic Kyphosis Ovarian Dermoid Cyst
Gait posture; abdominal pain ↓
coordinated - coordinated Previous PCOS
movement movement ↓
Undergo
oophorectomy
↓
Large incision
↓
Impaired Physical
Mobility

2.Personal -Clean, neat, No - Inappropriate - Take a bath (Once a Impaired Physical

Hygiene body odor or minor appearance day) Mobility
body odor relative - Unpleasant body odor - Mild odor ↓
to work; no breath - No breath odor Unable to perform
odor. personal hygiene
↓
Self-Care Deficit
Understandable, - understandable
1.Verbal moderate pace; - moderate pace
Behaviour clear tone and - logical sequence NORMAL
inflection; - makes sense
Logical sequence; - has sense of reality
makes sense; has
sense of reality.

Vital Signs

Sympathetic Nervous
a. PR 60-100 bpm 110 bpm 108 bpm System
↓
Stimulate electrical
pain signal
↓
Reach CNS
↓
Elevated Pulse Rate

b. RR 12-20 cpm 24 cpm 23 cpm Sympathetic Nervous

System
↓
Stimulate electrical
pain signal
↓
Reach CNS
↓
Altered breathing
pattern
 c. BP 120/80 mmHg 125/90 mmHg 130/90 mmHg Sympathetic Nervous
System
↓
Stimulate electrical
pain signal
↓
Reach CNS
↓
Elevated Blood
Pressure

d.Temperatur 36.5 C 36.8 C 37.2 C

e NORMAL

Body Built

a. Height 164.592 cm 162.56 cm

b. Weight 110 to 140 lbs. 149.914

c. BMI 18.5-24.9 25.7 ---

B. Integumentary System
Final
Body Technique Normal Initial Assessment Analysis Diagnosis
Parts Used Findings Assessment

Skin

Skin
Color Inspection Varies from - Skin color - Skin color light NORMAL
light to deep light brown brown
brown; from
ruddy pink to
light pink;
from yellow
overtones to
olive.

Unifor Inspection -Generally - Generally -Generally uniform

mity of uniform except uniform except except in areas
Skin in areas in areas exposed exposed to the sun;
Color exposed to the to the sun; areas areas of lighter NORMAL
sun; areas of of lighter pigmentation (palms,
lighter pigmentation lips, nail beds) in
pigmentation (palms, lips, nail dark-skinned people
(palms, lips, beds) in dark-
nail beds) in skinned people
dark-skinned
people

Edema Inspection -No edema - No presence of - No presence of

and edema edema NORMAL
Palpation

Skin Palpation Uniform with -with warm -with warm range of Undergo surgery
tempera normal range range of temperature due to ↓
ture temperature due fever Due to large incision
to fever ↓
Abdominal pain
↓
Hypernatremia

Skin Palpation When pinched,

Turgor (lifting and skin springs
pinching back to its NORMAL
skin on an previous state --------------- ------------------
extremity) (is elastic);
may be slower
in older adults.
Hair Inspection Evenly
and distributed hair
Palpation Thick hair
Silky, resilient -------------- ----------------- NORMAL
hair
No infection
or infestation

Nails Inspection Smooth texture -smooth texture -smooth texture

Highly -pinkish nails -pinkish nails
vascular and - intact - intact epidermis
pink in light- epidermis - capillary refill <2
skinned - capillary refill seconds NORMAL
patients; dark- <2 seconds
skinned clients
may have
brown r black
pigmentation
in longitudinal
streaks
Intact
epidermis
Generally less
than 2 seconds

C. Cephaulocaudal Assessment

Body Technique Normal Findings Actual Findings Final Findings Analysis / Nsg.
Parts Used (October 17, 2020) Diagnosis

Head Inspection and Rounded - normocephalic

(Skull Palpation (normocephalic and symmetric
and Face and symmetric, - presence of NORMAL
Skull) with frontal, uremic frost ---------------------
parietal, and
occipital
prominences);
smooth skull
contour.

Facial Inspection -Symmetric or - slightly

features slightly asymmetric facial NORMAL
asymmetric facial features
features; - palpebral fissures
palpebral fissures equal in size ----------------------
equal in size; - symmetric --
symmetric nasolabial folds
nasolabial folds.
 Facial Inspection -Symmetric facial - symmetric facial
movemen movements movements ---------------------- NORMAL
ts -

Eyes and Inspection (ask Hair evenly - hair evenly

Vision client to raise distributed; skin distributed
\ and lower the intact Eyebrows - skin intact NORMAL
External eyebrows) symmetrically - eyebrows are ----------------------
Eye aligned; symmetrically -
Structure equal movement aligned with equal
movement

Eyebrow Inspection Equally - equally

s distributed; curled distributed ---------------------- NORMAL
slightly outward - curled slightly ---
outward

Eyelashes -Skin intact; no -skin intact

discharge; no - no discharge ---------------------- NORMAL
discoloration - no discoloratiom -
Lids close - lids close
symmetrically symmetrically

Eyelids Inspection -Approximately -skin intact

15 to 20 - no discharge
involuntary blinks - no discoloration
per minute; - lids close ---------------------- NORMAL
bilateral blinking symmetrically -
When lids open,
no visible sclera
above corneas,
and upper and
lower borders of
cornea are slightly
covered.

Bulbar Inspection -Transparent; -transparent

conjuncti capillaries - capillaries
va sometimes sometimes evident
evident; sclera - sclera appears
appears white white ---------------------- NORMAL
(darker or -
yellowish and
with small brown
macules in dark
skinned clients)

Cornea Inspection -Transparent, - transparent

shiny, and - shiny
smooth; details of - moist
the iris are visible. - details of the iris ---------------------- NORMAL
In older people, a are visible
thin, grayish
white ring around
the margin, called
arcus senilis, may
be evident.

Pupils Inspection -Black in color; -Black in color; 4 mm in diameter

 equal in size; equal in size; NORMAL
normally 3 to 7 normally 3 to 7 mm
mm in diameter; in diameter; round,
round, smooth smooth border, iris
border, iris flat flat and round.
and round.

Accommo Inspection -Pupils constrict -PERRLA (pupils

dation when looking at equally round and
near objects; react to light and
pupils dilate when insufficient) ---------------------- NORMAL
looking at far --
objects.

Pupils converge
when a near
object is moved
toward the nose.

To record normal
assessment of the
pupils, use the
abbreviation
PERRLA (pupils
equally round and
react to light and
accommodation)

When looking
straight ahead,
clients can see
objects in the
periphery.

Visual Inspection -Temporally, -peripheral object

Fields peripheral objects can be seen at any
[retina can be seen at angle
and right angles (90°) ---------------------- NORMAL
neuronal to the central --
visual point of vision.
pathways The upward field
to the of vision is
brain and normally 50°,
second because the
(optic) orbital ridge is in
cranial the way. The
nerve] downward field of
vision is normally
70°, because the
cheekbone is in
the way. The
nasal field of
vision is normally
50° away from
the central point
of vision because
the nose is in the
way.

Extraocul -Both eyes -both eyes are

ar muscle Inspection coordinated, coordinated
test moving in unison, - symmetric ---------------------- NORMAL
with parallel movement with --
alignment. parallel alignment

Inspection Color same as - color same as

Ears facial skin facial skin
 Auricles Symmetrical - symmetric and
Auricles aligned aligned with outer ---------------------- NORMAL
with the outer canthus of the eye -
canthus of the
eye.

Palpation
-Mobile, firm, and -firm
not tender; pinna - mobile NORMAL
✔ Gently
recoils after it is - no tenderness
pull the folded. - pinna recoils after ---------------------- NORMAL
auricle it is folded ---
upward,
downward
, and
backward.
✔ Fold the
pinna
forward (it
should
recoil).
Push in on the
tragus. Apply
pressure to the
mastoid
process.
External Inspection Distal third
Ear Canal contains hair
follicles and
glands
Dry cerumen,
grayish-tan color; --------------------- NORMAL
or sticky, wet
cerumen in
various shades of
brown

Tympanic Inspection Pearly gray color, (-) (-)

Membran (visualizing by semi transparent
e using an NORMAL
otoscope) (-)

Gross Inspection Normal voice - normal voice NORMAL

Hearing tones audible tones audible --------------------- NORMAL
Acuity
Test
Able to repeat the - able to repeat the
✔ Whisper
phrases correctly phrases correctly in
test ( to in both ears both ears
assess NORMAL
high- Sound is heard in
frequency both ears or is
hearing) localized at the
✔ Weber’s center of the head NORMAL
(Weber negative)
test (to
assess
bone Air-conducted
conductio (AC) hearing is ----------------------
n by greater than -
examining bone-conducted
the (BC) hearing,
lateralizati i.e., AC > BC
on of (positive Rinne)
sounds)
✔ Rinne’s
Test
 - symmetric and NORMAL
External Inspection -Symmetric and straight
Structure straight - no discharge or NORMAL
No discharge or flaring ----------------------
flaring -uniform in color -
Uniform color

- no tenderness and NORMAL

Palpation -Not tender; no lesions ---------------------- NORMAL
lesions --

- air moves freely NORMAL

Patency Inspection -Air moves freely as the client ---------------------- NORMAL
as the client breathes through -
breathes through the nares
the nares.
- no lesions NORMAL
Nasal Inspection -Mucosa pink - mucosa is pink NORMAL
Cavities Clear, watery - clear ----------------------
discharge, No ---
lesions

Nasal septum - nasal septum is in NORMAL

Nasal Inspection intact and in midline and intact ---------------------- NORMAL
Septum midline. -

Not tender - no tenderness NORMAL

Facial Palpation ---------------------- NORMAL
Sinuses -
Inspection and Uniform pink
Mouth Palpation color (darker, e.g.,
bluish hue, in
Lips and Mediterranean
Buccal groups and dark --------------------- ---------------------- NORMAL
Mucos skinned clients)
Outer Soft, moist,
Lips smooth texture
Symmetry of
contour.

Inner Inspection Ability to purse

Lips and lips
Buccal Uniform pink
Mucosa color (freckled -------------------- --------------------- NORMAL
brown
pigmentation in
dark-skinned
clients
Palpation Moist, smooth,
soft, glistening,
and elastic texture
(drier oral mucosa
in older clients --------------------- ---------------------- NORMAL
due to decreased --
salivation)

Teeth and Inspection 32 adult teeth

gums Pink gums (bluish
or brown patches
in dark-skinned
clients) Moist,
firm texture to -------------------- ---------------------- NORMAL
gums --
No retraction of
gums

Dentur Inspection Smooth, intact No dentures (-)

es (if dentures
applicable
)
Inspection Central position - central position
Pink color (some
brown
pigmentation on ---------------------- NORMAL
tongue borders in
dark-skinned
clients);

Tongue

Tongue Palpation Moist; slightly - no lesions

movement rough; thin - no tenderness ----------------------
whitish coating -- NORMAL
smooth; no
lesions Raised
papillae (taste
buds)
No tenderness

Inspection Moves freely; no - moves freely

tenderness --------------------- NORMAL
NORMAL
Base of Inspection Smooth tongue - smooth tongue
the base with base with
tongue, prominent veins prominent veins ------------------- NORMAL
the mouth
floor, and
the
frenulum
Palate Inspection Light pink, - smooth
smooth, soft - soft palate
palate - pale palate
Lighter pink hard --------------------- NORMAL
palate, more
irregular texture

Uvula Inspection Positioned in mid - positioned in mid

line of soft palate, line of soft palate
rises during - smooth posterior --------------------- NORMAL
vocalization wall

Oropharyn Inspection Pink and smooth - pink and smooth

x posterior wall posterior
- smooth posterior ---------------------- NORMAL
wall
Tonsils Inspection Pink and smooth -pink
No discharge -smooth
Of normal size or -no discharge
not visible -grade 1 (normal)
• Grade 1
(normal): The
tonsils are behind
the tonsillar
pillars (the soft
structures ---------------------- NORMAL
supporting the ---
soft palate).

Neck Inspection Muscles equal in - muscles equal in

size; head size ---------------------- NORMAL
centered - head centered ---
Observe Inspection Coordinated, - coordinated
head smooth - smooth
movement movements with movements without ---------------------- NORMAL
no discomfort. discomfort ---

Sternoclei Inspection Head flexes 45° - head flexes 45°

domastoid ---------------------- NORMAL
muscle ---
Trapezius Inspection Head - head
muscle hyperextends 60° hyperextends 60° ---------------------- NORMAL
---
Muscle Palpation Equal strength - equal strength ---------------------- NORMAL
strengt ---
h
Lymph Palpation Not palpable - lymph nodes are ---------------------- NORMAL
Nodes not palpable ---
Trachea Palpation Central placement - trachea is in
in midline of midline
neck; spaces are
equal on both ---------------------- NORMAL
sides ---

Thyroid Inspection Not visible on - not visible on

Gland inspection inspection ---------------------- NORMAL
Gland ascends - gland ascends ---
during during swallowing
swallowing but is but is not visible
not visible
Upper
Extremiti
es Inspection and No lesions, no
Palpation edema, uniform in
Skin and color, uniform NORMAL
nails temperature,
blanch test of less
than 2 seconds

Bones Inspection and Able to resist - able to resist

Palpation applied pressure applied pressure NORMAL
symmetrically symmetrically
Muscle Inspection and Equal strength on NORMAL
strength Palpation each body side
and tone

Bicep Inspection and Equal strength on

Palpation each body side NORMAL
Arms and Inspection,
Forearms Palpation and
Auscultation NORMAL
Wrist and Inspection and Equal strength on
finger Palpation each body side
muscles NORMAL
Grip Inspection and Equal strength on
strength Palpation each body side
NORMAL
Joint Inspection and No swelling No - Tenderness on - Tenderness on
Palpation tenderness, back and pelvic. back and pelvic. Ovarian Dermoid
swelling, - Joints doesn't - Joints doesn't Cyst
crepitation, or move smoothly move smoothly
nodules because of the ↓
Joints move presence ovarian Pressure on and
smoothly dermoid cyst compress the
nerves
at the back of the
pelvis

↓
Back Pain and
Pelvic Pain

Range of Palpation and Varies to some - Limited range of - Limited range of

motion Inspection of degree in motion motion Ovarian Dermoid
 movement accordance with - Has restriction of - Has restriction Cyst
person’s genetic the patient's of the patient's
makeup and movements. movements due to ↓
degree of physical ovarian dermoid Back and pelvic
activity cyst. pain

↓
Limited Range of
motion

↓
Activity
Intolerance

Brachial Percussion Symmetric, - symmetric, - symmetric, Sympathetic

and within normal increased pulse rate increased pulse Nervous System
radial range - irregular rate
pulses Regular - irregular due to
pain which causes ↓
increased pulse Stimulate
rate. electrical pain
signal

↓
Reach CNS

↓
Elevated Pulse
Rate

Sensation Palpation Light tickling or - light tickling

touch sensation sensation
Able to - can discriminate ---------------------- NORMAL
discriminate sharp and dull -
“sharp” and sensations
“dull” sensations

Chest

Posterior Inspection Anteroposterior to - ratio of 1:2

Thora transverse - thorax is ---------------------- NORMAL
x diameter in ratio symmetric -
of 1:2
Thorax symmetric
Palpation Spine vertically - spine vertically
aligned aligned
Spinal column is - spinal column is
straight, right and straight
left shoulders and - right and left
hips are at same shoulders and hips ---------------------- NORMAL
height. are at the same -
Skin intact; height.
uniform - skin intact
temperature - uniform
temperature
Respirato Palpation Chest wall intact; - chest wall intact
ry no tenderness; no - no tenderness ---------------------- NORMAL
Excurs masses -
ion
Thorax Palpation Full and - symmetric thorax
for symmetric thorax expansion during
vocal expansion (i.e., deep inspiration
(tactile when the client
 fremit takes a deep
us) breath, your
thumbs should ---------------------- NORMAL
move apart an -
equal distance and
at the same time;
normally the
thumbs separate 3
to 5 cm [1.2 to 2
in.] during deep
inspiration.
Palpation Bilateral - heard clearly at
symmetry of the apex of the
vocal fremitus lungs
Fremitus is heard ---------------------- NORMAL
most clearly at the -
apex of the lungs
Palpation Low-pitched - low pitched
voices of males voices
are more readily
palpated than ---------------------- NORMAL
higher pitched -
voices of females
Palpation Percussion notes - resonant over all
resonate, except lung fields
over scapula
Lowest point of
resonance is at the
diaphragm (i.e., at NORMAL
the level of the ----------------------
8th to 10th rib -
posteriorly)

Note: Percussion
on a rib normally
elicits dullness.
Auscultation Vesicular and - bronchovesicular
bronchovesicular breath sounds ---------------------- NORMAL
breath sounds. -
Anterior Inspection Quiet, rhythmic, - quiet
Thora and effortless - rhythmic ---------------------- NORMAL
x respirations. - effortless -
respirations
Palpation Full symmetric - full and
excursion; thumbs symmetric
normally separate ---------------------- NORMAL
3 to 5 cm (1.2 to 2 -
in.)
Palpation Same as with - symmetric thorax ---------------------- NORMAL
posterior thorax -
Percussion Percussion notes - resonant over all
resonate down to lung fields
the sixth rib at the - flat over bones
level of the and muscles
diaphragm but are - dullness over
flat over areas of heart, liver,
heavy muscle and tympanic ---------------------- NORMAL
bone, dull on -
areas over the
heart and the
liver, and
tympanic over the
underlying
stomach.
Auscultation Bronchovesicular - bronchovesicular
and vesicular breath sounds ---------------------- NORMAL
breath sounds -
Heart
 Auscultation No pulsations - no pulsations ---------------------- NORMAL
Tricus No lift or heave - no lift or heave -
pid
area
Aortic Auscultation Pulsations visible - Pulsations visible - Pulsations
area in 50% of adults - Palpable in most visible
and palpable in PMI in fifth LICS - Palpable in
most PMI in fifth at or medial to most PMI in fifth NORMAL
LICS at or medial MCL LICS at or medial
to MCL - No lift or heave to MCL
No lift or heave - No lift or heave
Epigast Auscultation Aortic pulsations - Increased aortic - Increased aortic Hypertension
ric pulsations pulsations ↓
area Vasoconstriction
↓
Increase
peripheral
resistance
↓
Cardiac
hypertrophy
↓

Increased
Cardiac Output

S1: usually heard - normal S1, S2

at all sites Usually and S4 sounds
louder at apical
area
S2: usually heard
at all sites Usually
louder at base of
heart Systole:
silent interval; ---------------------- NORMAL
slightly shorter -
duration than
diastole at normal
heart rate (60 to
100 beats/min)
Diastole: silent
interval; slightly
longer duration
than systole at
normal heart
rates.
S3 in children and
young adults
S4 in many older
adults
Carotid Palpation Symmetric pulse - fast pulse Hypertension
Arteri volumes volumes (increased ↓
es cardiac rate) Vasoconstriction
↓
---------------------- Increase
- peripheral
resistance
↓
Cardiac
hypertrophy
↓
Increased
Cardiac Output
Palpation Full pulsations, - quality remains
thrusting quality same when client
Quality remains bretahes, turns
same when client head and changes
breathes, turns from sitting to ---------------------- NORMAL
 head, and changes supine position. -
from sitting to
supine position
Palpation Elastic arterial - elastic arterial
wall wall ---------------------- NORMAL
-
Auscultation No sound heard - no sound heard on ----------------------
on auscultation auscultations - NORMAL
Jugular Inspection Veins not visible - veins are not ---------------------- NORMAL
Veins visible -
Periphera Palpation Symmetric pulse
l volumes
Pulses Full pulsation
---------------------- NORMAL
-

Inspection In a dependent - no presence of

position, presence distention and
of distention and nodular bulges at
nodular bulges at calves NORMAL
calves. When
limbs elevated,
veins collapse
(veins may appear
tortuous or
distended in older
people).
Inspection Symmetric in size - symmetric in size ---------------------- NORMAL
-
Palpation Limbs is not - limbs is not ---------------------- NORMAL
tender tender -
Inspection Skin color; pink - skin color; pink ---------------------- NORMAL
-
Palpation Skin temperature - uniform skin
not excessively color not too warm ---------------------- NORMAL
warm or cold or cold -
Palpation No edema -no edema ---------------------- NORMAL
-
Palpation Skin texture - skin texture ----------------------
resilient and moist resilient and moist - NORMAL
Capillary Inspection and Immediate return ----------------------
Refill Palpation of color (less than - NORMAL
Test 2 seconds)
Breast

Inspection Females: rounded

Size,sym shape; slightly
metry, unequal in size;
contour generally
or shape symmetric Males: ---------------------- NORMAL
breasts even with -
the chest wall; if
obese, may be
similar in shape to
female breasts

Skin Inspection Skin uniform in

color (similar to
skin of abdomen ---------------------- NORMAL
if not tanned) -
Areola Inspection Skin smooth and ----------------------
intact - NORMAL
Nipples Inspection Diffuse
symmetric
horizontal or
vertical vascular
pattern in light-
 skinned people
Striae (stretch
marks); moles and
nevi

Round or oval
and bilaterally the
same Color varies
widely, from light
pink to dark
brown
Irregular
placement of
sebaceous glands
on the surface of
the areola
(Montgomery’s ----------------------- ---------------------- NORMAL
tubercles) -

Round, everted,
and equal in size;
similar in color;
soft and smooth;
both nipples point
in same direction
(out in young
women and men,
downward in
older women)

No discharge,
except from
pregnant or
breast-feeding
females
Inversion of one
or both nipples
that is present
from puberty
Palpate Inspection No tenderness,
the masses, or
axillary, nodules ----------------------- ---------------------- NORMAL
subclavic -
ular, and
supraclav
icular
lymph
nodes
.
Assessme Palpation No tenderness,
nt of masses, nodules,
breast for or nipple
masses, discharge ----------------------- ---------------------- NORMAL
tendernes -
s, and any
discharge
from the
nipples.

Abdomen Inspection -unblemished skin - surgical scar - surgical scar due

-uniform color - uniform skin to surgery Ovarian Dermoid
Silver-white striae color - 2cm size of the Cyst
(stretch marks) or scar ↓
surgical scars Undergo surgery
↓
Large Incision
↓
Scar
↓
 Impaired Skin
Integrity

Inspection Flat, rounded - scar - scar

(convex), or Ovarian Dermoid
scaphoid Cyst
(concave) ↓
Undergo surgery
↓
Large Incision
↓
Scar
↓
Impaired Skin
Integrity

(Ask the client No evidence of - no evidence of

to take a deep enlargement of enlargement of
breath and to liver or spleen liver or spleen ---------------------- NORMAL
hold it) -
Abdomin Inspection Symmetric - symmetric
al contour contours
movemen
ts ---------------------- NORMAL
associated -
with
respiratio
n,
peristalsis
, or aortic
pulsations
.
Inspection Symmetric - symmetric
movements movements caused
caused by by respirations
respiration
Visible peristalsis
in very lean ---------------------- NORMAL
people -
Aortic pulsations
in thin people at
epigastric area
Vascular Inspection No visible - no visible - no visible
patter vascular pattern vascular pattern vascular pattern
n

NORMAL

Bowel Auscultation Audible bowel

sounds (use sounds
diaphragm of
stethoscope)
----------------------- ---------------------- NORMAL
-
 Auscultation Absence of
(use the bell of arterial bruits
the ----------------------- ---------------------- NORMAL
stethoscope) -

Peritoneal Auscultation Absence of - absence of

Friction friction rub friction rub ---------------------- NORMAL
Rubs -
Palpation No tenderness; - unrelaxed - unrelaxed Ovarian Dermoid
relaxed abdomen abdomen abdomen, Cyst
with smooth, - tenderness tenderness, ↓
consistent tension - inconsistent inconsistent Undergo surgery
tension tension due to ↓
abdominal pain Large Incision
after surgery ↓
Abdominal Pain

Urinary Palpation Not palpable - not palpable ----------------------

bladder - NORMAL

Muscuske
letal Inspection Equal size on - equal size on both ---------------------- NORMAL
Syste both sides of body sides of the body -
m
Muscle

No contractures - no contractures NORMAL

No tremors - no tremors
NORMAL

Muscle Palpation
strength 1. 5
1. Sterno 2. 5
cleido 3. 5
mastoi 4. 4
d 5. 4
2. Trapez 6. 5
ius 7. 5
3. Deltoi 8. 5 NORMAL
d 9. 5
4. Biceps 10. 5
5. Tricep 11. 5
s 12. 5
6. Wrist 13. 5
and
Finger
Muscl
es
7. Grip
strengt
h
8. Hip
muscle
s
9. Hip
abduct
ion
10. Hip
adduct
ion
11. Hamst
rings
12. Quadri
ceps
13. Muscl
es of
the
 ankles
and
feet
Bones Inspection No deformities - no deformities ---------------------- NORMAL
-
Joints Palpation No tenderness or - no tenderness or
swelling swelling ---------------------- NORMAL
-
Female
Genita
ls and
Inguin Inspection There are wide Not Applicable
al variations; ---------------------- NORMAL
Area generally kinky in
the menstruating
Public adult, thinner and
area straighter after
menopause
Distributed in the
shape of an
inverse triangle

Pubic skin intact, Not Applicable

no lesions
Skin of vulva area
slightly darker ---------------------- NORMAL
than the rest of -
the body
Labia round, full,
and relatively
symmetric in
adult females
Clitoris, Inspection Clitoris does not
urethral exceed 1 cm (0.4 Not Applicable
orifice, in.) in width and 2
and cm (0.8 in.) in
vaginal length Urethral
orifice orifice appears as
a small slit and is
the same color as ---------------------- NORMAL
surrounding -
tissues
No inflammation,
swelling, or
discharge
Inguinal Inspection No enlargement Not Applicable ----------------------
lymph or tenderness. - NORMAL
nodes
Anus Inspection Intact perianal - intact perianal
skin; usually skin
slightly more - slightly more
pigmented than pigmented than the
the skin of the skin of the buttocks
buttocks Anal - anal skin is
skin is normally normally more ---------------------- NORMAL
more pigmented, pigmented, coarser, -
coarser, and and moister than
moister than perianal skin and is
perianal skin and usually hairless
is usually hairless.
 Asia Pacific College of Advanced Studies
College of nursing
A.H. Banzon St. Ibayo, City of Balanga, Bataan

COURSE IN THE WARD

DATE MANAGEMENT INDICATION

June 11, 2020 AM Please admit to room of choice under my

service Due to present condition

Dermoid cyst on right ovary

For observation, diagnosis and treatment

Secure consent for ex lap on 6:11 am, on June
11, 2020 AM Right to appropriate medical care

Right for information and legal purposes

Secure consent

Monitor V/S Q shift and record

Sign of change in the patient's condition

Used to identify a predisposition to a

disease or disorder

Clue to illness or disease that can be

hurting the organ systems

Monitor v/s

NPO
Preparation for an operation

For exploratory laparotomy

To prevent vomiting

IVF of patient: D5NR 1 liter for 10 hours

IVF get the benefits immediately

D5nr use for fluid and electrolytes

resuscitation

Inform me of admission
The doctor need to know about the
information of the patient

Reasons why a patient is being admitted

Inform

Refer accordingly

May go ahead with contemplated procedure

*CP cleared
Assess the patient's general medical
condition

↓
 Helps doctors to decide if the patient is
suitable for the surgery

CP cleared

June 12, 2020 Schedule for ex lap at 11:00 am

Is surgery to open up the belly area

Operation is performed to examine

abdominal organs

Dr. Lucas for Anesthesia

Anesthesia keeps you from feeling pain
during surgery

Dr. Lucas monitor the vs of pt including

how heart and lungs working

Profurex 1.5gm/ IV anst 1 hour prior to OR

Used to treat a wide variety of bacterial
infections

Used to prevent infection from certain

surgeries

Belongs to a class of drugs known as

cephalosporin antibiotics

It works by stopping the growth of

bacteria

(Post anesthesia) S/P explore lap oophorectomy under spinal

anesthesia
Performed with patient under general
anesthesia

Spinal anesthesia often for genital, urinary

tract or lower body procedures

Used when the procedure is too painful

w/out any pain medicine

To rr, o2 inhalation for 1 hour

To correct alveolar and/or tissue hypoxia

Receive oxygen therapy

 ↓

Prevent development of Hypoxemia

Reduced chest wall and diaphragmatic

activity

Flat on bed for 8 hours

Positions after surgery requires lying
straight on your back

Maintain adequate respiratory function

With no constricting external compression

on the respiratory system

NPO then may have clear liquid, tea, crackers 8

hours post op the soft diet once with flatus
Prevention of aspiration pneumonia

Ability to pass gas is sign that

gastrointestinal tract is waking up

It is a sign that digestive organs are

returning to their normal state

IVF: D5nr 1 liter for 8 hours

IVF get the benefits immediately

D5nr use for fluid and electrolytes

resuscitation

Ketorolac 30mg/ IV q8 anst

Used to relieve moderately severe pain,
usually after surgery

Class of medications called NSAIDs

Works by stopping the body's production

of a substance

Causes pain, fever, and inflammation.

 Nubain 5mg/ IV prn for severe pain q6
Pain reliever

Used to treat moderate to severe pain

Used for treating pain just after surgery

After intravenous injection: 2 to 3mins

The duration of action of nalbuphine

ranges from 3 to 6 hours

Monitor V/S q1 till stable the q4

Change in the patient's condition

Normal vital sign ranges:

BP: 90/60 mm Hg to 120/80 mm Hg. RR:

12 to 18 breaths per minute. Pulse: 60 to
100 beats per minute. Temperature:
36.5°C to 37.5°C

Watch out for profuse vaginal bleeding

Infection of the cervix , or cancer of the
uterus

Cause abnormal bleeding

Call doctor when it occurs

Refer

*Specimen for histopath ℅ Dr. Celestino

Examination of sampled whole tissues

Which are removed during surgical

operations

June 12, 2020 Moderate to high back rest

Upper half is between 60° and 90°

Used for feeding the patient, improved

breathing, and etc.

Mefenamic acid 500mg q8

Used to relieve mild to moderate pain

↓
 Class of medications called NSAIDs

Works by stopping the body's production

that causes pain, fever, and inflammation

June 12, 2020 DAT

3:30 PM Advised in relation to surgery

Ready for advancement to the next stage

To solid food and finally regular diet

IVF to consume
Discontinue IV fluids

Fluid volume has returned to baseline

Patient is being discharged from the

facility

Remove IFC now, check voiding 6hours after,

refer unable to void Instructed to remove Foley catheter

Help prevent infection and other

complications

Incomplete bladder emptying

Muscles of the bladder are not able to

squeeze properly to empty the bladder

Caused by surgery

Insert Dulcolax suppository after removal of

IFC Laxative that stimulates bowel movements

Used to treat constipation

Produce a bowel movement in 6 to 12

hours

Domperidone 10mg q8
An anti-sickness medicine

Helps to stop feeling or being sick

 ↓

To treat stomach pain

Cefuroxime 500mg q8
To treat a wide variety of bacterial
infections

Known as a Cephalosporin antibiotic

Works by stopping the growth of bacteria

Encourage ambulation
Stimulates circulation

Help stop the development of stroke-

causing blood clots

Walking improves blood flow

Refer

June 13, 2020 May go home anytime

11:30 am After treatment

Process called hospital discharge

When you no longer need to receive

inpatient care

Please advice

Laboratory

Date Laboratory Actual Result Normal Result Analysis

May 25, 2020 Chest PA (Adult) -Both lungs fluid is -patient stands or sits upright Normal
essentially clear. approximately 6 feet in front
-Diaphragm and sinuses of the beam source and faces
are negative. the receptor.
-Heart is not enlarged -Penetration: the vertebrae
with no deformity. behind the heart are barely
-Visible bony thoracic visible.
cage shows no abnormal -diaphragm can be traced up
changes. until reaching the edge of the
spine.
Impression:
NORMAL CHEST
FINDINGS

May 25, 2020 Abdomen -Negative for -Abdomen is soft

pneumoperitoneum. -symmetric Normal
-Gas pattern -non-tender without
unremarkable. distention.
-Traces of fecal material -There are no visible lesions
in the colon. or scars.
-No air fluid levels. -The aorta is midline without
-Psoas shadows and flank bruit or visible pulsation.
stripes intact.
-No abnormal masses nor
calcification.

June 4, 2020 ECG N/A Normal range 120 – 200 ms Normal

(3 – 5 small squares on ECG
paper). QRS duration
(measured from first
deflection of QRS complex to
end of QRS complex at
isoelectric line). Normal
range up to 120 ms (3 small
squares on ECG paper).

June 28, 2020 HBsAg 0.09 1.00 Non-reactive

June 28, 2020 Blood Urea 2.54mmol/L 2.5-6.1mmol/L Normal

Nitrogen

Fasting Blood 98.8mg/dL 86-105mg/dL Normal

Sugar

Serum Sodium 139.4mmol/L 135-148mmol/L Normal

Serum Potassium 3.98mmol/L 1.5-5.7mmol/L Normal

Creatinine 55.0 µmol/L 62-106 µmol/L Low-protein

intake
↓
Metabolism →
breakdown to
energy
↓
Less creatine are
created
↓
When creatine
breakdown →
Waste product
from muscle
 tissue
↓
Less creatinine
produced
↓
Filtered through
kidney
↓
Released in the
bloodstream
↓
Passed it out to
urine
↓
Imbalanced
Nutrition: Less
than Body
Requirements

June 28, 2020 WBC Count 6.82 4.00-10.00 Normal

Hematocrit 0.50 0.37-0.54 Normal

Hemoglobin 162 110-150 Hemoglobin

↓
Found in red
blood cells
↓
Carry out oxygen
to the lungs and
other body tissues
↓
Part of body
tissue has tumor
↓
High hemoglobin
levels occur
↓
Body Require
oxygen levels
capacity
↓
To supply the
body tissue
↓
Hx PCOS →
caused of
dermoid cysts
↓
Oxygen supply
from the ovary
can be blocked
↓
Ineffective Tissue
Perfusion

DRUG STUDY
 Drug Name Mechanism of Indication Contraindication Adverse Effects Nursing
Action Interventions
Generic Nalbuphine
Name: interacts with For severe Hypersensitivity CNS: dizziness, •For direct I.V.
NUBAIN Opiate receptor site pain to nalbuphine or fatigue injection through an
its components. CV: tachycardia I.V. line with a
Brand Name: GI: Abdominal compatible infusing
NALBUPHIN cramps, vomiting solution, give drug
E Binds with kappa GU: Decreased slowly—no more
HYDROCHL receptor in CNS urine output than 10 mg over 3 to
ORIDE RESP: Dyspnea, 5 minutes. Inject into
pulmonary edema, free-flowing normal
Drug respiratory saline solution,
Classification: Alteration of depression, D5W, or lactated
Chemical perception and wheezing Ringer’s solution.
class: emotional response SKIN:
Phenanthrene to pain Sensation of warmth •If patient is opioid-
derivative Other: Injection-site dependent, expect
burning, pain, drug
Therapeutic redness, swelling to cause withdrawal
class: Increased threshold symptoms, such as
Analgesic, to pain abdominal cramps,
anesthesia anorexia, anxiety,
adjunct backache, bone or
joint pain,
Available Reduced confusion,fear,
Dosage: perception to pain fever, irritability,
5mg muscle spasms, nasal
congestion, nausea,
Route: opioid craving,
IV / PRN q6 restlessness,
sensation of
crawling skin, sleep
disturbances, tremor,
uneasiness,
vomiting, and
yawning.

Drug Name Mechanism of Indication Contraindication Adverse Effects Nursing

Action Interventions
Generic
Name: Mefenamic acid To relieve Hypersensitivity BODY: fever,
MEFENAMI binds the mild to infection • Assess patients
C ACID prostaglandin moderate CARDIO: who develop severe
synthetase pain hypertension, tachycar diarrhea and
dia
receptors COX-1 vomiting for
DIGESTIVE
Drug and COX-2. SYSTEM: dry
dehydration and
Classification: mouth, gastrointestinal electrolyte
Classification: bleeding, jaundice imbalance.
NSAID’s HEMIC &
LYMPHATIC
Available Inhibiting the SYSTEM:
Dosage: action of melena, rectal
500mg cap prostaglandin bleeding,
synthetase stomatitis, thrombocyt
Route: openia
NERVOUS
PO / q8
SYSTEM: depression,
drowsiness;
insomnia, malaise,
receptors send nervousness, , vertigo
prostanoid RESPIRATORY:
signaling in asthma, dyspnea
activity-dependent SKIN: sweat
plasticity EYE: blurred vision
UROGENITAL
 SYSTEM:
dysuria, proteinuria,
renal failure
Symptoms of pain
are temporarily
reduced

Drug Name Mechanism of Indication Contraindication Adverse Effects Nursing

Action Interventions
• NOTES:
Generic Blocking of For Contraindicated Significant: Laboratory tests may
Name: peripheral manageme in patients with Elevated prolactin be done periodically
DOMPERID dopamine nt of known levels, while taking this
ONE dyspepsia, hypersensitivity hypersensitivity medication to
heartburn, to domperidone, reactions monitor its effects
epigastric in the presence of Gastrointestinal and prevent side
Drug Domperidone pain, gastro-intestinal disorders: Dry effects.
Classification: facilitates Gastric nausea, haemorrhage, mouth, diarrhoea,
emptying and obstruction or transient intestinal • MISSED DOSE: If
vomiting. perforation and in cramps. you miss a dose, take
Classification:
patient with a Nervous system it as soon as
D2 receptor antagonist;
prolactin- disorders: remembered; do not
Prolactin releaser
Increased releasing pituitary Headache, migraine, take it if it is near the
esophageal and tumor. dizziness, time for the next
Available gastric peristalsis convulsions. dose, instead, skip
Dosage: Psychiatric the missed dose and
disorders: resume your usual
10mg nervousness, loss of dosing schedule. Do
lowered esophageal libido, Renal and not "double-up" the
Route: sphincter pressure urinary disorders: dose to catch up.
PO Urinary retention. • STORAGE: Store
Reproductive at room temperature
system and breast between 59 and 86
Decreased small disorders: breast degrees F (15 to 30
bowel transit time pain or degrees C) away
tenderness,amenorrh from heat and light.
oea. Do not store in the
Skin and bathroom.
subcutaneous tissue
disorders: Rash

Drug Name Mechanism of Indication Contraindication Adverse Effects Nursing

Action Interventions
Generic Name: Used for the short- Pain OB/GYN: GI: GI pain, diarrhea,
Ketorolac term treatment of Contraindicated - vomiting, nausea
Tromethamine moderate to severe during labor and Assess blood pressure
pain in adults delivery because it Dermatologic: (BP) periodically and
Brand Name: may adversely sweating, dry mucous compare to normal
Toradol affect fetal membrane, pruritus values
Drug circulation and Correct hypovolemia
Classification: usually used before inhibit uterine prior to administration
Anti-pyretic or after medical contractions of ketorolac
NSAID procedures or after Be aware that patient
surgery may be at risk for CV
Available events, GI bleeding,
Dosage: renal toxicity, monitor
30mg q8 anst accordingly.
Route: IM, IV, Reducing pain helps Monitor urine output
Oral you recover more in older adults and
comfortably patients with a history
of cardiac
decompensation, renal
impairment, heart
failure, or liver
dysfunction as well as
works by blocking those taking diuretics
your body's Keep emergency
production of certain equipment readily
natural substances available at time of
that initial dose, in case of
cause inflammation severe hypersensitivity
 reaction.
Protect drug vials from
light.
helps to decrease Administer every 8
swelling, pain, or hours to maintain
fever serum levels and
control pain.
Don’t forget to assess
first the patient before
administering this
not be used for mild
drug: know the history
or long-term painful
Monitor for fluid
conditions such as
retention and edema in
arthritis
patients with a history
of CHF
Health teaching
Anti-inflammatory Use the lowest dose
and analgesic
that is effective in
activity; inhibits
prostaglandins and treating your
leukotriene synthesis condition
In case of
hypersensitivity, be
sure that emergency
equipment is
available
Ketorolac should not
be used for longer
than 5 days,
including both
injection plus tablets
explained that the
side effects of this
medication includes
drowsiness,
gastrointestinal
bleeding, diarrhea,
dry mouth and
constipation
Drug Name Mechanism of Indication Contraindication Adverse Effects Nursing
Action Interventions
Generic Name: works by fighting - Hypersensitivity to
Cefuroxime bacteria in your body prophylaxis cephalosporin GI: diarrhea, anorexia, Monitor I&O rates and
sodium against antibiotics; ; vomiting pattern
infection to pregnancy Monitor for
Brand Name: abdominal (category B), manifestations of
Profurex where there lactation hypersensitivity
Drug used to treat many is increased Monito for signs and
Classification: kinds of bacterial risk of symptoms of
Second- infections infection anaphylaxis during
generation first dose
cephalosporins Culture infection, and
arrange for sensitivity
Available severe or life- tests before and during
Dosage: threatening forms therapy if expected
1.5gm/IV anst response is not seen
1hr prior to OR Before giving dug. ask
patient if she is allegic
Route: IV, IM to penicillin or
cephalosporin
to prevent infection Obtain specimen for
from certain culture and sensitivity
surgeries tests before giving first
dose
Give oral drug with
food to decrease GI
upset and enhance
absorption
Have vitamin K
available in case
hypoprothrombinemia
occurs
Discontinue if
hypersensitivity
 reaction occurs
Drug Name Mechanism of Indication Contraindication Adverse Effects Nursing
Action Interventions
Generic Name: used to treat -Short term contraindicated ● Stomach/
Bisacodyl constipation relief in patients with ● monitor fluid
constipatio abdominal
and electrolyte
n pain or
Brand Name: - ileus, levels
-Used to cramping
Dulcolax intestinal ● assess for
Drug works by increasing treat consti obstructionacut ● Nausea
Classification: pation or to e abdominal abdominal
the movement of the ● Diarrhea
Laxatives, empty the conditions distention and
intestines
Stimulant bowels including appe bowel function
● Weakness
before ndicitis, acute ● Monitor
Available surgery, inflammatory ● irregular
patients
Dosage: colonoscop bowel diseases, heartbeat receiving
helping the stool to
1 suppository y, x-rays, or and severe concomitant
come out ● severe
(10 mg) rectally other abdominal pain anticoagulants
intestinal associated with dizziness
once daily or as
medical nausea and ● trouble ● Assess-history
a single dose
Route: Oral, procedure vomiting which breathing of
Rectal promotes evacuation may be constipation,
of the colon by indicative of causes
altering intestinal the ● Encourage
fluid and electrolyte aforementioned
absorption exercise to
severe
increase
conditions
peristalsis

NCP
NURSING CARE PLAN:
Cues Nursing Analysis Planning Nursing Rationale Evaluation
Diagnosis Interventions

Subjective: Acute pain Ovary STG: Monitor the To localize if Goal has been met as
"ang sakit ng related to ↡ pain (location, an abscess evidenced by patient
tiyan ko tissue Produces After 3hours duration and develops will be able to reduce
kumikirot trauma graafian of nursing intensity) pain from 8/10 to
kirot pa" as secondary follicles interventions Maintain semi To reduce 5/10 and patient be
verbalized by to ↡ patient will fowler position diaphragmatic able to demonstrate
patient abdominal Release of be able to as indicated irritation and relaxation also
surgery motion reduce the abdominal provide comfort.
Objective: ↡ report pain Move client tension
Pain scale Oocyst from 8/10 to slowly in
8/10 become 5/10 painful area To reduce
BP 130/90 corpus muscle tension
T 38.5 luteum LTG: Provide and minimize
RR 18 ↡ diversional pain movement
PR 82 No After 2 days activities and To promote
-facial fertilization of nursing comfort relaxation and
grimace ↡ intervention measures; enhance client
Enlargement patient will massage and coping abilities
of corpus be able to instruct in by refocusing
luteum demonstrate relaxation attention
↡ relaxation visualization
Ovarian cyst and provide exercises.
↡ comfort. Provide
Removal of frequent oral To reduce
ovarian care. Remove nausea and
cyst(surgery) noxious vomiting
↡ environmental
Acute pain stimuli

Cues Nursing Analysis Planning Nursing Rationale Evaluation

Diagnosis Interventions
Subjective: Risk for For exlap STG: **Independent
“Kahapon lang infection oophorectom After a 3 Nursing -goal was met as
ako related to y hours of Intervention evidenced by
naoperahan, surgical ↡ nursing -Fever may patients ability to
pagkatapos intervention Surgical intervention, -Assess signs indicate verbalized at least 3
kanina s as incision/proc patient will and symptoms infection ways to prevent
nakakaramdam evidence by edure be able to of infection surgical infection
ako ng presence of impaired the verbalize at especially the
pangangati sa fever with skin least 3 ways body -goal was met as
parteh ng tahi redness and ↡ to prevent temperature -maintaining evidenced by
ko.” as swelling Possible entry surgical -maintain aseptic patient’s was free
verbalized by near the of infection aseptic technique from any signs and
the patient incision site microorganis technique serves as a first symptoms of
m when changing line of defense infection as
Objective: ↡ LTG: dressing or against manifested by
Risk for After 1 day of when caring infection and absence of fever
T-38.9 infection nursing wound regular wound
Facial grimace related to intervention caring/dressing
Discomfort surgical the patient promotes fast
Redness and interventions will be free healing and
swelling in the as evidence from any -Emphasized drying of
incision site by presence signs and necessity of wounds.
of fever with symptoms of taking
redness and infection as antibiotics as -
swelling near manifested by ordered discontinuation
the incision absence of of treatment
site fever. -Encourage when clients
increase in feels well may
fluid intake result in return
of infection
-fluids help
promote
diluted urine,
-Limit visitors frequent
emptying of
the bladder
**Dependent reducing the
Nursing stasis of urine.
Intervention This helps to
- Administer reduce the risk
antibiotics as of having a
ordered by the bladder
physician infection.
-restricting
visitation
. reduces the
transmission of
pathogens.

-antibiotics
will help kill
and stop the
proliferation
and growth of
the bacteria
which could
cause infection

Assessment Nursing Analysis Goals Nursing Rationale Evaluation

Dx. (Short/ Interventions
Long-term)
Subjective: Acute Pain Ovary Short Term: Independent: Short Term:
“sumasakit po may be ↡ After an hour -Assess reports -Examines the After an hour of
yung puson ko.” related to Hormonal of nursing of pain and degree of nursing intervention,
As verbalized by Physical Imbalance intervention, sensory discomfort and patient was able to:
the patient. Agents ↡ patient will alterations, verifies the -Express reduction
(dermoid Preventing be able to: noting need for in pain or
cyst) Corpus -Express location, analgesia and discomfort.
Luteum reduction in duration, and evaluates its -Appear relaxed and
formation pain or intensity (0 to effectiveness. able to sleep or rest
Objective: ↡ discomfort. 10 [or similar] - Provides appropriately.
- Self-report of Lowering -Appear scale). understanding
intensity and Steroid relaxed and of sensory
characteristics Hormone able to sleep - Explain the alterations.
of pain using Production or rest causes of pain Long Term:
standardized ↡ appropriately. to the client. -Promotes After a series of
rating scale. No ovulation relaxation, nursing intervention,
- Guarding and ↡ refocuses patient was able to
protective Occurrence attention away identify factors that
behaviors. Long Term: - Provide basic from the aggravate or relieve
of Ovarian
-Self-focused After a series comfort and discomfort, pain.
Cyst
of nursing diversional and may
↡
intervention, activities. enhance
Acute Pain
patient will Encourage coping
may be
be able to early abilities.
related to
identify ambulation
Physical
factors that and use of - Relieves
Agents
aggravate or relaxation fatigue,
(dermoid
relieve pain. techniques, increasing
cyst)
guided coping ability
imagery, and
Therapeutic - Reduces fear,
Touch. augmenting
appropriate
- Provide
pain relief, to
opportunities
enhance
for
mobility and
uninterrupted
coping
sleep.
abilities.

- Provide
accurate
information
related to
patient-
controlled - Provides
analgesia relief from
(PCA) or discomfort or
opioids to pain and
reduce fear of facilitates rest
addiction. and
participation in
postoperative
therapy
Collaborative:

-Administer
PCA (patient-
controlled
analgesia),
opioids, or
non-opioids, as
indicated.
 DISCHARGE PLAN
Dermoid Cyst

● Medication ● Nubain (5mg)

● Mefenamic Acid (500mg cap)

● Domperidone (10 mg)

● Ketorolac tromethamine (30mg q8 anst)

● Cefuroxime sodium (1.5gm/IV anst 1hr prior to OR)

● Bisacody (1 suppository (10 mg) rectally once daily or as a single dose)

● Exercise ● Mild Exercise and stretching

● Massaging the lower back, thighs, buttocks, and stomach can help
 loosen tense muscles and reduce pain.

● Treatment ● Weight loss

s
● Over the counter medication

● Heat increases blood flow, helping to reduce pain.

● Dietary Changes

● Relaxation techniques

● Health Teachings ● Eat fruits, vegetables, and whole grains.

● Drink 6 to 8 glasses of water every day, unless directed otherwise.

● Encourage client regular ob-gyn check up

● Explain the health risks of her condition, to give her knowledge about her
condition that she can have another ectopic pregnancy if not treated
properly
by medical professional.
● Use providine solution when cleaning your surgical incision.

● Provide the client an information why she needs to take this medication.

● OPD ● Make a follow-up appointment as directed by our staff or to your doctor.

● Diet ● Diet as Tolerated

● Healthy meals with rich in iron.

● Proper diet