Case Study: Tubo-Ovarian Abscess

In Partial Fulfillment of the Requirements for the Subject

Care of Mother and Child at Risk or with Problem (Acute & Chronic) RLE

Submitted by:
Angel, Klien Jean S.
Borromeo, Janette H.
Dorigo, Danilo Jr. R.
Faustino, Avegail D.
Guillermo, Kristine Faith V.
Gumaru, Kristine Ariane L.
Manuel, Mizylore P.
Rasquero, Faye Ingrid I.
Turaray, Lady Rose A.
Yap, Krizeth Cherel C.

Bachelor of Science in Nursing

May 2023

Tiffany Lou C. Torres, RN, MAN

CLINICAL INSTRUCTOR
OBJECTIVES
General objectives
The general objectives of this case study for student nurses are to enhance their
understanding of tubo-ovarian abscess (TOA) and its implications for patient care. The
objectives include gaining knowledge on the etiology and risk factors associated with TOA,
comprehending the pathophysiological processes involved in abscess formation, and
familiarizing themselves with the diagnostic methods used to confirm TOA. Additionally, the
objectives aim to equip student nurses with an understanding of the appropriate treatment
approaches for TOA, including medical management with antibiotics. Overall, this case study
intends to provide student nurses with valuable insights into the assessment, diagnosis, and
management of TOA, enabling them to deliver competent and holistic care to patients affected
by this condition.
Specific objectives
● Recognize the risk factors and etiology associated with TOA: Gain knowledge of the
factors that contribute to the development of TOA, such as pelvic inflammatory disease
(PID), sexually transmitted infections, previous pelvic surgeries, and intrauterine device
usage.
● Understand the pathophysiology of TOA: Comprehend the underlying mechanisms
involved in the formation of tubo-ovarian abscesses, including the progression from
pelvic inflammation to abscess formation, the role of bacterial infection, and the
subsequent inflammatory response.
● Learn diagnostic methods and interpretation: Familiarize themselves with the clinical
presentation and diagnostic techniques used to confirm TOA, such as physical
examination findings, laboratory tests (complete blood count, inflammatory markers),
imaging modalities (ultrasound, computed tomography), and the interpretation of
microbiological analysis results.
● Explore treatment approaches: Gain an understanding of the various treatment modalities
available for TOA, including medical management with appropriate antibiotic therapy,
considerations for pain management, and potential indications for surgical intervention.
● Develop skills in patient care and education: Learn how to provide holistic care to
patients with TOA, including monitoring vital signs, managing pain and discomfort,
promoting adherence to medication regimens, and educating patients on self-care
measures and prevention strategies to minimize the risk of TOA recurrence.
● Enhance critical thinking and decision-making abilities: Apply knowledge gained from
the case study to analyze patient scenarios, make informed clinical judgments, and
participate in collaborative care planning for individuals with TOA.
By achieving these specific objectives, student nurses will be better equipped to recognize,
assess, and provide appropriate care for patients with tubo-ovarian abscesses, contributing to
improved outcomes and patient satisfaction.

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OVERVIEW
Definition
A Tubo-Ovarian Abscess (TOA) is an inflammatory mass involving the fallopian tube,
ovary and occasionally, other adjacent pelvic organs. These abscesses are found most commonly
in reproductive age women and typically result from upper genital tract infection. A tubo-ovarian
abscess is most often caused by pelvic inflammatory disease (PID). According to 2022 research,
the majority of people with a TOA are sexually active females of reproductive age. Nearly 60%
of people with the condition have never given birth.
Signs and symptoms
1. Pelvic pain: The most common symptom of a TOA is severe pelvic pain. It may be
localized on one side or may affect the entire pelvic region. The pain can be constant or
intermittent and may worsen with movement or sexual activity.

2. Fever: A TOA often leads to fever, which is typically high-grade (above 100.4°F or
38°C). The fever may be accompanied by chills and sweating.

3. Vaginal discharge: Some women with a TOA may experience abnormal vaginal
discharge. It can be thick, yellow, greenish, or foul-smelling.

4. Painful urination: Inflammation and infection in the pelvic region can cause discomfort or
pain during urination.

5. Irregular menstrual bleeding: TOA can disrupt the normal menstrual cycle, leading to
irregular or heavier-than-usual bleeding.

6. Painful sexual intercourse: Engaging in sexual activity may be painful or uncomfortable

due to the inflammation and infection in the pelvic area.

7. Nausea and vomiting: In severe cases of TOA, women may experience nausea and
vomiting, along with other systemic symptoms such as fatigue and weakness.

Epidemiology
These abscesses most commonly are found in reproductive-age women after an upper
genital tract infection. However, a TOA also can occur without a preceding episode of PID or
sexual activity and occasionally can develop as a complication of a hysterectomy.
Previously, nearly 20% of hospitalized PID cases were found to have a TOA. However,
in 2002, the Centers for Disease Control and Prevention (CDC) released new guidelines for the
evaluation and treatment of sexually transmitted diseases, which increased the number of
patients being diagnosed with and treated for PID and reduced the prevalence of TOA to a mere
2.3%.

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 Of note, women who are HIV positive with PID generally have a slower clinical
resolution of the disease and therefore an increased risk for the development of a TOA.

Risk factors
1. Age: Women who are the age of 15 to 40 years old are more at high risk and older
women may have larger abscesses with higher inflammatory markers.

2. Intrauterine Device ( UID) Insertion: Women long term IUd use can increase a person’s
chances of TOA if they are immunocompromised.

3. Multiple Sexual Partners: Having multiple sexual partners can increase a person’s
chances of contacting a sexually transmitted infection that causes a TOA.

4. Pelvic inflammatory disease (PID): People with untreated PiD are more likely to develop
a TOA as a complication of disease. Currently 20% of those with PID have a TOA.

5. Endometriosis: Those with coexisting endometriosis are 2.3% more likely to develop a
TOA. This may be due to a bacterial invasion. In addition, fluids in the endometrium may
be a breeding ground for pathogens to thrive.
Complications
1. Rupture: If a tubo-ovarian abscess is not diagnosed or treated promptly, it may continue
to grow and eventually rupture. Rupture can lead to the spread of infection into the
abdominal cavity, resulting in peritonitis, a potentially life-threatening condition.

2. Sepsis: When a tubo-ovarian abscess ruptures or if the infection spreads to other organs,
it can cause sepsis. Sepsis is a severe systemic infection that can lead to organ failure and
can be life-threatening.

3. Infertility: Tubo-ovarian abscesses and the underlying PID can cause scarring and
damage to the fallopian tubes, which may result in infertility. The scarring can obstruct
the fallopian tubes, preventing the passage of eggs from the ovaries to the uterus, thereby
reducing the chances of conception.

4. Chronic pelvic pain: Even after successful treatment of a tubo-ovarian abscess, some
women may experience chronic pelvic pain. The pain may be due to scarring, adhesions,
or ongoing inflammation in the pelvic region.

5. Ectopic pregnancy: Damage to the fallopian tubes from a tubo-ovarian abscess increases
the risk of ectopic pregnancy. An ectopic pregnancy occurs when a fertilized egg
implants outside the uterus, typically in the fallopian tube. This condition is dangerous
and requires immediate medical attention.

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 6. Recurrence: In some cases, tubo-ovarian abscesses can recur, especially if the underlying
PID is not fully treated or if there are ongoing risk factors such as multiple sexual
partners or unprotected sex.

Diagnostics
1. Blood Test: A blood test may reveal elevated levels of some clinical biomarkers of a
TOA, such as white blood cell count erythrocyte sedimentation rate, and C-reactive
protein. It can also help healthcare professionals detect the presence of pathogens in the
body.

2. Urine Test: A urine test may help doctors rule out any underlying urinary tract infection
responsible for the condition.

3. Transvaginal Ultrasound: Transvaginal Ultrasound produces clear images of the female

pelvic organs. It can help doctors detect an anomaly in the anatomical architecture of the
uterus, ovaries, tubes, cervix and pelvis.

4. Laparoscopy: This is a minimally invasive procedure that helps a surgeon access the
internal structure of the pelvis.

5. Endometrial biopsy: Following a laparoscopy, the doctor may take a small piece of tissue
from the uterus and examine it under the microscope.
Medical-Surgical management
1. Intravenous antibiotics: Broad-spectrum antibiotics are the mainstay of medical treatment
for TOA. The choice of antibiotics should cover both aerobic and anaerobic pathogens.
Commonly used regimens include:
● Cefoxitin or cefotetan plus doxycycline
● Clindamycin plus gentamicin
● Ampicillin/sulbactam plus doxycycline
● A carbapenem (e.g., meropenem or ertapenem) alone

2. Analgesia: Pain management is essential in TOA. Nonsteroidal anti-inflammatory drugs

(NSAIDs) and opioid analgesics may be used to alleviate pain.

3. Laparoscopy: This minimally invasive surgery allows doctors to drain any abscess and
remove damaged tissues in the female reproductive system.

4. Salpingectomy: If there is damage to the fallopian tube, the doctor will perform a
salpingectomy to remove it and prevent further infection.

5. Oophorectomy: Following a TOA rupture, a doctor will remove a damaged ovary by

performing an oophorectomy.

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Nursing consideration
1. Pain Management: Tubo-ovarian abscess can cause pain and discomfort, and it’s
important to ensure the patient’s managed effectively. This involves monitoring the
patient’s pain levels regularly.
2. Contraceptive/Safe Sex: Educating patients in safe sex and using contraceptives can
prevent having TOA.

3. Emotional Support: Having TOA can be an emotional experience for many women, and
it’s important for nurses to provide emotional support and reassurance to the patient's
needs. This may involve listening to their concerns, answering their questions, and
providing information about what to expect during the recovery period.

4. Mobility: Having a TOA patient may experience pain in her pelvic that can cause the
patient difficulty to stand so nurses should help patient mobility as needed, and
encourage them to get up and walk around once they are able to do so safely.
References:

Healthwise staff. (n.d.). Tubo-ovarian abscess: Care instructions. MyHealth.Alberta.ca

Government of Alberta Personal Health Portal.
https://myhealth.alberta.ca/Health/aftercareinformation/pages/conditions.aspx?hwid=uf7109

C;, K. N. (n.d.-a). Tubo-ovarian abscess. National Center for Biotechnology Information.

https://pubmed.ncbi.nlm.nih.gov/28846347/

Ewumi, O. (n.d.). Tubo-ovarian abscess: Symptoms, causes, and treatment. Medical News
Today. https://www.medicalnewstoday.com/articles/tubo-ovarian-abscess

DEMOGRAPHIC DATA

Name: Strawberry

Age: 40

Sex: Female

Weight: 65 kg

Height: 165 cm

BMI 23.9 (NORMAL)

Date of birth: September 11, 1982

Address: San Pedro-San Pablo, Aurora, Isabela

Civil status: Married

Religion: Iglesia Ni Cristo

Nationality: Filipino

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 Date/Time of admission: May 16, 2023 | 7 pm

Admitting diagnosis: GRAVIDA 0 TUBO OVARIAN ABSCESS, MULTIPLE

MYOMA PRIMARY INFERTILITY

Final diagnosis:

MEDICAL HISTORY

Past medical history

According to the patient, Strawberry, she experienced pain in her lower abdomen and felt
weak while at school. As a result, she was taken to the Clinic in Aurora on January 25, 2020,
where she was diagnosed with a tubo-ovarian abscess (TOA). The clinic prescribed Clindamycin
to her, but she stopped taking it after one day due to experiencing vomiting.

Subsequently, on March 28, 2021, Strawberry decided to visit the Cabatuan Family
Clinic to address her concerns about pain in her lower right abdomen and feeling bloated. During
this visit, she was once again diagnosed with a tubo-ovarian abscess (TOA).

Strawberry experienced pain again, this time in her lower abdomen, specifically in the
right lower quadrant (RLQ) and left lower quadrant (LLQ). As a result, she sought medical
attention at SIMC and was admitted from May 19, 2022, to June 4, 2022. Her physician at SIMC
prescribed Clindamycin for seven days and scheduled weekly ultrasounds for her. She had an
ultrasound on June 3, 2022 which revealed the presence of a tubular structure. The doctor
mentioned the possibility of surgery if she continued to experience pain in both her left and right
lower quadrants. However, due to her desire to conceive, Strawberry declined surgical
management and chose to pursue medical management alone.

Present medical history

Patient Strawberry, presented with hypogastric pain and was admitted to Southern Isabela
Medical Center on May 16, 2023 at 7 pm. She attributed the cause of her pain to a tubo-ovarian
abscess. Three days before seeking medical attention, her hypogastric pain escalated to a severity
of 7 out of 10. The day prior to her consultation, she experienced a similar level of hypogastric
pain along with fever, but did not report any abnormal vaginal bleeding. On May 17, 2023, at
3:34 pm, she underwent an ultrasound examination and inquired about the possibility of surgery
and its scheduling.

Family history

The patient stated that her mother has diabetes and her father has heart disease. She also
stated that she is the only child in their family.

Genogram

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Psychological history

The patient is not diagnosed with any psychological disorder.

Social history

Patient Strawberry started to drink wine when she was 15 years old until now, she also stated she
only drinks occasionally especially on New Year’s Eve. Patient is a non-smoker and not a recreational
drug user.

Obstetric history

Patient Strawberry experienced menarche at the age of 10, marking the onset of her
menstrual cycle. She describes her menstrual cycle as regular, but she has been experiencing
dysmenorrhea (painful menstruation). At the age of 16, she sought the help of a traditional healer
(manghihilot) to alleviate her dysmenorrhea symptoms. In terms of her sexual history, Patient
Strawberry had one previous boyfriend before her current husband. Her first sexual encounter,
also known as coitus, took place at the age of 19 with her first boyfriend and occurred five times
before they broke up. Following her marriage, at the age of 28, she and her husband engaged in
their first sexual intercourse. The patient also mentioned that she did not use any form of
contraception.

PHYSICAL ASSESSMENT

Date/Time: May 17, 2023 | 10 am

General Survey

Patient is awake, oriented, aware of her surroundings,talkative,well groomed, she has an

ectomorphic body type and does not avoid eye contact with the student nurses during the
interview. The patient is female, 40. The patient has a BMI of 23.9.3 which lies in the normal
range for someone, her height 165 cm and weight 65 kg. During the interview the patient
maintained good composure and answered all of the questions honestly and consistently
throughout the session. The interview and physical examination went smoothly and the student
nurses ensured to leave the patient in good shape afterward.

Vital signs

Blood pressure: 100/90

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Pulse rate: 95

Respiratory rate: 18

Temperature: 37.8 °C

Oxygen saturation: 98% at RA

Area Modality Actual Findings Interpretation

Head
Inspection Normocephalic or NORMAL
proportionate to body
size

Round in shape

Palpation No presence of masses NORMAL

and non-tender

Hair
Inspection The patient’s hair is NORMAL
evenly distributed
covering the whole
scalp, with no presence
of lice. Hair is oily, thin
and straight,

Dark brown in color, Because of highlights.

Unpleasant smell.
Because of not being
able to take a bath.

Scalp
Inspection There are no scars, free NORMAL
from lice, nits and
moist, no dandruff

Palpation No lesions, no NORMAL

tenderness, no masses

Face
Inspection The shape of the NORMAL
patient’s face is oval,
symmetrical

Upon smiling, the curve

is symmetrical, no signs
of drooping.

Cranial nerve VII(facial

8
 nerve) is intact

Presence of sunspots ABNORMAL

Years of exposure to
ultraviolet (UV) lights
from the sun’s rays,
accelerates the
production of melanin.
Melanin may clump
together or be produced
in higher
concentrations, causing
sunspots.

Palpation No presence of pain or NORMAL

tenderness, no masses

Cranial nerve V
(trigeminal nerve) is
intact

Eyebrows
Inspection The patient’s brow hair NORMAL
is evenly distributed,
symmetrically aligned
and black in color.

Palpation No lumps, no nodules, NORMAL

no pain during
palpation

Eyelashes
Inspection Evenly distributed and NORMAL
black in color

Eyes
Inspection Eyes are symmetrical in NORMAL
size and position, dark
brown in color, no
abnormal secretion.

Patient was able to

follow the movement of
the object left to right,
up and down, and
forward up unto the tip
of her nose.

Cranial nerve
III(Oculomotor),
IV(Trochlear),

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 VI(Abducent) are intact

The Pupils are Equal

Round Reactive to
Light and
Accommodation

Visual acuity snellen

eye chart read at 6
meters(20ft) away – ABNORMAL
can no longer read the
letters, nearsighted Due to nearsightedness
and astigmatism
Eye prescription of
-2.50 in Left eye, -3.00
in Right eye,
nearsighted

Cranial nerve II (Optic)

is intact NORMAL

Sclera The sclera is white in

Inspection color, it is moist and NORMAL
has no presence of
lesions.
Conjunctivae Both conjunctivae are
Inspection pinkish, no presence of NORMAL
lesions, no swelling and
it is moist.
Iris The iris is moist and
Inspection shiny with no discharge NORMAL
and cloudiness.
Pupil Black in color, rounded,
Inspection and movement is NORMAL
normal.
Upon shining the
penlight, from 4 mm,
the pupil constricted to
2 mm

Nose
External inspection Symmetrical, lies on NORMAL
the midline of the face,
no discharge, no
swelling, no lesions, no
nasal flaring, and no
masses.

The patient was able to

identify the scent of
alcohol without seeing
it

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 Cranial nerve I
(olfactory) is intact

Pink mucosa, no
Internal inspection lesions, nasal septum NORMAL
intact.
Absence of pain and
External palpation tenderness, nares are NORMAL
patent
Lips The patient lips is pink,
Inspection soft, moist, with no NORMAL
evidence of lesions, no
cracking
Teeth 14 teeth to the upper
Inspection and 14 teeth to the ABNORMAL
lower, 1 dental caries, 4
absence of teeth. Presence of 1 dental
caries due to poor oral
hygiene

Gums The patient’s gums is

Inspection pinkish, no swelling, no NORMAL
bleeding
Tongue
Inspection The patient tongue is in NORMAL
the midline of the
mouth, pinkish, no
lesions, and. there is a
sense of taste

Upon instruction, the

patient was able to
move her tongue freely
upward, downward,
leftward, and
rightward.

Cranial nerve IX
(glossopharyngeal),
Cranial nerve XII
(hypoglossal) is intact

Ears The patient’s ears

Inspection matches the color of her NORMAL
face, there are no
redness and swelling,
presence of earwax
(yellow)

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 Inspection Hearing acuity-Voice NORMAL
sounds audible on both
ears as we performed a
watch tick test.

Cranial nerve VIII

(Vestibulocochlear) is
intact

There is no presence of
Palpation pain, tenderness, or NORMAL
lumps.
Neck The patient’s neck is
Inspection aligned symmetrically NORMAL
with the head at central
position
Lymph nodes
Inspection and The patient’s lymph NORMAL
palpation nodes are not visible or
inflamed, and no
tenderness
Chest and
lungs Inspection The patient has no NORMAL
lesions, no wounds

Palpation The patient has no NORMAL

tenderness or masses

Auscultation Normal breath sounds NORMAL

(vesicular)
Abdomen
Inspection The surface is uniform NORMAL
in color, no presence of
rashes, no lesions, no
stretch marks

Abdominal
circumference is 36
inches

Palpation Presence of pain or ABNORMAL

tenderness in Right and
left Lumbar, Right and Because of the
left Iliac, and inflamed fallopian tube
Hypogastric region. and ovary
Pain - 7

Auscultation Normoactive bowel NORMAL

sounds

Upper
extremities Inspection and The patient has no NORMAL
palpation lesions, arms are equal
in size, no involuntary
movements, color is

12
 even
Skin
Inspection The skin complexion of NORMAL
the patient is fair

Presence of scab in feet

ABNORMAL

(Because of insect
bites)

Palpation The skin has a good NORMAL

skin turgor

Nails
Inspection Pink tones can be seen NORMAL
on the patient’s nail
beds, no clubbing

The toenails are (Because of nail polish)

magenta in color

Palpation The patient capillary NORMAL

refill is <2 seconds

Lower
extremities Inspection and The patient has no NORMAL
palpation lesions, equal in size,
no involuntary
movements color is
even

Presence of scab in feet ABNORMAL

(Because of insect
bites)

Genitalia
Inspection Presence of vaginal ABNORMAL
bleeding (dark brown in
color) Because of the
inflamed fallopian tube
and ovary

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11 GORDON’S FUNCTIONAL HEALTH PATTERN

Date/Time: May 17 | 11am

Before Hospitalization During Hospitalization

I.HEALTH The patient said that she still

PERCEPTION-HEALTH According to the patient, considers herself less
MANAGEMENT health is wealth for her, and healthy than others. She
PATTERN good health enables a person manages her health by
to enjoy life. However, she following and cooperating
considers herself not as with the health care
healthy as others since she provider's orders and health
abuses her health by eating teachings such as avoiding
unhealthy foods and has unhealthy foods since she
often been hospitalized wants to live a long life and
before. She manages herself is looking forward to a fast
by not practicing detrimental recovery.
habits such as drinking
alcohol and smoking
cigarettes. She only drinks
alcohol occasionally on New
Year's Eve. Aside from that,
she takes ascorbic acid as a
vitamin. The patient also
mentioned that there was an
instance where she went to a
manghihilot once at the age
of 16 when she was
suffering from
dysmenorrhea.

Moreover, the patient has no

known allergies. On the
other hand, whenever the
patient has common
illnesses such as fever, cold,
and cough, she does not
resort to herbal medications
but rather takes OTC drugs
such as paracetamol.

II. NUTRITIONAL – According to the patient, she According to the patient, on

METABOLIC PATTERN eats 3 meals per day. Her
appetite is good, and there is
no difficulty swallowing.
She is picky when it comes
to food, and she has no food
allergies. In her diet, she
includes meat, fish,
vegetables, and rice. She
eats meat 3x a week and fish
once a week. She only eats
vegetables as a side dish.
the 2nd day upon admission,
the doctor ordered her for
DAT at 6 a.m. and DAT
again on May 18 at 7 a.m.
Her appetite did not change;
however, she had difficulty
swallowing. She eats the
food given by the hospital
and consumes 2 glasses of
water in one day.

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 Her favorite food is sinigang
na baboy. The patient barely
eats fruits, but she does eat
mango, watermelon, and
pineapple. She also likes
eating junk food and sweets,
such as chocolate and leche
flan. The patient drinks
coffee only once a day in the
morning and consumes 8
glasses of water per day. She
also drinks soft drinks and
usually consumes 2 bottles
(12 oz.) in one day. She also
drinks milk only when
having difficulty sleeping.

III. ELIMINATION The patient said that she During hospitalization, the
PATTERN defecates once a day. The patient did not defecate.
color is either brown or Upon admission, she had
yellow and has a texture of just urinated twice. The
soft blobs with clear-cut color of her urine is brown,
edges. She does not feel any and there is a slight foul
pain when defecating. odor. There is pain while
However, the last time she urinating.
defecated was 3 days ago,
before admission. The
patient urinates 5x or more
per day. The urine color is
light yellow and has no
strong odor. There is a slight
pain and difficulty when
urinating.

IV. ACTIVITY – The patient said that she
EXERCISE PATTERN does household chores such
as laundry, cooking, washing
the dishes, and floor
sweeping. Since she is an
educator, her daily routine is
to go to school and teach
students, which serves as her
exercise. There are no
problems with gait. The
patient can feed, bathe, and
groom herself, and she does
not easily get tired. As per
her hobbies, the patient
usually hangs out with her
family every weekend, and
they're most likely to go to
malls and parks.
Since the patient is
hospitalized, her activities
are limited. She is just lying
on her bed, and whenever
she gets bored, she
communicates with her
husband and adopted son via
video call. The patient
cannot feed, bathe, and
groom herself; she has
difficulties performing the
said activities due to her
condition, and so she needs
the assistance of her SO and
healthcare providers.

V. SLEEP – REST The patient said that she The patient said that upon
PATTERN goes to sleep at 9 p.m. and admission, she had only 3

15
 wakes up at 5 a.m. She is
more comfortable in the
side-lying position when
sleeping. She also takes naps
every weekend at 2 p.m. and
usually consumes 1-2 hours.
The quality of her sleep is
poor and interrupted; she
manages it by drinking 1
glass of milk.
VI. COGNITIVE The patient is oriented to
PERCEPTUAL PATTERN people, time and place
responses verbally. Her
educational attainment is
college graduate. The patient
is able to read with a
250/300 eye grade, she is
nearsighted. Her sense of
taste is just as good as her
sense of smell. Her sense of
hearing on the right side of
her ear is well heard, loud
and clear. Her sense of touch
is normal, and the sensation
is present.
VII. According to the patient, she
SELF-PERCEPTION/SELF has a good self-image; she
CONCEPT PATTERN does not have any
insecurities about her
physical appearance, and she
accepts every bit of her
flaws.
VIII. ROLE –
RELATIONSHIP According to the patient, she
PATTERN and her husband have a good
relationship with each other.
They have an adopted son,
whom they treat like their
own biological child. The
hours of sleep, starting at 2
a.m. and waking up at 4 a.m.
Her sleep is interrupted due
to the discomfort of the
place and when there are
health care providers doing
their rounds. The patient
can’t take naps since she is
not comfortable in the
hospital environment. The
quality of her sleep is still
interrupted.
The patient is oriented to
people, time and place
responses verbally. During
the interview, she was
responsive and active. Her
sense of sight is 250/300 eye
grade. The dilation and
constriction of her pupil are
normal. She is nearsighted.
Her sense of touch, taste,
and smell is good.
According to the patient, her
self-perception has changed
due to her condition. She
cannot accept the fact that
she has been hospitalized
and will likely undergo an
operation. She also
mentioned that she feels
guilty as a teacher since she
left her job and her
coworkers took over her role
at the school where she is
attending.
According to the patient, her
husband took over her roles
and responsibilities as a wife
in their household.
Moreover, her coworkers
took over her role as an
educator at the school. She
maintained a good
16
 patient has a good relationship with her
relationship with her son. husband and son. She said
Misunderstanding and fights that her family and
coworkers understood her
are not usual in their family,
condition and were hoping
but if there are conflicts, for a fast recovery.
they resolve them through
verbal communication. The
patient also mentioned that
she has a good relationship
with her coworkers in their
workplace.
Misunderstandings are not
usual in their workplace, but
if there are conflicts, they
resolve them through verbal
communication.

IX. COPING/ STRESS According to the patient, When the patient is

TOLERANCE PATTERN whenever she gets stressed, overthinking, she said that
she usually eats until she she only talks to her son via
gets full. She also hangs out video call to calm herself
on weekends with her family because her husband cannot
and spends their time come to the hospital
watching movies at the frequently due to hospital
cinema. The patient also restrictions.
mentioned that she usually
talks to her son after work
and communicates with her
husband so she can express
her feelings and thoughts.
According to her, she is
satisfied with her coping
mechanisms.

X. SEXUALITY – Due to her condition, she is

REPRODUCTIVE According to the patient, she
PATTERN had her first menstruation at
the age of 10 and was
regular until now; however,
she still experiences
dysmenorrhoea. She usually
consumes 3 pads of sanitary
napkins fully soaked. She
had one boyfriend before her
husband, to whom she gave
her virginity at the age of 19.
They had coitus 5x and
stopped after their breakup.
unable to perform any
sexual activity. However,
she is hopeful that after the
operation, it will not affect
her sexual performance. She
also stated that during the
healing process, they would
just focus on taking care of
their son.
Moreover, there is moderate
vaginal bleeding where she
consumes 4 pads of sanitary
napkins.

17
 After 9 years of having no
sexual activity, at the age of
28, she and her husband had
their first coitus after their
wedding. She did not use
any contraceptives.

The patient is sexually

active; they almost had
coitus 4x times a week.
There are no reports of
sexual dissatisfaction, and
she has never experienced
difficulties with sexual
functioning. Overall, she is
satisfied

XI. VALUE – BELIEF The patient still prays every

PATTERN The patient's religion is
Iglesia Ni Cristo. She said
that having faith in our
Almighty God is important
because it helps her in her
day-to-day life. She attends
Thursday and Sunday
masses together with her
family. She prays daily and
believes that prayer is a
powerful way to stay close
to and deepen her
relationship with God.
day, but she cannot attend
Thursday and Sunday masses
due to her condition. She said
that she holds a strong faith in
God and believes that God will
guide and protect her family.
She prays that God will help
her during and after her
operation, and she prays for a
fast recovery.

She believes in quack

doctors since she was once
engaged in their practices
but does not support them.
The patient also stated that
she believes in superstitious
beliefs.

ANATOMY AND PHYSIOLOGY

18
 The female reproductive system consists of various organs that work together to
facilitate reproduction. These organs include the ovaries, fallopian tubes, uterus, cervix, and
vagina.

Ovaries: The ovaries are a pair of small, almond-shaped organs located on either side of the
uterus in the pelvic cavity. Their main function is the production of eggs (ova) and the secretion
of female sex hormones, such as estrogen and progesterone. Ovaries contain thousands of
follicles, each of which houses an immature egg.

Fallopian Tubes: Also known as uterine tubes or oviducts, the fallopian tubes are two thin,
muscular tubes that extend from the sides of the uterus and open near the ovaries. These tubes
serve as a pathway for the eggs to travel from the ovaries to the uterus. Fertilization of an egg by
a sperm usually occurs within the fallopian tubes.

Uterus: The uterus, also called the womb, is a hollow, pear-shaped organ located in the pelvic
cavity between the bladder and rectum. It has thick muscular walls and a lining called the
endometrium. The uterus is designed to receive and nurture a fertilized egg, allowing it to
develop into a fetus. If fertilization does not occur, the endometrium is shed during menstruation.

Cervix: The cervix is the lower part of the uterus that connects it to the vagina. It is a
cylindrical-shaped structure with a small opening called the external os, which allows the
passage of menstrual blood during menstruation and serves as the entry point for sperm during
intercourse. The cervix also produces mucus that changes consistency throughout the menstrual
cycle to facilitate or inhibit sperm transport.

Vagina: The vagina is a muscular, elastic canal that extends from the cervix to the external
genitalia. It serves as a passageway for menstrual flow, receives the penis during sexual
intercourse, and acts as the birth canal during childbirth. The vagina has a naturally acidic
environment, which helps maintain the health and balance of beneficial bacteria.

19
Uterine adnexa: includes the fallopian tubes, ovaries, and supporting structures such as the
ligaments and blood vessels in the pelvic region.

20
PATHOPHYSIOLOGY

21
COURSE IN THE WARD

22
Date & Time Progress Notes Doctors Order Interpretation

5/16/23 G0 Tubo-Ovarian Admit under Dr. For further

abscess multiple Conde/Aglugub/Pintucan monitoring
7 pm myoma primary management,
infertility service and
evaluation of the
for medical patient's condition.
management

Secure consent for To have ethical

admission & considerations and
management to protect patients
freedom to make
healthcare decisions.

DAT To ensure a high

intake of nutritious
food.

IVF: PLRS 1L x 42 For fluid

gtts/min replacement &
access in
medication.

Clindamycin 900mg To treat certain types

every 8 hours of bacterial
infections.

Gentamycin 240mg once To prevent or treat a

a day wide variety of
bacterifections.

Labs: To help figure out

what disease on
CBC, Na, K, BT, Hbsag, condition a person
Syphilis, UA, crea, has based on their
vaginal Gs/CS, TVS sign & symptoms.

Monitor vital sign every Monitoring vital

4 hours signs for baseline
comparison of vital
signs.

Paracetamol 300mg IV To help treat pain &

PRN for fever reduce a high
temperature.

Refer accordingly To ensure they

receive the care they
need.

23
 5/17/23 Start KCL tab. 2 To prevent potassium
tablets 3 x a day for 3 loss or replace
2:23 am days potassium loss.

Refer accordingly To ensure they

receive the care they
need.

5/17/23 (+) hypogastric pain DAT To ensure a high

intake of nutritious
6 am (+) R & L lower food.
quadrant tenderness

BP: 100/90 Facilitate TVS To guide a certain

procedures
RR: 20

T: 36.8

PR: 108 Continue Meds. To make sure the

body has an
Oxygen: 99 effective amount of
the drug at all times

Watch out for severe Because many

abdominal pain disease can present
with abdominal pain

Refer accordingly To ensure they

receive the care they
need.

5/17/23 (+) febrile episode PLRS 1L X 12 For fluid

hours replacement &
7:10 am (+)hypogastric pain access in medication
(+)tenderness RLQ to
LLQ

BP: 100/90 Give celocoxib To relieve pain

200mg/cap every 12
RR: 20 hours for pain

24
 T: 37.8

PR: 103 Daily perineal care To prevent infection,

skin irritation and
Oxygen: 98 getting rid of
unpleasant body
odors.

Continue IV If treatment stops

antibiotics and pt becomes sick
again, the remaining
bacteria may become
resistant.

Refer accordingly To ensure they

receive the care they
need.

Please facilitate To guide a certain

TVS at 2nd floor procedures

5/18/23 Decrease DAT To ensure a high

hypogastric pain intake of nutritious
7 am food.
(-) febrile episode

(-) dyspnea
BP:110/70

PR: 92

RR: 20

T: 36.5

(+) minimal vaginal IVF: PNSS 1L To maintain fluids

bleeding and electrolytes

awake, ambulatory Continue IV meds To make sure the

and oral meds body has an
(-) effective amount of
the drug at all times.
Abdomen: flabby,
(+) palpable
hypogastric mass,
with tenderness
upon palpation

Follow up pelvic To guide a certain

with TVS result procedure
relay once available

25
 Monitor vital signs Monitoring vital
every 4 hours sign for baseline
comparison of vital
sign

Refer accordingly To ensure receive

the care they need

LABORATORY RESULT

HEMATOLOGY CBC-5 PARTS

Date: 05-16-23

TEST RESULTS NORMAL INDICATIONS

VALUE

WBC Significance: WBC are an important

16 10^9/L 4.00 - 10.00 part of the immune system, they help
the body fight bacteria, viruses, and
other foreign invaders.
Indication: High
Implication: High WBC count usually
indicates that the body is fighting an
infection.

Neutrophil % Significance: Neutrophils are a type of

86.1 % 50.0 - 70.0 white blood cell that help your immune
system fight infections and heal
injuries.
Indication: High
Implication: High neutrophil count is a
sign that your body has an infection.
Neutrophilia can point to a number of
underlying conditions and factors,
including: infection, most likely
bacterial.

26
Lymphocyte % Significance: Lymphocytes are the
9.4% 20.0 - 40.0 cells that determine the specificity of
the immune response to infectious
microorganisms and other foreign
substances.
Indication: Low
Implication: Low lymphocyte
indicates greater higher risk for
infection

Monocyte % Significance: Monocytes turn into

4.2 % 3.0 - 12.0 macrophage or dendritic cells when an
invading germ or bacteria enters your
body. The cells either kill the invader or
alert other blood cells to help destroy it
and prevent infection.
Indication: Normal
Implication: There is nothing going on
in the patient’s body which may cause
alteration of monocyte %.

Eosinophils % Significance: Eosinophils are a type of

0.2 % 0.5 - 5.0 % white blood cell that play a role in the
immune system by helping fight
infections and boost inflammation in
the body
Indication: Low
Implication: Low Eosinophils is a mild
result due to the medication
(corticosteroids)

Basophils % Significance: The physiological role of

0.1 % 0.0 - 1.0 basophils is thought to be the release of
cytokines, leukotrienes and histamine
to aid immunity to pathogens.
Indication: Normal
Implication: There is nothing going on
in the patient’s body which may cause
alteration of basophil %.

27
 RBC Significance: Red blood cells, also
5.31 10^12L 3.550 - 5.00 known as erythrocytes, deliver oxygen
to the tissues in your body.
Indication: High
Implication: High Red blood cells
(RBC) is indicates as increase in
oxygen that carrying in the cells of
blood

Hemoglobin Significance: Hemoglobin is the

11.1 g/dL 11.0 - 15.0 protein contained in red blood cells that
is responsible for delivery of oxygen to
the tissues.
Indication: Normal
Implication: There is nothing going on
in the patient’s body which may cause
alteration of hemoglobin value.

Hematocrit Significance: Hematocrit measures the

34.7 g/dL 37.0 - 47.0 volume of red blood cells compared to
the total blood volume (red blood cells
and plasma).
Indication: Low
Implication: Low Hematocrit is
usually signs of anemia that can cause
of blood loss, nutritional deficiencies,
or in the medications

MCV Significance: Mean corpuscular

65.3 fL 80.0 - 100.0 volume (MCV) is a laboratory value
that measures the average size and
volume of a red blood cell.
Indication: Low
Implication: Low Macrocytosis
(MCV) is usually indicates as anemia,
or prolonged blood loss

MCH Significance: Mean corpuscular

20.9 pg 27.0 - 34.0 hemoglobin (MCH) is a measurement
of the average amount of hemoglobin in
each red blood cell.
Indication: Low

28
 Implication: Low mean corpuscular
hemoglobin (MCH) indicates as the
presence of iron deficiency anemia

MCHC Significance: The purpose of an

32.0 g//dL 32.0 - 36.0 MCHC test is to evaluate whether RBC
are carrying an appropriate amount of
hemoglobin.
Indication: Normal
Implication: There is nothing going on
in the patient’s body which may cause
alteration of MCHC

Platelet Significance: Platelets are tiny blood

153 10^9/L 150 - 450 cells that help your body form clots to
stop bleeding
Indication: Normal
Implication: There is nothing going on
in the patient’s body which may cause
alteration of platelet

RDW-CV Significance:The RDW value depicts

15.7 % 11.0 - 16.0 whether the red blood cells are of
normal size and shape.
Indication: Normal
Implication: There is nothing going on
in the patient’s body which may cause
alteration of RDW-CV

RDW-SD Significance: The RDW value depicts

38.1 fL 35.0 - 56.0 whether the red blood cells are of
normal size and shape.
Indication: Normal
Implication: There is nothing going on
in the patient’s body which may cause
alteration of RDW-SD

MPV Significance: MPV test measures the

12.7 fL 6.5 - 12.0 average size of the platelet
Indication: High
Implication: High MPV is indicate’s as
higher plates

29
 PDW Significance: PDW reflects how
15.8 15.0 - 17.0 uniform the platelets are in size.
Indication: Normal
Implication: There is nothing going on
in the patient’s body which may cause
alteration of PDW

PCT Significance: Procalcitonin is a protein

0.194 % 0.108 - 0.282 that is produced by the body in
response to bacterial infections, and its
level in the blood can indicate the
presence and severity of a bacterial
infection.
Indication: Normal
Implication: There is nothing going on
in the patient’s body which may cause
alteration of PCT

NRBC% Significance: Nucleated Red Blood

0.00 % 0.00 - 9999.99 Cell (NRBC) is to measure the normal
result or absence for the blood
Indication: Normal
Implication: There is nothing going on
in the patient’s body which may cause
alteration of NRBC %

Date: 05-16-23

Hemolysis (H): 17 ICTERUS (I): 2 TURBIDITY (T): <20

ASSAY RESULT HIT RANGE

Creatinine 78.2 umol/L 46.0 - 92.0

Date: 05-16-23

Hemolysis (H): 15 ICTERUS (I): 2 TURBIDITY (T): <20

30
 ASSAY RESULT HIT RANGE

Potassium LO 3.11 mmol/L 3.50 - 5.10

Sodium 135.1 mmol/L 135.0 - 145.0

BLOOD CHEMISTRY
Date: 05-13-23

Examination Result Normal Values

Creatinine F (BT2) 189.90 53.0 - 106 umol/L

RBS 211 80 - 120 mg/dL

Sodium (Easylyte) 14.2.1 135 - 148 mmol/L

Potassium (Easylyte) 2.63 3.5 - 5.3 mmol/L

Pt name: Strawberry Patient ID: 122530

Physician: Pagcanlungan, Marjorie Espiritu Case No.: 2023-0158UTZ
Room No.: Ward 2 (GYNE) Age: 40
Sex: F Rendered date: May-17-2023
Birth date: Sep-11-1982 Released date: May-17-2023

SONOGRAPHIC REPORT
TRANSVAGINAL

DATE AND TIME DONE: 05/17/2023 3:34 PM

PELVIC (TRANSVAGINAL) TRANSVAGINAL
Findings:
Uterus: Normal-sized, anteverted measuring 7.23 x 4.89 x 4.23 cm with borders and
inhomogenous parenchymal echopattern. Focal area of hyperechogenicity is noted along the
anterior myometrial region and demonstrate linear echogenic striations. Some vascularities are
seen on color flow.
Endometrium: Echogenic with full thickness of 1.01 cm with minimal endometrial cavity fluid
along the lower segment.
Adnexae: A complex cystic tubular structure with low level internal echoes measuring 5.37 x
4.87 x 2.74 cm is noted on the right adnexal region. Likewise, a complex cystic tubular structure
with low to mid level internal echoes is also noted on the left measuring 6.83 x 6.37 x 5.59 cm.
No vascularity appreciated on the color flow. No normal-looking ovaries are also seen at the time
of examination.
Cervix: Note of few Nabothian cysts
Cul-de-sac: no posterior cul de sac fluid collection

IMPRESSION:
CONSIDER FOCAL ADENOMYOSIS

31
FINDINGS IN THE BILATERAL ADNEXAL REGION MAY SUGGEST AN
INFECTIOUS/INFLAMMATORY
PROCESS SUCH AS PYOSALPINX AND/OR TUBO-OVARIAN ABSCESS FORMATION.
SUGGEST CLINICAL CORRELATION AND FOLLOW-UP STUDY.

32
DRUG STUDY

Name of Drug Mechanism of Action Indication and Adverse and Side effects Nursing Responsibilities
Contraindication

Generic name: Thought to inhibit Indication: Side effects:

Celecoxib prostaglandin synthesis, Management of acute pain Nausea, edema, dizziness, Before:
impending cyclooxygenase-2, headache
Brand name to produce anti-inflammatory, Contraindication: ● Observe 14 rights in
Celebrex analgesic, and antipyretic Contraindicated in patients Adverse effects: drug administration
effects. hypersensitive to drug, Ø ● Check the doctor's
Drug classification sulfonamides, aspirin, or other order to avoid
Therapeutic class NSAIDs. mistakes.
NSAIDS Analgesic ● Assess pain score
Contraindicated in patients ● Assess history of
Dosage who experienced asthma, allergies
200mg urticaria, or allergic-type
reactions after taking aspirin During:
Route or other NSAIDs and in those
PO who have demonstrated ● Verify patient’s
allergic-type reactions to identity
Frequency sulfonamides ● Give drug with food,
BID milk, or antacids
● Do not increase or
double dose; follow
exactly as prescribed
and indicated

33

Name of Drug Mechanism of Action
Generic name inhibits bacterial protein
Clindamycin synthesis by binding to the
23S RNA of the 50S subunit
Brand name of the ribosome. Clindamycin
Cleocin Dalacin is bacteriostatic.
Indication and
Contraindication
Indication:
infections caused by sensitive
staphylococci, streptococci,
pneumococci, bacteroides,
fusi bacterium, clostridium
perfringens, and other
Adverse and Side effects
Side effects:
Hypersensitivity:
Rashes nausea, vomiting,
stomach pain, mild skin rash,
and vaginal itching or
discharge
After:
● Educate patient about
side effects.
● Monitor for adverse
effect
● Instruct
discontinuation of
medication if the
adverse effect occurs.
● Document and record
to the chart.
Nursing Responsibilities
Before:
● Observe 14 rights in
drug administration
● Check the doctor's
order to avoid
34
Drug classification sensitive aerobic and
Antibiotic anaerobic
organisms.-endocarditis
Dosage prophylaxis for dental
900mg procedures in patients allergic
to penicillin-acne
Route vulgaris-bacterial vaginitis.
PO
Contraindication:
Frequency Contraindicated in patients
TID hypersensitive to drug or
lincomycin
mistakes.
Adverse effects: ● Assess pain score
Ø ● Assess history of
allergies
During:
● Verify patient’s
identity
● Give drug with food,
milk, or antacids
● Do not increase or
double dose; follow
exactly as prescribed
and indicated
After:
● Educate patient about
side effects.
● Monitor for adverse
effect
● Instruct
discontinuation of
medication if the
adverse effect occurs.
● Document and record
to the chart.
35
Name of Drug Mechanism of Action Indication and Adverse and Side effects Nursing Responsibilities
Contraindication

Generic name The primary mechanism of Indication: Side effects:

Gentamycin action is generally accepted to Gram negative infection •Hearing loss Before:
work through ablating the Contraindication: •Dizziness
Brand name ability of the ribosome to •Weak or shallow breathing ● Observe 14 rights in
Garamycin discriminate on proper • Neurotoxicity •Numbness or tingly sensation drug administration
Cidomycin transfer of RNA messenger •Severe stomach ache ● Check the doctor's
•Aminoglycosides order to avoid
Drug classification mistakes.
Antibiotics •Neuromuscular blockage Adverse effects: ● Assess pain score
Ø ● Assess history of
•Respiratory paralysis allergies
Dosage
240 mg
During:
Route
● Verify patient’s
IV
identity
● Give drug with food,
Frequency
milk, or antacids
OD
● Do not increase or
double dose; follow
exactly as prescribed
and indicated

36
 After:

● Educate patient about

side effects.
● Monitor for adverse
effect
● Instruct
discontinuation of
medication if the
adverse effect occurs.
● Document and record
to the chart.

Name of Drug Mechanism of Action Indication and Adverse and Side effects Nursing Responsibilities
Contraindication

Indication: Side effects:

Generic name Maintain acid base balance, CNS: Confusion, restlessness, Before:
isotonicity and electro • To prevent hypokalemia weakness or heaviness of
Potassium Chloride physiological balance of the limb, flaccid paralysis, ● Observe 14 rights in
cell. • Severe hypokalemia parenthesis drug administration
CV: Arrhythmia, cardiac ● Check the doctor's
Activator in many enzymatic

37
Brand name reactions. Essential to Contraindication: arrest, heart block, ECG order to avoid
transmission of nerve changes, hypotension mistakes.
Kaligen impulses contraction of •known hypersensitivity or GI: Abdominal pain, diarrhea, ● Assess pain score
cardiac, skeletal and smooth intolerance Flatulence, nausea and ● Assess history of
muscle, gastric secretions vomiting allergies
•Hyperkalemia Metabolic: Hyperkalemia
Dosage Respiratory: Respiratory During:
•Severe renal impairment with paralysis
750 mg oliguria, anuria or azotemia ● Verify patient’s
Route Adverse effects: identity
•Heat cramps
Ø ● Give drug with food,
Oral milk, or antacids
● Do not increase or
Frequency double dose; follow
exactly as prescribed
TID and indicated
Drug classification After:
Therapeutic Potassium ● Educate patient about
supplements
side effects.
● Monitor for adverse
effect
● Instruct
discontinuation of
medication if the
adverse effect occurs.
● Document and record
to the chart.

38
Name of drugs Mechanism of action
Generic Name: Antipyretic: Reduces fever by
acting directly on the
Paracetamol hypothalamic heat-regulating
center to cause vasodilation
and sweating, which helps
dissipate heat.
Brand Name:
Tylenol
Classification: Analgesic
Indication and
contraindication
Temporary reduction off ever,
temporary relief of minor
aches and pains caused by
common cold and influenza,
headache, sore throat,
backache, menstrual cramps.
Contraindication
Contraindicated with allergy
to acetaminophen.
Adverse effect Nursing responsibility
CNS: headache Before:
• Observe 14 rights in
drug administration
CV: chest pain, dyspnea,
myocardial damage • Check the doctor's
order to avoid mistakes.
• Assess pain score
GI: hepatic toxicity and
failure, jaundice • Assess history of
allergies
39
(nonopioid) Antipyretic
GU: acute renal failure, renal
tubular necrosis
Use cautiously with impaired
Dosage:5 hepatic function, chronic
alcoholism, pregnancy,
00mg/tab lactation Hematologic:
methemoglobinemia-
cyanosis; hemolytic
anemia-hematuria, anuria;
Frequency: PRN neutropenia, leukopenia,
pancytopenia,
thrombocytopenia,
hypoglycemia
Hypersensitivity: rash, fever
During:
• Verify patient’s
identity
• Give drug with food,
milk, or antacids
• Do not increase or
double dose; follow exactly as
prescribed and indicated
After:
• Educate patient about
side effects.
• Monitor for adverse
effect
• Instruct
discontinuation of medication
if the adverse effect occurs.
• Document and record
to the chart
40
NURSING CARE PLAN
Date/Time: MAY 17 10:00 AM

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

subjective: “ ang sakit hyperthermia related to After 1 hour of nursing INDEPENDENT after 1 hour of nursing
ng ulo ko parang inflammation of intervention the patient Monitor use of to minimize shivering. interventions the goal
nilalagnat ako” reproductive possibly temperature will hypothermia blanket and was met and the patient
evidenced by increased decrease from 37.8 to wrap extremities with maintained her normal
objective: body temperature 36.5 bath towels temperature of 36.5,
-37.8 C maintain vital signs at
-pale Identify the triggering will help guide the normal levels.
-warm to touch factors for hyperthermia treatment and nursing
-body weakness and review the client’s interventions.
history

41
 monitor vital signs notes progress and
changes of condition

Provide a tepid bath or Enhances heat loss by

sponge bath evaporation and
conduction

Encourage adequate provide cool liquids to

fluid intake help lower the body
temperature

DEPENDENT to reduces fever

administer anti pyretic as
ordered

Date/Time: MAY 17 10:30 AM

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

42
subjective: “sumasakit Alteration of comfort At the end of the shift INDEPENDENT At the end of the shift
yung tyan ko at diko na related to pain as the patient will be able determine the type of to help the patient to the goal was met as
alam gagawin ko” evidenced by a pain to report a decrease of discomfort the patient is identify the focus of evidence by:
scale rating of 7, pain from 7 to 4 and experiencing such as discomfort Expression Of reduction
objective: localized on her facilitate comfort of the physical pain,feeling of of discomfort, facial
- Guarding behavior lower abdomen patient. discontent, lack of ease grimace Appearance
- (+) Facial Grimace with self being relaxed
-pain scale 7-10 pain scale 4/10
provide appropriate to provide
comfort measures nonpharmacological
examples change of pain management
position, use of heat/cold
compress

Establish a trusting Building trust can help

relationship with the facilitate treatment
patient. plans, and it is more
likely for the patient to
express his or her
concerns.

use appropriate to limit unpleasant

distraction with music, sensation and promote
reading, chatting, ease and relaxation and
watching tv. to refocus attention

DEPENDENT to make the best use of

Assist the client to use pharmacological
and modify medication pain or symptom
regimen management

43
 Administer medications to increase comfort and
to ease discomfort. improve rest and
healing.

Date/Time: MAY 17 11:30 AM

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

subjective: “ nag Risk for Situational after 8 hours of nursing INDEPENDENT after 8 hours of nursing
ooverthink ako dahil sa Low Self-Esteem interventions the client encourage the patient to to promote positive interventions the client
kalagayan ko parang related to as possibly will be: express her feelings sense of self and coping was able to:
nawawalan ako ng pag evidenced by perceived acknowledge factors that ability acknowledge factors that
asa sa sarili stigma of infection lead to possiblibilty of lead to possiblibilty of
of reproductive system feelings, identify feeling feelings, identify feeling
active listen convey a
objective: and underlying dynamics and underlying dynamics
clients concerns message of
Ø for negative perception for negative perception
and negative acceptance and
of self, express positive of self, express positive
verbalizations confidence in
self appraisal self appraisal
without clients ability to
goal was partially met
jugement. deal with
whatever occurs

44
 provide feedback of to allow the patient to
clients self negating experience a different
remarks or behavior view

give reinforcement for positive words of

progress noted encouragement
promote continuation
of efforts, supporting
development of
coping behaviors

Date/Time: MAY 17 11:00 AM

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

subjective: “” Poor genital hygiene after 1 hour of nursig INDEPENDENT

related to pain as interventions the client
objective: evidenced by will be able to:
identify the

45
46
DISCHARGE PLAN
MEDICATION:
Instruct the patient that she has to continue the medication given.
Instruct on the right time, right frequency and with the right dose.
ENVIRONMENT/EXERCISE:
Avoid lifting anything heavier than your baby.
Gentle walking will help you recover from your surgery.
Avoid sudden movements and heavy work.
TREATMENT:
Advised to take it easy rest when possible.
Advised to apply abdominal binder.
Advised to elevate both feet.
HEALTH TEACHING:
Instruct the patient for exclusive breastfeeding and after the baby is fed, let her burp so that she
does not aspirate.
Instruct the patient not to have sex until the wound is not healed and you have decided on a birth
control method.
Watch your incision for signs of infection, such as more redness or drainage.
When fever is high, prolonged wound healing, bad smell of the wound arises.

OUTPATIENT:
Advised the patient to follow up check-up as physicians ordered.
DIET:
DAT such as fruits, vegetable, whole grains, and good quality of protein’s (egg, chicken, fish)
Avoid carbonated drinks, citrus juices, coffee, tea, and spicy food.
HYGIENE:
Advised daily wound care
Advised daily perineal care
Advised daily bathing
SPIRITUAL:
Encourage the patient to pray daily and ask God’s continuous healing.
Encourage the patient to continue to have a positive outlook in life.

47