I.

INTRODUCTION

Uterine fibroids, or leiomyomas, are tumors or growths made of smooth

muscle cells, fibroblasts, and other material that grow in or on the wall of the uterus or
womb. They are the most common non-cancerous tumors in women of childbearing age.
Uterine fibroids can cause pain and abnormal bleeding from the uterus.

Although exact causes are unknown, research evidence suggests that any or all
of these factors might play a role in the growth of uterine fibroids:1

 Genetics (e.g., genetic mutations in the MED12, HMGA2,

COL4A5/COL4A6, or FH genes)

 Estrogen and progesterone

 Growth hormones

 Micronutrients, such as iron, that the body needs only small amounts of in the
blood. For instance, a deficiency of vitamin D may be associated with uterine
fibroids.

 Major stresses

It is likely that fibroids are caused by many factors interacting with one
another. Once we know the cause or causes of fibroids, our efforts to find a cure or even
prevent fibroids could move ahead more quickly.

Fibroids usually grow in women of childbearing age, and research suggests

that they may shrink after menopause. However, research also shows that they are more
likely to shrink in postmenopausal white women than in postmenopausal black women.
For African American women, fibroids typically develop at a younger age, grow larger,
and cause more severe symptoms.

Several factors may affect a woman’s risk for having uterine fibroids,
including the following:

 Age (older women are at higher risk than younger women)

 African American race

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  Obesity

 Family history of uterine fibroids

 High blood pressure

 No history of pregnancy

 Vitamin D deficiency

 Food additive consumption

 Use of soybean milk

Factors that may lower the risk of fibroids:

 Pregnancy (the risk decreases with an increasing number of pregnancies)

 Long-term use of oral or injectable contraceptives

Many women have no symptoms of fibroids. However, uterine fibroids can cause
uncomfortable or sometimes painful symptoms, such as:

 Heavy bleeding or painful periods

 Anemia (when you don’t have enough red blood cells)
 Bleeding between periods
 Feeling “full” in the lower abdomen (belly)—this is sometimes called pelvic
pressure
 Frequent urination (caused by a fibroid pressing on the bladder)
 Pain during sex
 Lower back pain
 Reproductive problems, such as infertility, multiple miscarriages, and early onset
of labor during pregnancy
 Obstetrical problems, such as increased likelihood of cesarean section

Unless a woman has symptoms, it’s likely she does not know she has uterine
fibroids. In some cases, though, health care providers find fibroids during a routine
gynecological exam. During this exam, the health care provider checks the size of your

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uterus by putting two fingers of one hand into the vagina while using the other hand to
press lightly on your abdomen. If you have fibroids, your uterus may feel larger than
normal, or it may feel irregularly shaped.

The size of the fibroids does not seem to be related to the severity of
symptoms, so even small fibroids may cause considerable symptoms and heavy periods.
If you have symptoms but your health care provider cannot feel any fibroids during a
manual examination, he or she may use one or more types of imaging technology—
machines that create a picture of the inside of your body—to diagnose uterine fibroids.

Medications for uterine fibroids target hormones that regulate your menstrual
cycle, treating symptoms such as heavy menstrual bleeding and pelvic pressure. They
don't eliminate fibroids, but may shrink them. Medications include:

 Gonadotropin-releasing hormone (GnRH) agonists. Medications

called GnRH agonists treat fibroids by blocking the production of estrogen and
progesterone, putting patient into a temporary menopause-like state. As a result,
menstruation stops, fibroids shrink and anemia often improves.

Many women have significant hot flashes while

using GnRH agonists. GnRH agonists typically are used for no more than three to
six months because symptoms return when the medication is stopped and long-
term use can cause loss of bone. The doctor may prescribe a GnRH agonist to
shrink the size of the fibroids before a planned surgery or to help transition patient
to menopause.

 Progestin-releasing intrauterine device (IUD). A progestin-releasing IUD can

relieve heavy bleeding caused by fibroids. A progestin-releasing IUD provides
symptom relief only and doesn't shrink fibroids or make them disappear. It also
prevents pregnancy.

 Tranexamic acid (Lysteda, Cyklokapron). This nonhormonal medication is

taken to ease heavy menstrual periods. It's taken only on heavy bleeding days.

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 Nonsteroidal anti-inflammatory drugs (NSAIDs), which are not hormonal
medications, may be effective in relieving pain related to fibroids, but they don't reduce
bleeding caused by fibroids. Your doctor may also suggest that you take vitamins and
iron if you have heavy menstrual bleeding and anemia.

Surgical treatments may involve a hysterectomy. A hysterectomy is the

surgical removal of the uterus, and most likely, the cervix. Depending on the reason for
the surgery, a hysterectomy may involve removing surrounding organs and tissues, such
as the fallopian tubes and ovaries.

There are different types of hysterectomies:

 Total hysterectomy: Removing your uterus and cervix, but leaving your ovaries.

 Supracervical hysterectomy: Removing just the upper part of your uterus while
leaving your cervix.

 Total hysterectomy with bilateral salpingo-oophorectomy: Removing your

uterus, cervix, fallopian tubes (salpingectomy) and ovaries (oophorectomy). If
you haven't experienced menopause, removing your ovaries will start menopausal
symptoms.

 Radical hysterectomy with bilateral salpingo-oophorectomy: The removal of

your uterus, cervix, fallopian tubes, ovaries, the upper portion of your vagina and
some surrounding tissue and lymph nodes. This type of hysterectomy is
performed when cancer is involved.

Myomas affect, with some variability, all ethnic groups and approximately 50%
of all women during their lifetime. While some remain asymptomatic, myomas can cause
significant and sometimes life-threatening uterine bleeding, pain, infertility, and, in
extreme cases, ureteral obstruction and death.

A study conducted in 2016 by Chibber, S. et. Al., suggests that there are
significant ethnic differences in fibroid prevalence and related uterine anatomy even in
asymptomatic women. The research found that when compared to other groups, fibroid
prevalence and size remained the highest among African American women. Rates in East

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Asian women and South Asian women were similar to those found in Caucasian women.
Rates and sizes were lowest among Hispanic women, which could indicate later age of
onset and/or a different pathophysiology. Comparisons of uterine anatomy also showed
that African American women had significantly larger ovarian volumes and thicker
endometrium. Collectively, these results warrant an exploration of ethnic-specific
consideration when developing treatment options for patients with fibroids.

In relation to that, a research conducted by (Murji, A. et. Al., 2020) concluded

that Black and East Asian women have an increased clinical manifestation of uterine
fibroids compared to White women and prefer uterine preservation. There is a
discrepancy between disease burden and patient-reported outcomes that may reflect
ethnocultural differences in disease experience.

It’s extremely rare for a fibroid to go through changes that transform it into a
cancerous or a malignant tumor. In fact, one out of 350 people with fibroids will develop
malignancy. There’s no test that’s 100% predictive in detecting rare fibroid-related
cancers. However, people who have rapid growth of uterine fibroids, or fibroids that
grow during menopause, should be evaluated immediately.

In 2019, a study was conducted by the Philippine Obstetrical and Gynecological

Society wherein 135 accredited hospitals all over the Philippines submitted their census
on the number of obstetric and gynecologic cases from January 2019 to December 2019.
A total of 365,947 cases were reported, 11% (39,921) were gynecologic cases.

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 Among the 39,921 gynecologic cases reported, Leiomyoma (24%), Abnormal
Uterine Bleeding-Polyp (AUB-P) (22%), and Abnormal Uterine Bleeding-Malignancy
(AUB-M) (12.87%) were the top gynecologic diagnosis.

II. BIOGRAPHICAL DATA

Name: Ma. Bering

Age: 50

Ward: OB Gyne

Sex: Female

Birthdate: August 18, 1972

Birthplace: Bangued, Abra,Philippines

Address: Zone 7, Bangued, Abra, Philippines

Nationality: Filipino

Religion: Roman Catholic

Occupation: Housewife

Case Number: 025264

Date of Admission: February 17, 2023

Time of Admission: 8:45 am

Admitting Diagnosis: G1 P1(1001) Myoma Uteri

Final Diagnosis: G1 P1(1001) Myoma Uteri

Admitting Physician: Dr. Berna

Attending Physician: Dr. Berna

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 III. NURSING HISTORY
A. Past history

The patient stated that she had experienced mumps, measles, common coughs, colds,
and flu when she was a kid and was treated without the supervision of a physician. She
also stated that she experienced an allergy to chicken and had a kidney stone during her
high school days. She also experienced difficulty breathing that she described felt as if
riding a Ferris wheel or roller coaster. In her adulthood, she was hospitalized during her
pregnancy with her son, who underwent normal spontaneous delivery.

B. Present history

On April 20, 2020, she went for a check-up because she was experiencing menstrual
periods 3 times a month and was concerned that it was no longer normal. On her first
doctor they thought it's just a sign for menopausal. Then, she went to the medical center
in Calaba and the medical center in Dagupan, Pangasinan, and their diagnosis was
myoma.

On February 17, 2023, she went to the Abra Provincial Hospital to get more information
and confirmation about her case. After a routine assessment, her admitting doctor, Dr.
Gross, ordered a complete blood count (CBC) test. She underwent laboratory work and
an ultrasound, which revealed a G1-P1 (1001 type) myoma uteri.

C. Obstetric History

GTPALM scoring

G– 1, T – 1, P – 0, A – 0, L – 1

 Menstrual History
a. Past Menstrual Cycle
o Regularity
- Patient stated she had a regular menstruation since her first period
o Amount of bleeding
 Number of days

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 - The patient reported of having three to four days of
menstrual bleeding per 28 days of menstrual cycle.
 Volume
- The patient reported having a normal flow, and consuming
at least 7-8 pads per menstrual period.
o Associated pain.
- The patient reported having menstrual cramps during menstruation.

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 IV. ANATOMY AND PHYSIOLOGY

The uterus is a female reproductive organ that is responsible for many

functions in the processes of implantation, gestation, menstruation, and labor.

The uterus is a thick-walled

muscular structure that lies in the midline
of the abdominal pelvic cavity. It contains
three layers: the endometrium (innermost
layer), myometrium, and the perimetrium
(outermost layer). The endometrium’s
thickness and structure vary based on
hormonal stimulation

Throughout the menstrual cycle, the endometrium grows progressively thicker

with a rich blood supply to prepare the uterus for potential implantation of an embryo. In
the absence of implantation, a portion of this layer is shed during menstruation.

The myometrium is the middle and thickest layer of the uterus and is composed of
smooth (involuntary) muscle. The myometrium contracts during menstruation to help
expel the sloughed endometrial lining and during childbirth to propel the fetus out of the
uterus. The outermost layer, or serosa, is a thin fibrous layer contiguous with extrauterine
connective tissue structures such as ligaments that give mechanical support to the uterus
within the pelvic cavity. Non-pregnant uterine size varies with age and number of
pregnancies, but is approximately three and a half inches long and weighs about one sixth
of a pound.

The uterus has four parts: the fundus, corpus, isthmus, and cervix. The corpus
is the largest segment and connects to the cervix via the isthmus. The cervix connects the
uterine body to the vaginal lumen. The uterus sits posterior to the bladder and anterior to
the rectum.

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V. PATHOPHYSIOLOGY

Predisposing factor: Precipitating factor:

Age (40) Eating habits
Obesity
↑Adipose tissue
↑Estrogen Production Estrogen stimulates Conversion of androgens
proliferation of uterine into estrogen
smooth muscles

Benign proliferation of
monoclonal myometrial cells
into discrete masses

MYOMA UTERI

↑Endometrial Surface ↑ Stimulation ↑ Pressure on

Area: 10.03 cm growth of Blood Endometrium
Vessels

Frequent Urination
Uterine Bleeding

Constipation

Difficulty emptying
Anemia bladder

Pelvic pressure or
pain

↑Chance of
miscarriage

↓Fertility

LEGEND
DIAGNOSIS CLINICAL MANIFESTATION COMPLICATIONS
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 VI. LABORATORY AND DIAGNOSTIC TESTS

Parameter Result Ref. Range

WBC 5.3 x 10^3/uL 4.0 - 10.0
Lymph # 2.4 x 10^3/uL 0.8 - 4.0
Mid # 0.7 x 10^3/uL 0.1 - 1.5
Gran # 4.5 x 10^3/uL 2.0 - 7.0
Lymph % 30.1 % 20.0 - 40.0
Mid % 11.8 % 3.0 - 15.0
Gran % 42.6 % 50.0 - 70.0
HGB L 8.6 g/dl 11.0 - 15.0
RBC 4.22 μ 10^6/uL 3.50 - 5.00
HCT L 25.4 % 37.0 - 47.0
MCV L 71.9 fL 80.0 - 100.0
MCH L 18.3 pg 27.0 - 34.0
MCHC L 29.8 g/dL 32.0 - 36.0
RDW - CV H 20.0 % 11.0 - 16.0
RDW - SD 44.6 fL 35.0 - 56.0
PLT H 367 x 10^3/uL 100 - 300
MPV 9.3 fL 6.5 - 12.0
PDW 16.5 9.0 - 17.0
PCT 0. 276 % 0.108 - 0.282

SIGNIFICANCE

 Low level of HGB indicates excessive blood loss due to uterine bleeding that
causes anemia
 Low levels of RBC indicate excessive blood loss due to uterine bleeding that
causes anemia
 Low levels of HCT indicates low level of RBC due to excessive blood loss due to
uterine bleeding that causes anemia
 Low levels of MCH indicates smaller RBC size, and low levels of HGB due to
uterine bleeding that causes anemia
 low levels of MCHC indicates smaller RBC size, and low levels og HGB due to
uterine bleeding that causes anemia
 Low levels of MCV indicates a smaller size of RBC due to low HGB due to
excessive blood loss due to uterine bleeding that causes anemia
 High levels of RDW-CV indicate: most of the RBC are different in size.
 High PLT indicates presence of uterine bleeding that causes anemia

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 Test Concentration Unit Result Remark Reference
CHOLESTEROL 235.7 mg/dL ^ RFH <=200.0
TRIGLYCERIDE 106.9 mg/dL Normal <=150.0
GLUCOSE 100.44 mg/dL ^ RFH 71.00-
HEXOKINASE 99.00
HDL 46.2 mg/dL Normal 40.0-60.0
CREATININE 0.8 mg/dL Normal 0.6-1.1
SOX
BLOOD UREA 18.4 mg/dL Normal 6.0-24.0
NITROGEN
LDL 140.91 mg/dL ^ RFH <=135.00

SIGNIFICANCE
 Your total cholesterol and HDL (good) cholesterol are among numerous factors
your doctor can use to predict your lifetime or 10-year risk for a heart attack or
stroke. Your doctor will also consider other risk factors, such as age, family
history, smoking status, diabetes and high blood pressure.
 the elevated hexokinase activity resulted in enhanced glycolysis and increased
glycogen storage in the heart, indicating that glucose phosphorylation is an
important step determining cardiac glucose utilization.
LDL (low-density lipoprotein) cholesterol, sometimes called “bad” cholesterol, makes up
most of the body's cholesterol. High levels of LDL cholesterol raise the risk for heart
disease and stroke.

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 VII. DRUG STUDY

DRUG STUDY
Mechanism of
Generic Name Indication Nursing Implications Rationale
Action
Tramadol Tramadol modulates Tramadol is used to 1. Check the medication ordered.  To ensure that the
the descending pain relieve moderate to medication was
pathways within the moderately severe 2. Read the medication ordered.
Brand Name information.
central nervous pain. Tramadol  To have adequate knowledge
Ultracet
system through the extended-release about the drug.
binding of parent and tablets and capsules 3. Assess for hypersensitivity
Classification M1 metabolite to μ- are only used by to the drug.  To decrease the incidence
Opiate opioid receptors and people who are 4. Check the dose, time, and of untoward reactions.
(narcotic)analgesic the weak inhibition of expected to need route.  To ensure the desired
the reuptake of medication to relieve dose, frequency, and right
norepinephrine and pain around-the-clock. 5. Perform hand hygiene. route.
serotonin.
D.R.F.F.T  To prevent
6. Prepare medications for one contamination/spread of
Dosage:100mg patient at a time. microorganisms.
Route: IV  To prevents errors in
Frequency: q8 7. Identify the patient. medication administration.
Form: Vial  To ensures the right patient
Timing: 9:00 am, 5:00 pm, 1:00 am 8. Perform necessary receives the medications and
Precautions Contraindications assessment prior to helps prevent errors.
Use cautiously with the following Contraindicated with the medication administration.  To establish specific
conditions: following conditions: 9. Explain the purpose and parameters prior to
This medicine may cause adrenal Tramadol is contraindicated action of medication to the administration.
gland problems. Check with your in patients who have had a patient.  To reduce anxiety, to gain
doctor right away if you have hypersensitivity reaction to any compliance, and to know
darkening of the skin, diarrhea, opioid. 10. Assist the patient to an what to expect.
dizziness, fainting, loss of appetite, upright position. (Note:  To protects the patient
mental depression, nausea, skin depending on the route of from aspiration
rash, unusual tiredness or administration).
11. Store the medicine at room  To preserve the medicine.
weakness, or vomiting.
temperature away from
moisture and heat.
12. Document the administration  Timely documentation helps
of the medication immediately to ensure patient safety.
after administration.
Side Effects Adverse Reactions (Note: depending on the route of
.  shallow administration).
 Headaches breathing,
 Feeling sleepy  difficulty or
 Feeling or being sick noisy breathing,
 Dry mouth  confusion,
 Sweating  more than usual
 Low energy sleepiness

13
 DRUG STUDY
Generic Name Mechanism of Indication Nursing Implications Rationale
Action
Tranexamic Acid The binding of Decrease heavy 1. Check the medication ordered.  To ensure that the
plasminogen to fibrin menstrual bleeding and medication was ordered.
induces fibrinolysis - by cause necrosis of the 2. Read the medication  To have adequate knowledge
Brand Name occupying the necessary fibroids. information. about the drug.
Cyklokapron binding sites tranexamic
acid prevents this 3. Assess for hypersensitivity to  To decrease the incidence of
dissolution of fibrin,
Classification the drug. untoward reactions.
thereby stabilizing the clot  To ensure the desired dose,
Antifibrinolytics 4. Check the dose, time, and
and preventing frequency, and right route.
hemorrhage. route.
D.R.F.F.T 5. Perform hand hygiene.
 To prevent
Dosage:1gram contamination/spread of
microorganisms.
Route: IV 6. Prepare medications for one
 To prevents errors in
Frequency: q 8 patient at a time. medication administration.
Form: Ampule  To ensures the right patient
7. Identify the patient.
Timing: 7am, 3pm, 11pm receives the medications and
Precautions Contraindications helps prevent errors.

Before taking tranexamic acid, tell Tranexamic acid can cause 8. Perform necessary assessment To establish specific
your doctor or pharmacist if you are fibroid necrosis and prior to medication parameters prior to
allergic to it; or if you have any infarction, resulting in pain administration.
administration. 
other allergies. This product nay and providing a site for To reduce anxiety, to gain
9. Explain the purpose and action
contain inactive ingredients, which infection. Tranexamic acid compliance, and to know
of medication to the patient. what to expect.
can cause allergic reactions or other has been associated with 
problems. deep vein thrombosis and 10.Assist the patient to an upright
To protects the patient from
is therefore contraindicated aspiration
position. (Note: depending on
in women who have or are
the route of administration).
at risk of developing 
thromboembolic disease. 11.Administer the medications: To facilitate swallowing of
a. Offer water. solid drugs.

To encourage the patient’s
b. Ask the patient preference participation in taking the
Side Effects Adverse Reactions
in taking the medications  medications.
 diarrhea  seizures, by hand or in a cup. To ensure that the drug is
 dizziness  pulmonary embolism, c. Remain with the patient swallowed.

 nausea and vomiting,  deep vein thrombosis, until each medication is
To preserve the medicine.
swallowed.
 muscle pain.  anaphylaxis, 
12.Store the medicine at room Timely documentation helps
 headaches, temperature away from to ensure patient safety.
 backache, moisture and heat.
 abdominal pain, 13.Document the administration
of the medication immediately
 nausea, after administration.
 vomiting, (Note: depending on the route of
administration).
 diarrhea,
 fatigue,

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 DRUG STUDY
Mechanism of
Generic Name Indication Nursing Implications Rationale
Action
Ketorolac Anti-inflammatory Short-term 1. Check the medication ordered.  To ensure that the
and analgesic management of medication was
2. Read the medication ordered.
Brand Name activity; inhibits moderating severe information.  To have adequate knowledge
Toradol prostaglandins and acute pain for about the drug.
leukotriene single dose 3. Assess for hypersensitivity
Classification synthesis treatment to the drug.  To decrease the incidence
4. Check the dose, time, and of untoward reactions.
Anti-pyretic route.  To ensure the desired
NSAID dose, frequency, and right
D.R.F.F.T 5. Perform hand hygiene. route.
Dosage: 30 mg (3 dose)
 To prevent
Route: IV 6. Prepare medications for one contamination/spread of
Frequency: q6 patient at a time. microorganisms.
Form: Ampule  To prevents errors in
7. Identify the patient. medication administration.
Timing: 9 am, 3 am
Precautions Contraindications  To ensures the right patient
Use cautiously with the following Contraindicated with the 8. Perform necessary receives the medications and
conditions: following conditions: assessment prior to helps prevent errors.
Be aware that patient may Contraindicated medication administration.  To establish specific
9. Explain the purpose and parameters prior to
be at risk for CV events, GI with significant action of medication to the administration.
bleeding, renal toxicity, renal impairment, patient.  To reduce anxiety, to gain
monitor accordingly. aspirin allergy, compliance, and to know
recent GI bleed or 10. Assist the patient to an what to expect.
upright position. (Note:  To protects the patient
perforation Use from aspiration
depending on the route of
cautiously with administration).
impaired hearing; 11. Store the medicine at room  To preserve the medicine.
allergies; hepatic temperature away from
conditions. moisture and heat.
12. Document the administration  Timely documentation helps
Side Effects Adverse Reactions of the medication immediately to ensure patient safety.
 Headache  CV: edema after administration.
 Dizziness  EENT: tinnitus (Note: depending on the route of
administration).
 Diarrhea  GI: dyspepsia, GI
 Sweating pain, peptic
 Somnolence ulceration,
 Constipation stomatitis, GI
hemorrhage
 GU: renal
impairment
 Other: pain at
injection site

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 VIII. NURSING CARE PLAN

NURSING CARE PLAN

Assessment

Objective Data:
-VS taken as follows: - Grimacing
Temperaure – 35.1 °C - Pain Scale: 8/10
BP – 150/80 mmHg
PR – 59 bpm
RR – 27 BPM
SpO2 – 98 %

Nursing Diagnosis

Acute pain related to postoperative surgical incisions as evidenced by subjective and objective cues

Planning

After 4 hours of nursing intervention, patient will be able report pain is relieved/controlled.

Nursing Interventions Rationale

 Assessed level of pain and monitored VS
 Obtained client assessment to pain
including location, characteristics,
onset/duration, intensity, precipitating,
and aggravating factors.
 Evaluated client’s response to analgesic
and assisted in transitioning or altering
drug regimen, based on individual needs
and protocols.
 Acknowledged the pain experience and
convey acceptance of client’s response to
pain.
 Encouraged adequate rest periods.
 Discussed with SO(s) ways in which they
can assist client with pain management.
 Administered analgesics, such as
Ketorolac and Cefuroxime as indicated.
 Serves as baseline data
 To rate out worsening of underlying
condition/development of complications.
 Increasing or decreasing dosage, stepped program
helps in self-management of pain.
 Reduces defensive responses, promotes trust, and
enhances cooperative with regimen.
 To prevent fatigue that can impair ability to manage
or cope with pain.
 Family members/SOs was provided assistance by
transporting client to prevent walking long
distances, or by taking on client’s strenuous chores,
supporting timely pain control, encouraging eating
nutritious meals to enhance wellness, and providing
gentle massage to reduce muscle tension.
 To maintain acceptable level of pain.

Evaluation

After 4 hours of rendering nursing intervention, patient did not report decreased pain.
 Goal unmet

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 NURSING CARE PLAN
Assessment

Objective Data:
 VS at home. - with surgical incision at the lower abdominal area
T- 36.4 C - with dry intact dressing at the surgical site
BP- 100/70 mmHg
PR- 55 bpm
RR- 18 BPM
SpO2- 97%

Nursing Diagnosis

Impaired Skin Integrity related to surgical procedure

Planning

Within 2 hours of nursing intervention, the patient will be able to manifest dry and intact wound dressing.

Nursing Interventions Rationale

 Assessed operative site for redness,
swelling, lose sutures, or soaked dressing
 Monitored VS
 Encouraged patient to verbalize her any
untoward feelings especially pain,
discomfort as well as changes noted in
operative site
 Encouraged patient to engage ambulation
and have her SO assist her in such activities
 Instructed patient and SO to refrain from
touching/scratching operative site
 Provided regular dressing care
 To check integrity monitor progress of healing
 Serves as baseline data
 To allow continuous monitoring and assessment of
patient condition
 To promote circulation to the surgical site for
timely healing
 To avoid accumulation of moisture at the operative
site this may lead to skin breakdown
 To prevent harbor in operative site

Evaluation

After 2 hours of nursing intervention, the patient has able to manifest dry and intact wound dressing.

17
 NURSING CARE PLAN
Assessment
Objective Data:
-VS at home. - Grimacing
Temperaure – 36.4 °C - (+) surgical incision intact dressing
BP – 100/70 mmHg
PR – 55 bpm
RR – 18 BPM
SpO2 – 97 %

Nursing Diagnosis
Risk for infection related to post-operative surgical incision.
Planning
After 1 hour of nursing interventions, patient will have knowledge in identifying the risk factors
of infection, and be free from any signs and symptoms of related to infection.
Nursing Interventions Rationale
 Assessed for presence of host-specific factors
that affect immunity:
1. Extremes of age  Elderly and newborn are more susceptible to disease and
infection than the general population
2. Presence of underlying disease  The client may have a disease that directly impacts the
immune system or may be weakened by prolonged
diseases conditions
3. Lifestyle  Personal habits or living situations such as persons
sharing close quarters and/or equipment
4. Nutritional status  Malnutrition weakens the immune system; elevated
serum glucose levels provide growth media for
pathogens
5. Trauma  Loss of skin and tissue integrity, invasive diagnostic
procedure or surgery, premature rupture of amniotic
membrane, urinary catheterizations, sharps, and
needlesticks are common paths of pathogen entry
 That could be signs of developing localized infection
 Changes in skin color and warmth at insertion
sites of invasive lines, sutures, surgical incisions,  That could be signs of developing systemic infection
and wounds  To help the patient identify the present risk factors that
 Changes in mental status, skin warmth and color, may add up to the infections.
heart, and respiratory rate  To help the client modify/changed avoid some of the
 Note risk factors for occurrence of infection in environmental factors present which could reduce the
incision. incidence of infection.
 Shared health teachings especially in  Antibiotics will help kill and stop the proliferation and
identification of environmental risk factors that growth of the bacteria which could cause infection.
could add up on infection.
 Taking antibiotics such as Cloxacillin, as ordered
by the physician.
Evaluation
After 1 hour of nursing intervention, patient was able to gain knowledge and was able to identify the risk factor of
infection, and freed from any signs and symptoms of related to infection.

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 IX. DISCHARGE PLAN AND HEALTH TEACHINGS

Patient may resume a normal diet after returning home. Limit activity for 2 weeks
following surgery. Climbing stairs, walking, and light housework may be resumed at
patient’s own pace. No lifting, pushing, or pulling anything greater than 10 pounds for 6
weeks following surgery. Patient may resume driving 2 weeks following surgery. No
sexual intercourse, tampons, or douching for 6 weeks following surgery. Patient may
shower any time after returning home.

Patient must avoid heavy lifting (more than 3–4 kg) for 4–6 weeks, depending on the
advice of the surgeon. This will depend on the method of the surgery.

MEDICATIONS:

Advice the patient to follow and take the prescribed medication regimen needed
for effective treatment and fast recovery.

Patient may be prescribed antibiotics to help treat or prevent infection. Remind

patient to be sure to take all of the antibiotics even if he/she starts to feel better.

Patient may be prescribed pain medicine. Remind patient to not wait until the pain
becomes severe before taking the medicine. It may not work as well if he/she waits too
long to take it between doses.

EXERCISES:

 Instruct the patient to limit heavy exercise and plan regular naps and quiet
activities gradually increasing over the following weeks
 Instruct the patient to ambulate by walking around the house for a short period

TREATMENT:

 Encourage patient to eat nutritious foods such as fruits and vegetables

 Educate and perform the patient on how to aseptically clean the umbilical cord of
the baby

HYGIENE:

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  Educate the patient about proper hygiene and its importance
 Instruct the patient to keep incision clean and dry. It’s OK to wash the skin
around your incision with mild soap and water.
 Don’t use oils, or creams on your incision. Ask your healthcare provider before
using lotions on your incision

OUT-PATIENT:

 Advise the patient to come back for follow up checkup

 Instruct to notify the physician if any problem or complication arises
 Instruct patient to visit the healthcare provider again to be sure you are healing
well as well as to keep all follow-up appointments. Be sure to tell healthcare
provider if you have hot flashes, mood swings, or irritability. Medicine may help
ease these symptoms.

DIET:

 Follow any diet instructions given by your healthcare provider. You may need to
start with liquids and then slowly add solid foods back into your diet.
 Encourage the patient to eat nutritious foods like fresh fruits, vegetables, and
whole grains to provide the right energy it needs
 If you have constipation, your healthcare provider may tell you to add more fiber
to your diet. You may also be told to use a laxative or stool softener. These can
often be bought over the counter.
 To help your body recover from surgery, eat a well-balanced diet that includes a
variety of foods. Include proteins such as lean meat, fish, eggs, milk, yoghurt,
nuts, and legumes/beans
 Instruct the patient to Drink plenty of fluids

SPIRITUALLY:

 Instruct the patient always to pray and have faith in God in regard to her heal

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 You may feel a sense of loss and sadness after having a hysterectomy. Talking to
other women who have had a hysterectomy may help by providing emotional
support and reassurance

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