PELVIC ORGAN PROLAPSE

I. DEMOGRAPHIC DATA

A. Initials of Clients Name: E. 2013 B. Address: GMA Cavite C. Age: 62 years old

Date of Admission: Feb.17,

D. Birth Date: November 15, 1950 Date of Interview:Feb.19, 2013 E. Birth Place: Cavite Primary Informant: Patient F. Gender: Female Secondary Informant: Relatives G. Civil Status: Widow Other Data Sources: Chart H. Religion: Christian Born again

I. Highest Educational Attainment: High school graduate

J. Occupation: Housewife

II. REASON FOR SEEKING HEALTH CARE

Patient ER complaint about her low abdominal pain and stated pakiramdam ko kasi malalaglag ang matres ko pag naglalakad ako.

III. HISTORY OF PRESENT ILLNESS

Patient ER started to experienced low abdominal pain since January. From then the pain became intermittent until now so she decided to go to hospital and the doctor diagnosed this as a pelvic organ prolapsed.

IV. PAST MEDICAL HISTORY

Patient ER didnt experience any illness at birth and during her childhood. Patient ER doesnt remember if she has complete immunization. Patient stated, alam ko may mga bakuna ako pero di ako sigurado kung kumpleto. Patient ER stated that she has no allergies and she doesnt undergo in any surgical operation. Patient experienced hypertension since she gave birth to her fifth (5th) child. She takes medicine such as Losartan to lower her blood pressure.

V. OBSTETRIC-GYNECOLOGICAL HISTORY
The client had her first menstruation or menarche in 1967 thats when she was 14 years old. During her menstruation, she did not experience any discomfort. According to her, she used to consume 3~5 sanitary napkins per day during her menstruation. She had 30~31-day cycle of menstruation that ranged from 5~7 days. Her last menstrual period was in year 1997 that is when she was 47 years old. Prior to the start of her menopausal stage, she felt hot flashes, headache and loss of libido.

She did not use any kind of contraceptive method. Client E.R. has 8 children. She delivered all her children via normal spontaneous delivery. She never had any abortion or miscarriage. There were no occurrences of problem during her pregnancy and delivery. Prior to her hospital admission, client experienced lower abdominal pain and she could also feel that her uterus was somewhat descending. pakiramdam ko malalaglag ang matres ko. As stated by the client.

She decided to consult in a health center in their barangay and from there, she was referred to KPFH. February 17 of this year after her consultation to the said hospital, she was immediately admitted and was diagnosed of pelvic organ prolapsed. OB SCORE: Gravida: 8 Para: 8 Term: 8 Preterm: 0 Abortion: 0 Live birth: 8

VI. HEREDO-FAMILIAL HISTORY

Genogram

VII. DEVELOPMENTAL HISTORY

Stage Specific Task(s) Generati vity vs. Creativity, productivity Evidences of Milestone Achievement Patient verbalized ako pa rin ang nagaalaga sa mga apo ko.

and concern Patients proven her productivity

stagnatio
n

for others

and concern for others.

B. L. KHOLBERGS MORAL DEVELOPMENT

Stage Specific Task(s) Social contact Patients legalistic orientation believe higher Evidences of Milestone Achievement Patient ER have mature form of a moral reasoning when she asked moral why it is wrong to steal from

principle
applies as

others. Patient stated ..dahil

such hindi naman sa akin yun at

equality kasalanan yun sa Diyos.

justice.

VIII. GORDONS 11 FUNCTIONAL HEALTH PATTERNS

A. Health Perception- Health Management She rarely visits the barangay health center for check-ups because she thinks that keeping herself healthy will prevent her from getting ill. Whenever she has a free day patient walks around their community for an exercise. Every morning, she cleans their house and says that it is her way or form of exercising. She has no allergy.

She is careful in everything she does to promote safety. E.R does not smoke or drink alcoholic beverages. E.R is now being hospitalized and considered that she is not healthy anymore. She is expecting to recover from her present condition with the help and support from her family and the health providers attending to her needs. She thinks, one good way to keep herself healthy is by eating more vegetable than meat. Patient stated Bihira lang ako kumain ng karne madalas ang ulam namin mag anak ay gulay.

B. NUTRITIONAL-METABOLIC

Patient E.R. usually eats 3 to 5 times a day and drinks 6 to 7 glasses of water a day. Her usual breakfast is bread and a cup of coffee. Hindi naman araw-araw kaming nagkakarne. Nagluluto naman ako sa bahay ng may gulay. Hindi naman nagrereklamo mga anak ko. Gusto ko kasi ng gulay, as verbalized by E.R.
She does not have any allergies to foods.

3 DAY DIET RECALL

MEALS Saturday Sunday Monday

Breakfast
6am
Snacks 9am

1 cup of rice, 1 cup of pakbet, 1 1 cup of rice, 1pc of tortang 1 cup of rice, 1 cup of chopsuey cup of coffee 1pcs of bread 1 glass of water talong, 1 cup of coffee. 1pcs of bread 1 glass of water 1 cup of coffee. 1pcs of bread 1 glass of water

Lunch
12nn
Snacks 3pm

- 1 cup of rice, 1cup of ginisang 1 cup of rice, 1cup of tinolang 1 cup of rice, 1cup of pakbet 2 ampalaya, 1 glass of water manok 2 glass of water glass of water

1pcs of bread 1 glass of water

1pcs of bread 1 glass of water

banana que 1 glass of water

Dinner 6pm
Total Fluid Intake

1 cup of rice, 1pcs of fried 1 cup of rice, 1cup of kare kare 1 cup of rice, 1cup of 1 cup of galunggong, 1 cup of tinola 2 2 glass of water glasses of water. 1000mL 1000mL guinisang sayote 2 glass of water 1000mL

Interpretation She has a good appetite. She prefer 5 time meal. She prefer coffee than milk in the morning.l

C.ELIMINATION
Patient defecates once every morning and usually urinates four to five times a day, she characterized her urine as yellow in color. Medyo may pagka yellow. As stated by the client. The patient feels discomfort when urinating and defecating. Patient E.R. does not perspire excessively.

F.COGNITIVE-PERCEPTUAL
She can read and speak well. She listens attentively during the interaction. She established an eye to eye contact during the interview and answers readily. E.R is alert and calm during the interview. But before the operation, the client said that she feels anxious and worried about the operation. Medyo kinakabahan ako kasi hindi ko alam kung paano yung mga gagawin sakin. As stated by the client.

She is person, place, time oriented before and after the operation. E.R has a good memorization she can still remember the recent and remote memory. During the physical assessment of the eyes, client E.R. was asked to read a newspaper. She can still read newspaper without the use of eyeglasses but she mentioned that she has to put it away from her eyes about 12~15 inches. She does not have any problem in hearing. E.R speaks Tagalog and slight understands English.

G.SELF PERCEPTIONSELF PERCEPTUAL

E.R

is a friendly and happy person. She usually mingles with her friends in their neighborhood. She is a well-determined person and she wants to be happy and free from anxieties. Her family and relatives are always there for her to give assistance and support .She wants to have good health and live her life to the fullest. She feels anxious since she has been admitted to the hospital and scheduled to

undergo an operation. But still she has a positive view that it will result to a better health condition. She controls the situation by being positive. Patient stated that saglit lang naman ang sakit na mararamdaman ko sa operasyon kaysa sa panghabang buhay na problema na ito. Patient is trying to prepare herself for the consequences that might happen after the operation.

H. ROLE RELATIONSHIP
She can express her-self very well. Patient is a widower. Her husband died last 2000. In 2002, her son died of a vehicular accident. Client E.R. initially has 8 children. She has no occupation and lives with her siblings. Patients son said that his mother is supportive and caring with them and also as a grandmother. She is also very active and socializes with her friends and neighbor. E.R family is with her during her confinement, they are supportive in giving the necessary needs and wishing the patient to be well and to recover soon. She is firm to face her condition because she knows that her family will always be there for her.

I.SEXUALITY- REPRODUCTIVE
The client had her first menstruation or menarche in 1967 thats when she was 14 years old. During her menstruation, she did not experience any discomfort. According to her, she used to consume 3~5 sanitary napkins per day during her menstruation. She had 30~31day cycle of menstruation that ranged from 5~7 days. Her last menstrual period was in year 1997 that is when she was 47 years old. Prior to the start of her menopausal stage, she felt hot flashes, headache and loss of libido.

She did not use any kind of contraceptive method. Client E.R. has 8 children. She delivered all her children via normal spontaneous delivery. She never had any abortion or miscarriage. There were no occurrences of problem during her pregnancy and delivery. Prior to her hospital admission, client experienced lower abdominal pain and she could also feel that her uterus was somewhat descending. pakiramdam ko malalaglag ang matres ko. As stated by the client.

She decided to consult in a health center in their barangay and from there, she was referred to KPFH. February 17 of this year after her consultation to the said hospital, she was immediately admitted and was diagnosed of pelvic organ prolapsed. Since the client is on her menopausal stage, she has less ~ no interest on sexual activity. And also because of her husbands death that contributes to her sexually inactive life. She has 8 children. She has no history of vaginal bleeding. According to her, it is better to have her uterus removed than to carry the burden of having uterine prolapsed.

J. COPING STRESS

Client E.R. is not usually stressed. But after she was diagnosed of having pelvic organ prolapsed, she started to become worried and stressed. To cope with the situation and to minimize the worries, she tries to interact with her family members who are always available for her.

K. VALUE BELIEF

E.R. is a Born Again Christian and she goes to mass every Sunday with her family. The patient has a great value of sense when it comes to religion. E.R still believes that God will always help them especially towards her condition. According to her family they are praying for patients faster recovery. She said that she entrusted her life to God. She also mentioned that she does not believe in quack doctors and superstitious beliefs.

IX. COMPREHENSIVE PHYSICAL EXAMINATION

A.Vital Signs Date / Time of Exam: February 19, 2013 T = 36.6OC PR = 57 bpm RR = 25 cpm BP = 110/70 mmHg

ANTHROPOMETRIC DATA (ONLY THOSE APPLICABLE)

Height = 154.94 cm Weight = 54 BMI=22.55

GENERAL APPEARANCE
The patient build is appropriate for her age: Height: 154.94 Weight: 54 kg BMI: 22.5

Overall appearance is in normal range. The patient can stand well and walk alone. The general hygiene of the patient was good from cephalo-caudal. Her finger nails and toenails are clean and free from deformities and infestations. Patient E.R. is using dentures. Patient has no unpleasant body and breath odor. Wrinkles on her face are very evident. Grayish to white hair color are also evident. Varicose vein on both of her legs are seen. She still has good posture.

D.FOCUSED ASSESSMENT
Body Part Examined Actual Finding Normal Finding
Skin color ranges from pale white with pink, yellow, brown, or olive tones to dark brown or black. No strong odor should be evident, and the skin should be lesion free. Skin should be soft, warm, and slightly moist with good turgor and without edema.

Clinical Significance

INTEGUMENT Skin

Brown skin color Moist skin Good skin turgor Warm

temperature

Normal

(-) edema (-) skin lesions

Body Part Examined

Actual Finding

Normal Finding

Clinical Significance

Hair

Hair is Hair s normally evenly lustrous, distributed silky, Smooth, strong and thick hair elastic. strands Fine, Oily hair downy hair within the covers the scalp body. (-) signs of No infestation presence of of infection or infection infestation

Normal

Body Part Examined

Actual Finding

Normal Finding

Clinical Significance

Nail

(+) Pink Pink tones tones should be (+) convex seen. Some curvature longitudinal Nails are ridging is hard and normal. immobile There is 160 degreenormally a angle 160 degree between the angle nail and skin between the Prompt nail base return of and the skin. usual bed color

Normal

Body Part Examined

Actual Finding

Normal Finding

Clinical Significance

Nail

Prompt return of usual bed color

Nails are hard and basically immobile. Nails are smooth and firm; nail plate should be firmly attached to the nail bed. Pink tone returns immediately to blanched nail beds when pressure is released.

Body Part Examined

HEAD Skull and Face

Actual Finding
Head is normocephalic and is symmetrical (+) Full range of motion Face is symmetrical and proportionate (-) edema (-) lesions (-) nodules and massses

Normal Finding
Head is normocephalic and symmetric. Full range of motion up, down, and sideways is normal. Face is normally proportionate and symmetric. Movements are equal bilaterally. Absence of nodules or masses Smooth skull contour

Clinical Significance
Normal

Body Part Examined

Eyes and Vision

Actual Finding
The client possess difficulty reading the letters of the newspaper within the distance of 14 inches.
Eyebrows are symmetrical in shape and movement. Eyelashes are evenly distributed and curves outward along the lid margins

Normal Finding
Normal near visual acuity is 14/14 (with or without corrective lenses). This means the client can read what the normal aye can read from a distance of 14 inches.
Eyebrows should be symmetric in shape and movement. They should not meet in midline.

Clinical Significance
Presbyopia (impaired near vision) is indicated when the client moves the chart away from the eyes to focus on the print. It is caused by decrease accommodation. Presbyopia is a common condition in clients over age 45.
(According to J. Weber and J. Kelly; Health Assessment in Nursing, page 222)

Body Part Examined

Actual Finding
(-) swelling, discharge or lesions of eyelids. Upper and lower lids close and meet completely when closed.

Normal Finding
Eyelashes are evenly distributed and curve outward along the lid margins No swelling, discharge, or lesions of eyelids. The upper and lower lids close easily and meet completely when closed.

Clinical Significance

No inward or outward turning of lower eyelid

(-) redness, swelling, lesions in skin of both eyelids

Body Part Examined

Actual Finding
Eyeballs are in symmetrical alignment in sockets without protruding or sinking. (-) discharge, redness, lacerations and lesions on sclera and conjunctiva (-) swelling and redness over the areas of lacrimal gland.

Normal Finding
The lower eyelid is upright with no inward or outward turning. Skin on both eyelids is without redness, swelling, or lesions. Eyeballs are symmetrically aligned in sockets without protruding or sinking.

Clinical Significance

Body Part Examined

Actual Finding

Normal Finding
Sclera and conjunctiva are clear and free of discharge, lesions, redness or lacerations. No swelling or redness should appear over areas of the lacrimal gland. The cornea is transparent with no opacities. The oblique view shows a smooth and overall moist surface; the lens is free of opacities.

Clinical Significance

Body Part Examined

Actual Finding

Normal Finding
The iris is typically round, flat, and evenly colored. The pupil, round with a regular border, is centered in the iris. Pupils are normally equal in size (3 to 5 mm). The normal direct pupillary response is constriction.

Clinical Significance

Ears and Hearing

Ears are equal in Ears are equal in Normal size. size bilaterally (normally 4 to 10 Uniform in color. cm). Ears are symmetrical to the eyes (-) lesions, lumps, nodules (-) tenderness The skin is smooth with no lesions, lumps, or nodules. Color is consistent with facial color. Normally the auricle, tragus, and mastoid process are not tender.

Nose and Sinuses

Nose is midline in face.

Nose is midline Normal in face, septum is straight, and (-) discharge and nares are patent. tenderness. No discharge or (-) edema on tenderness is turbinates and present pink in appearance. Turbinates are pink and free of (-) tenderness edema. on sinuses No tenderness (-) nasal flaring palpated over sinuses. No nasal flaring

Mouth / Oropharynx

Pink and moist lips, tongue and buccal mucosa Tongue is pink, moist and moderate in size (-) lesions, ulcers, and nodules (+) strong resistance of the tongue Uvula hangs freely in the midline

Lips, tongue, and buccal mucosa appear pink and moist. No lesions are present. Tongue should be pink, moist, a moderate size with papillae (little protuberance) are present. No lesions, ulcers, or nodules are present. The tongue offers strong resistance.

Normal

Body Part Examined

Actual Finding
Use of dentures Gums are pink, moist and firm (-) lesions and masses

Normal Finding
Uvula is a fleshy, solid structure that hangs freely in the midline. Intact dentures Gums are pink, moist, and firm with tight margins to the tooth. No lesion or masses

Clinical Significance

Body Part Examined

Neck

Actual Finding
Neck is symmetrical without bulging masses. Neck movement is within normal range. Trachea is positioned midline (-) swelling and enlargement of lymph nodes

Normal Finding
Neck is symmetric with head centered and without bulging masses. Normally neck movement should be smooth and controlled with 45-degree flexion, 55degree extension, 40degree lateral abduction, and 70-degree rotation.

Clinical Significance

Body Part Examined

Actual Finding

Normal Finding
Trachea is midline. No swelling or enlargement of lymph nodes.

Clinical Significance
normal

Body Part Examined

THORAX & LUNGS

Actual Finding
Scapulae are symmetrical and non-protruding. Anteroposterior diameter is 1:2.

Normal Finding
Scapulae are symmetric and non-protrudin g. Shoulders and scapulae are at equal horizontal positions. The ratio of anteroposterior to transverse diameter in 1:2. No use of accessory muscles to assist breathing.

Clinical Significance

Body Part Examined

Actual Finding
Spine aligned in midline.

Normal Finding
Spinous processes appear straight, and thorax appears symmetric with ribs sloping downward at approximately a 45-degree angle in relation to the spine. Resonance is the percussion tone elicited over normal lung tissue.

Clinical Significance

(-) use of accessory muscles to breathe. Resonating to dullness

RR =25 cpm

Respirations normal should be unlabored and regular in all ages. Respirations should be 12 20 in adults. No adventitious sound should be heard.

(-) adventitious sound

ABDOMEN

Abdominal skin may be paler than the general skin tone because this skin is so seldom exposed to the natural elements. Scattered fine veins may be visible. Old, silvery, white striae or stretchmarks from past pregnancies or weight gain are normal.

Pale, smooth, minimally reaised old scars may be seen. Abdomen is free of lesions or rashes. Flat or raised brown moles, however, are normal and may be apparent. Abdomen is flat, rounded or scaphoid. Abdomen should be evenly rounded.

Body Part Examined

Actual Finding

Normal Finding
Abdomen is symmetric. Normally peristaltic waves are not seen although they may be visible in very thin people as slight ripples on the abdominal wall.

Clinical Significance

Body Part Examined

Actual Finding

Normal Finding
A series of intermittent, soft clicks and gurgles are heard at a rate of 5 to 30 per minute. Hyperactive bowel sounds that may be heard normally are the loud, prolonged gurgles characteristic of a stomach growling.

Clinical Significance

Body Part Examined

GENITALS

Actual Finding

Normal Finding
Pubic hair is distributed in an inverted triangular pattern and there are no sign of infestation. There should be no enlargement or swelling of the lymph nodes.

Clinical Significance

Body Part Examined

Actual Finding

Normal Finding
The labia majora are equal in size and free of lesions, swelling and excoriation. A healed tear or episiotomy scar may be visible on the perineum if the client has given birth. The perineum should be smooth.

Clinical Significance

Body Part Examined

Actual Finding

Normal Finding
The labia minora appear symmetric, dark, pink and moist. The clitoris is a small mound of erectile tissue, sensitive to touch. Bartholins glands are usually soft, nontender, and drainage free.

Clinical Significance

Body Part Examined

Actual Finding

Normal Finding
No drainage should be noted from the urethral meatus. The area is normally soft and nontender. The normal aginal opening varies in size according to the clients age, sexual history, and whether she has given birth vaginally. The vagina is typically tilted posteriorly at a 45-degree angle.

Clinical Significance

Body Part Examined

Actual Finding

Normal Finding
The client should be able to squeeze around the examiners finger. Typically, the nulliparous woman can squeeze tighter than the multiparous woman. No bulging and no urinary discharge.

Clinical Significance

Body Part Examined

Actual Finding

Normal Finding
The surface of the cervix is normally smooth, pink, and even. Normally, it is midline in position and projects 1 to 3 cm into the vagina. The cervical os normally appears as a sall, round opening in the nulliparous women and appears slit like in parous women.

Clinical Significance

Body Part Examined

Actual Finding

Normal Finding
Cervical secretions are normally clear or white without unpleasant odor. The vagina should appear pink, moist, and free of lesions and irritation. It should also be free of any colored, malodorous discharge.

Clinical Significance

Body Part Examined

Actual Finding

Normal Finding
The vaginal wall should be smooth, and the client should not report any tenderness. The cervix should feel firm and soft. It is rounded and can be moved somewhat from side to side without eliciting tenderness.

Clinical Significance

Body Part Examined

Actual Finding

Normal Finding
The fundus, the large upper end of uterus, is normally round, firm, and sooth. In most women, it is at the level of the pubis; the cervix is aimed posteriorly (anteverted position). The normal uterus moves freely and is not tender.

Clinical Significance

X. DIAGNOSTIC TEST NON-INVASIVE

Specific Test Urinalysis Actual Finding Color: yellow Transparency: turbid Reaction: acidic Specific gravity: 1.030 Epithelial cell: few Mucus threads: rare Bacteria: rare Normal Finding pH: freshly voided is normally acidic (-) bacteria Specific gravity: concentrated urine has a higher specific gravity, diluted urine has a lower specific gravity. Clinical Significance Urine specimen may be contaminated

Specific Test Radiology (x-ray)

Actual Finding Lung fields are clear Heart is not enlarge Thoracic aorta is atheromatous The rest of the structures are unremarkable.

Normal Finding Lung fields are clear Heart is not enlarge Thoracic aorta is not atheromatous

Clinical Significance Atheromatous degeneration of the walls of the arteries due to the formation of fatty plaques and scar tissue

Specific Test

Actual Finding

Normal Finding

Clinical Significance

Gynecology scan

Uterus: retroverted Normal ovaries Right ovary: lateral Normal uterus Left ovary: lateral should appear lateral. Most common position is for the long axis of the uterus to lie in approximately the same axis as the pelvis, that is, with the upper part tilted forward and the lower end, the cervix, inserted into the top of the vagina.

With a retroverted uterus the long axis is much closer to that of the vagina; the uterus tilts backwards.

B. INVASIVE
Specific Test Blood Chemistry ----Actual Finding ----Normal Finding Clinical Significance ------

Hematology

WBC: 5. 71 RBC: 4.39 hgB: 121 hct:36.7 platelet: 288 neutrophil:55 monocyte; 5.4 basophils: 0.2 clotting time:4minutes 30 seconds bleed time:2 minutes

WBC: 5-10 RBC: 4-5.5 hgB: 120-160 hct: 37-47 platelet: 150-450 neutrophil: 50-70 monocyte; 3-11 basophils:0-1 2-4minutes 2-4minutes

Normal Normal Normal Low Normal Normal Normal Normal Risk for bleeding Normal

Drugs

Indication

Action

Contraindication

Adverse Effect

Drug Interaction

Nursing Responsibility

Angiotensin II Receptor Blockers (losartan) Dose: 50 mg Route: oral Frequency: OD

Effective in lowering blood pressure as the ACE inhibitor and beta blockers.

Act by binding to angiotensin II receptor sites, blocking the very potent vasoconstrictor from binding to the receptor sites in the vascular smooth muscle, brain, heart and kidney.

Pregnancy (2nd and third trimester) hypersensitivity to ACE inhibitor

CNS Dizziness, insomnia, anxiety, confusion, head ache. CV Angina pectoris CVA Hypotension GI Diarrhea, anorexia, constipation GU Renal failure INTEG Alopecia, dry skin, rash RESPI Cough, upper respiratory infection, dyspnea

Lithium: increased toxicity Phenobarbital, Rifamycin: decreased hypertensive effect

Assess BP with positio n change pulse q4h. Monito r electro lytes: potassi um, sodium chlorid e. Monito r for edema in feet, legs daily. Assess for skin turgor, drynes s of mucou s membr anes for hydrati on status.

Captopril Dose: 25mg Route: sublingual Frequency: OD

Decreased blood pressure in hypertension; decreased pre load, after load in CHF.

Selectively suppress renninangiotensinaldosterone system; inhibits ACE; prevents conversion of angiotensin I to angiotensin II.

Pregnancy (second and third trimester) hypersensitivity lactation, heart block, children potassiumsparing diuretics.

CNS: Fever, chills CV Tachycardia Hypotension GI Impotence dysuria, nocturia, nephritic syndrome HEMA Anemia INTEG: Rash RESPI Bronchospas m, dyspnea

Alcohol: increased hypotension Digoxin, Lithium: increase serum levels, toxicity, insulin, increase hypoglycemia

Mayb e crush ed and mixed with food Monit or BP check for orthos tatic hypot ensio n Monit or for edem a in feet, legs daily. Assess for allergi c reacti on rash, fever, drug shoul d be discon tinued if antihi stami ne failed