A case presentation

Of a Patient with
UTERINE MYOMA

IRISH C. EDOMBINGO
BSN III-A
 OBJECTIVES OF THE CASE
PRESENTATION:
GENERAL OBJECTIVE
 At the end of my case presentation, the
listeners would be able to gain knowledge
and understand the case of a patient with
Myoma Uterine, also to enhance skills in
differentiating the difference of uterine
myoma and also to improve their attitude
towards patients with the same case as mine
and in caring for the patients with this kind
of case.

SPECIFIC OBJECTIVES:
 At the end of my case study presentation of Uterine myoma, the listeners
will be able to:
 Identify and understand my patient’s case.

 Know the clinical manifestations of the illness.


 Determine the different treatment for this case.

 Identify the diagnostic test to be done.


 Differentiate the normal from abnormal findings in my patients
laboratory results.

 Know the care plans for patients with this case.


 Trace and understand the Pathophysiology.

 Review the Anatomy and Physiology of the Reproductive System

  OVERVIEW


Uterine fibroid tumors or leiomyomas are

among the most common tumors among
women. In fact, it is apparent in 25-50% of
women. Uterine fibroid tumors are
typically non-cancerous.

 Patient’s Profile

Name: Patient “x”

Age: 41 y/o

Sex: Female

Civil Status: Single

Address: Alano extension, Pagadian City

Occupation: None

Date of birth: May 18, 1968


Place of birth: Davao del Sur
Religion: Roman Catholic

Father’s name: Juanito Pantullana

Mother’s name: Remedios Pantullana

Admission date: February 28, 2010

Admission time: 10:40 am

Room/Ward: OB-WARD

Chief complain:

 Hypogastric pain

ADMISSION DIAGNOSIS: Uterine Myoma

Attending Physician: Dr. Chandra Salvador
History of Past illness:

The patient was never been hospitalized before and

had not experienced any kind of diseases. She only
had mild illness such as cough, fever and
headache. She also experienced dysmenorrhea in
the 1st – 2nd day of her menstruation

  History of Present illness:
3 years prior to admission, the patient noticed a
mass on hypogastric area of her abdomen. She
thought that it was only due to her loaded works
and stress and so, she only consulted a “hilot”.
She didn’t mind to have a consultation on a
doctor because of lack of financial budget.
 1 year prior to admission, the
patient had undergone free medical check up
from the company where she was working with
and so, the UTZ’s result found out that she had
an enlarged uterus with intramural myoma
uterine.
 PHYSICAL ASSESSMENT

GENERAL SURVEY:
Received lying on bed conscious and coherent without
IVF. Patient is conscious and coherent, and also
responsive to certain questions and instructions given to
her. Tension and increased alertness was noted on the
patient upon receiving her.


VITAL SIGNS:
 T = 36.3oC
 P = 70 bpm
 R = 26 cpm
 BP = 120/70 mmHg

 SKIN
 warm to touch on upper extremities like in the palm of her hands
 cold temperature on the sole of the client
 Fair skin and brown in color
 Has a good skin turgor upon palpation
 Presence of scars on both upper and lower extremities
 HAIR
 Equally distributed hair
 Black with some white hair in color
 Slightly coarse
 No nodules, lumps and tenderness noted upon palpation
 Absence of lice and dandruff
 NAILS
 Nail beds are pinkish in color
 Smooth texture
 short nails with dirt noted
 good capillary refill, less than 2 seconds

 EYES
 symmetrical
 pupils are equally round and reactive to light accommodation
 pupils are black in color
 sclera is white
 eyebrows and eyelashes are equally distributed
 eyelashes are slightly curve
 pupils constricts symmetrically when lighted with a penlight
 Blurred vision on her both eyes


 EARS
 no deformities
 symmetrical
 no cerumen and dirt noted
 uniform in color
 no discharges noted
 mobile, firm, and not tender upon palpation
 helix of ears are in line with the outer canthus of the eye


 NOSE AND SINUSES
 nose is located in the midline of the face
 symmetrical
 proportionate to the face
 absence of discharges
 no nasal flaring
 uniform in color
 no skin breakdown
 nasal septum intact
 nasal hairs are evenly distributed
 no tenderness and pain upon palpation on facial sinuses
 MOUTH
 dry lips
 pinkish colored gums
 uvula is located at the midline of the soft palate
 teeth are yellowish in color
 with dental caries on his upper teeth
 hard palate is light pink in color
 tonsils are not inflamed
 buccal cavity is pinkish in color
 restricted tongue movement


 NECK AND THROAT
 neck muscles are equal in size
 absence of swollen lymph nodes
 trachea is centrally aligned
 no tenderness noted
 no thyroid gland enlargement noted
 thyroid gland ascends during swallowing
 equal strength during the assessment for his muscle strength
 ANTERIOR AND POSTERIOR CHEST

 quiet respiration
 no palpitations, no deformities
 symmetrical in shape
 absence of adventitious breath sound upon auscultation
 vesicular breath sound was present
 heart is not enlarged
 spine is vertically aligned
 absence of masses
 right and left shoulders are at same height
 full and symmetric chest expansion
 percussion notes resonate except over the scapula
 no visible pulsations on anterior and posterior areas of thorax from observing them to the side


 AXILLA
 presence of axillary hair
 skin is intact
 little perspiration noted
 no nodules and tenderness noted
 ABDOMEN
 has an enlarge mass noted on hypogastric area
 uniform in color
 no skin problems
 absence of bruits on all 4 quadrants
 no evidence of enlargement of liver and spleen
 liver is not palpable as well as the bladder

 MUSCULOSKELETAL
 has 10 fingernails and toenails
 uniform in color
 presence of scar in his calf and elbow
 presence of dirt in the fingernails and toenails
 no contractures noted
 Absence of tremors
 Has good muscle gait


 NEUROLOGIC
 Able to talk with sense
 Oriented
 Able to remember past events in life
 Coordinated and verbally responsive

GENOGRAM
 Gordon’s 11 Functional Health Pattern

USUAL APPRAISAL INITIAL APPRAISAL 03-01- ONGOING ONGOING

10 APPRAISAL1-03-02-10 APPRAISAL 01-03-10

1.) Health Perception- health Management   This is the day of her Patient still
Before Hospitalization: 
operation continues to receive
Patient has not been pregnant since Patient still confined in

before
Patient follows the doctor’s
her Post op. meds
advices and takes the meds bed taking rest after her
Experienced cold in ē past year.
given operation with catheter such as Cefuroxime,
She eats varieties of healthy foods such
Patient was confined because Patient is crying
 Ranitidine, Ketorolac
as fruits and vegetables and does not Patient is still
she will be operated and be because of happiness
smoke and take alcoholic beverage to that she is now free confined in bed
free from myoma.
keep healthy Patient is complaining of from her problem which without catheter.
The patient is aware that she has a
pain because she has was havingUterine Patient is
myoma
Family initially seeks the help of a
dysmenorrhea today of her myoma. experiencing pain
first day of menstruation. with a pain scale of 7
doctor and uses herbal meds and also 
She feels a little bit of tense out of 10.
takes OTC meds
Pt., experiences dysmenorrhea
for her operation to be done
tomorrow.
everytime she has menstruation
USUAL APPRAISAL INITIAL APPRAISAL ONGOING APPRAISAL1-03- ONGOING APPRAISAL 01-
USUAL APPRAISAL INITIAL APPRAISAL 03-01-02-10
03-01-10 ONGOING APPRAISAL1-03-03-10
ONGOING APPRAISAL 01-
10 02-10 03-10
Nutritional – Metabolic Pattern She is in soft She is NPO for this day. She is now allowed to
Eat vegetables, rice, dried fish and diet “ tea and Patient has ongoing IVF eat soft foods like
fish as daily food intake. crackers”
Water is her typical daily fluid intake.
And NPO at post of D5LR lugaw and adviced to
She does not gain weight according to
midnight. drink fluids.
her. She had
She usually has no appetite in foods
Patient has ongoing IVF
undergone Soap of D5LR
and does not crave for any foods. suds enema for
3.) Elimination Pattern her preparation
She urinates 5-6 times daily at about
for tomorrow’s
½ glasses per urination and states that
operation. She has a catheter Patient urinates 3x on
there is a urine that stays after
urination. attached because she the day.
Sensation of fullness even
Does urinate undergone operation She perspire a little
when finish urinating
She perspire more often whenever she thrice in the
with a urine output of No odor problem
has a lot of works. day. 150 cc.
She doesn’t have any odor problems. She perspires a
She perspire more
little
USUAL APPRAISAL INITIAL APPRAISAL 03-01-10ONGOING ONGOING APPRAISAL 01-03-
APPRAISAL1-03-02-10 10

Activity – exercise pattern

Patient’s daily activity includes
Her condition is
cleaning the house, washing Patient can no She is most progressing but still
clothes, grooming, cooking, home longer do usual dependent on more dependent on her
maintainance, does not do activities for she her SO for
household chores when the labor is confined and she doing things. SO.
started. needs rest but she
Sleep – rest pattern is able to do Patient sleeps
Usually sleeps at 9-10pm grooming, go to most of the time Patient has adequate
and wakes up at 5am. bathroom alone. after her sleep and rest whole
Has no nightmares operation day and night
Sleeps during siestas She has didn’t really She has no nightmare
sleep at night because Sleep during siestas
of new environment
in the hospital.
She has no
nightmares.
She feels quite tense
for the operation.
USUAL APPRAISAL INITIAL APPRAISAL 03-01-10ONGOING APPRAISAL1-03- ONGOING APPRAISAL 01-03-
02-10 10

Cognitive – perception Has no hearing difficulty Hearing acuity is good hearing acuity is good
pattern He receives medications No memory gap
Has no hearing difficulties Patient has nearsightedness
No memory gap
Patient says that she Patient says that her
Patient has nearsightedness but does not wears
does not feel pain now
but does not wears eyeglasses pain scale is 7 out of
eyeglasses because there is still the
, able to read or write
effect of anesthesia. 10.
No memory gap No memory gap
She manages pain by She continues to receive She continues to
She continues to receive
applying or taking medicines meds meds receive meds

7.) Self – perception /

self concept
Patient does not feels Patient feels happy Patient feels happy
good about herself Patient is worried after her successful about herself.
knowing she has a about her operation. operation. She has not taken her
myoma which is burden She is not taken a She is not taken a bath yet
to her. bath and has odor She feels good with
Patient is maintains to be
bath yet
She is comfortable the support coming
calm and does not easily
gets angry. with her visitors. from her family.
USUAL APPRAISAL INITIAL ONGOING APPRAISAL1-03- ONGOING APPRAISAL 01-03-
APPRAISAL 03- 02-10 10
01-10
8.) Role – relationship Her niece took all Her family is The patient cried after
pattern her hospital concerned about her seing the person who
Patient lives with her parents expenses. condition. took all her hospital
and nieces; extended family Her niece is with expenses.
her as her SO
Her sister is with her She has a good
They have a good relationship the whole night.
with her family. relationship with her
Family always come relatives who visited her.
Income is sufficient for their
daily needs. to visit her.
She is single and Her mother and sister
has no plan for She is contented with vited her and shows
9.) Sexually Reproductive marriage. her life. She feels the care and love to her.
pattern She had 3
Menstruation started when she care from her family.
boyfriends on her
was 16 years old. past but all got
Menstruation last 6-7 days with married with
heavy bleeding in 1st to 2nd day; another women.
7pads on first 2nd day. She said that she
She is single and has no plan for is still a virgin.
marriage.
She is not active in sexual life.
USUAL APPRAISAL INITIAL APPRAISAL 03- ONGOING APPRAISAL1- ONGOING APPRAISAL
01-10 03-02-10 01-03-10

10.) Coping – stress Patient is relaxed and Patient sleeps and relax Patient talks with her
tolerance pattern
Patient doesn’t always get
sleeping which helps in bed as her way of mother the things she
her cope up with the relieving from the experienced during
tensed; she only gets
operation because she is
stressed, angry when stress. weak.
her operation.
someone irritated her. Her niece is her SO All her family give She is able to show
Whenever she has a
problem, she consulted and and takes the support and her niece is smile.
talk with her sister to responsibilities. always with her, serves
relieve it. as her SO.

11.) Value – belief

pattern
Patient does not always go Patient often pray Patient does not forget
to church and pray. to pray for the successful Patient pray and seek
Religion is Roman catholic. and seek for help operation. help from God.
Patient has a believes in from God.. Receives meds as
both hospitalization when Patient follows the ordered by the doctor Has choose
gets sick, consult doctor and and trusted the care
also “hilot.
instruction of the hospitalization and
doctor and receives given by the hospital. trusted it.
her duely meds at
right time.
 DOCTOR’S ORDER

Date & Time Order

2-28-10 Pls. admit

11:OO AM TPR every 4H

Soft diet

Labs: CBC

FBS
ECG
CXR
for TAH once cleared

refer to Dr. Uy for CP clearance

Secure unit of FWB properly

Start Bisacodyl @ HS

Metronidazole 500mg 1 tab TID

Seen and axamined

History reviewed

No previous admission

BP: 100/60 HR= 76 RR= 16

Date & Time Order

3-01-10 Soft diet

8:00AM Tea and crackers for lunch and dinner
NPO post midnight

For elective TAH

Secure Consent

Inform anesthesia on care OR personel

Start IVF D5LR @ 30gtts @6H

Cefuroxime 750mg IVTT every 8H ANST

Bisacodyl suppository II/ rectum @ 6pm

SS enema @ 9pm or 6

Cleaning enema @ 5am until rectum is

clear
All prep

FF up blood for standby

Continue V/S monitoring


Date & Time Order

3-01-10
1:00pm
 NPO post midnight
-check vital signs prior to

O.R.
-Normal hygiene

Prior O.R-Ranitidine 50 mg

IVTT
-Metoclopramide 10 mg IVTT

-Continue pre-meds needed

-IVF / IVTT meds

Refer to O.R the following:

spinal needle G 25 #1

2)Midazolam

3)Butyphenol
Date & Time Order

03-02-10 10:40am - to PACU

10:40 AM  O2 inhalation 2 L/min
 NPO temporarily
 flat in bed x 8 hours then may
turn to sides.
 Monitor V/S q 15 min x 2 hours then q 30 min
until stable.
Monitor I & O

 Regulate IVF at 30 gtts/min

 IVF to ff. the following
D LR 1L
5
D W x 8 hours
5
D LR 1L
5
 Continue Cefuroxime 750mg q 8hr IVTT
 Ranitidine 50 mg, 8hr IVTT
 Nalbuphine HCl5mg IVTT q 6hr x 4 doses
only
-Ketorolac 30 mg q 8 hrs IVTT x 2 days for pain
 repeat hemoglobin 6hrs post-op.
 refer to Dr. Chandra Salvador for further
order.
 Refer accordingly.
 Diagnostic Test

Ultrasound Report Date: 04-13-09

Examination Performed: Pelvic ultrasound

Impression: Enlarge uterus w/ intramural myoma


Electrocardiogram Report
2-28-10
Analysis: 801 sinus rhythm, 401 short P-R internal

Laboratory Result:
Hematology Date: 02-25-10
WBC- 3, 250 cu/mm
Hemoglobin- 13.4 gms %
Differential count

Segmented neutrophils- 74%

Lymphocytes- 20 %
Eosinophils- .6 %
Hematology Date: 03-02-10
Hemoglobin- 12.4 gms %
 DRUG STUDY
 Doctor’s Order: Metronidazole 500mg 1tab q 8 hrs P.O.
 Generic Name: Metronidazole
 Brand name: Metrocream, MetroGel, Vaginal, Metrolotion, Noritate
 Classification: Anti-infectives. Antiprotozoals, Anti-ulcer
 Indication: Inflammatory papules and pustules of acne rosacea, bacterial
vaginosis
 Mechanism of action: Unknown. May cause bacterial effect by interacting
with bacterial DNA
 Dosage: 500mg P.O.
 Adverse Effects: dizziness, headache, cramps,pain, nausea, diarrhea,
constipation, rash
 Contraindication: Contraindicated in patients hypersensitivity to the drug.
 Nursing Responsibilities:
 Take full course of drug therapy; take the drug with food if GI upset occurs.
 Do not drink alcohol
 Your urine may appear dark; this is expected.

 Doctor’s Order: Cefuroxime 750mg q 8hrs ANST(-)
 Generic Name: Cefuroxime sodium
 Brand name: Kefurox, zinacef
 Classification: antibiotic, second generation cephalosporin
 Indication: pharyngitis, tonsillitis, infection of urinary and
lower respiratory tract
 Mechanism of action: hinders and kills susceptible bacteria
 Adverse Effects: dizziness, headache, malaise, diarrhea, nausea
 Contraindication: hypersensitivity to cephalosporin
 Nursing Responsibilities:
 Asssess pt’s infection before therapy and regularly thereafter
 Be alert for adverse reactions and drug interactions

 Total Abdominal Hysterectomy Surgical
Procedure

removal of uterus through an incision in the

lower abdomen.
This operation involves removing both the
body of the uterus and the cervix, which is
the lower part of the uterus.
can sometimes be done through the vagina
(vaginal hysterectomy);

 Generic Name: Ranitidine
 Brand Name: Zantac
 Classification: Histamine 2 antagonist
 Mode of Action: Competitively inhibits the action of histamine at the H2
receptors of the parietal cells f the stomach, inhibiting basal gastric acid
secretion and gastric acid secretion that is stimulated by food, insulin,
histamine, cholinergic agonist, gastrin, and pentagastrin.
 Dosage: Ranitidine 50mg q8 IVTT
 Indication: Post surgery antacid to prevent ulcer formation
 Contraindication: Hypersensitivity to ranitidine, lactation.
 Adverse Effects: malaise, insomnia, somnolence, urticaria, tachycardia,
bradycardia, leukopenia, pancytopenia, thrombocytopenia, gynecomastia,
impotence, hepatitis
 Nursing Responsibilities:
 Instruct patient to take his meal if nausea or vomiting occurs.


 metoclopramide
 Apo-Metoclop (CAN), Maxeran (CAN), Maxolon, Nu-Metoclopramide (CAN),
 Drug classes: GI stimulant, Antiemetic, Dopaminergic-blocking agent
 Therapeutic actions
 Stimulates motility of upper GI tract without stimulating gastric, biliary, or pancreatic secretions;
 Indications
 Relief of symptoms of acute and recurrent diabetic gastroparesis
 Short-term therapy (4–12 wk) for adults with symptomatic gastroesophageal reflux who fail to respond to
conventional therapy
 Parenteral: Prevention of nausea and vomiting associated with emetogenic cancer chemotherapy
 Prophylaxis of postoperative nausea and vomiting when nasogastric suction is undesirable
 Contraindications: Contraindicated with allergy to metoclopramide; GI hemorrhage, mechanical obstruction
or perforation; pheochromocytoma
 Adverse effects
 CNS: Restlessness, drowsiness, fatigue, lassitude, insomnia, extrapyramidal reactions, parkinsonism-like
reactions, akathisia, dystonia, myoclonus, dizziness, anxiety
 CV: Transient hypertension GI: Nausea, diarrhea
 Nursing considerations
 Take this drug exactly as prescribed.
 Do not use alcohol, sleep remedies, sedatives; serious sedation could occur.

 GENERIC NAME: BISACODYL
 BRAND NAME(S): Dulcolax, Fleet Bisacodyl, Magic Bullet
 Classification: stimulant laxative
 Action: It acts by irritating the digestive tract and stimulates
intestinal activity
 Indication: . It is used to treat constipation or to clean out the
intestinal tract before bowel examinations or bowel surgery
 Adverse Effects: stomach ache, cramping, weakness, sweating,
irritation of the rectal area, diarrhea, or dizziness
 Contraindication: hypersensitivity to the drug
 Nursing Responsibilities:
 If the patient is under 6 years of age, consult child's doctor
before using this medication.

 Generic Name: Ketorolac tromethamine
 Brand Name: Toradol
 Classification: NSAID, Nonopioid analgesic
 Mode of Action: Reduces the production of prostaglandins, chemicals that cells of the
immune system make that cause the redness, fever, and pain of inflammation and
that also are believed to be important in the production of non-inflammatory pain.
It blocks the enzymes that cells use to make prostaglandins (cyclooxygenase 1 and
2). As a result, pain as well as inflammation and its signs and symptoms - redness,
swelling, fever, and pain - are reduced.
 Dosage: Ketorolac 30mg q8 IVTT
 Indication: For short-term management (up to 5 days) of moderately severe acute
pain that otherwise would require narcotics. It most often is used after surgery.
 Contraindication: Hypersensitivity to ketorolac, renal Impariment, aspirin allergy
 Adverse Effects: gastric or duodenal ulcer, renal impairment, liver failure, dysuria,
bleeding, platelet inhibition, neutropenia, leukopenia, pancytopenia,
thrombocytopenia, bone marrow depression
 Nursing Responsibilities:
 Infuse slowly as a bolus over no less than 15 seconds
 NALBUPHINE HYDROCHLORIDE
 NUBAINE
 Drug Class: Narcotic agonist-antagonist analgesic
 Therapeutic Actions: Nalbuphine acts as an agonist at specific opioid
receptors in the CNS to produce analgesia, sedation but also acts to
cause hallucinations and is an antagonist at µ receptors
 Indications: Relief of moderate to severe pain. Preoperative analgesia,
as a supplement to surgical anesthesia, and for obstetric analgesia
during labor and delivery.
 Contraindications/cautions: Contraindications: hypersensitivity to
nalbuphine, sulfites; lactation.
 Adverse Effects:
 Sedation. Clamminess, sweating headache, nervousness, restlessness,
depression, crying, confusion, faintness, hostility, unusual dreams,
hallucinations, euphoria, dysphoria, unreality.
ANATOMY AND PHYSIOLOGY
The uterus is a hollow muscular organ located in
the female pelvis between the bladder and rectum.

The ovaries produce the eggs that travel through

the fallopian tubes.
Once the egg has left the ovary it can be fertilized
and implant itself in the lining of the uterus. The
main function of the uterus is to nourish the
developing fetus prior to birth.
Kinds of Fibroids/myoma depends on
their orientation in the uterine wall
PATHOPHYSIOLOGY
CUES AND NURSING DX OUTCOME CRITERIA NURSING RATIONALE
EVIDENCES INTERVETION

Fear related After my 8 hours of To reduce fear and


SUBLECTIVE DATA:
to care, the patient will be Explain the
 help patient to be
“Nakulbaan man impending able to: procedure detailedly calm and relax
ko, hadlok ang akong Demonstrate understanding to the patient.


pamati nga operahan

surgery Helps to enhance
through use of effective Help her
 

ko unya dapit.” as secondary to coping behaviors and acknowledge that her self-esteem
verbalized by the Total resources. her fear of surgery is
patient. Abdominal Display appropriate range normal.
 Enhances sense of

OBJECTIVE DATA:
v/s = T = 36.3oC Histerectom of feelings and lessened Provide opportunity trust and nurse-


P = 70 bpm y. fear. for questions and patient relationship

R = 26 Verbalize knowledge of answer honestly.
cpm safety about the surgery. Manage
Which can cause

BP = stress to the patient.

Acknowledge and discuss environmental
120/70 mmHg
- increased respiratory fears, recognizing healthy factors such as loud
rate benefits than unhealthy noises, harsh
- increased perspiration fears. lighting.
- increase alertness
NURSING INTERVETION RATIONALE EVALUATION

 To reduce fear and help patient Verbalized accurate knowledge

Take and monitor vital signs. to be calm and relax of safety about the surgery.
Stay with the patient or make Helps to enhance her self- Acknowledged and discussed
arrangements to have someone esteem fears, recognized healthy
else be with her. To identify physical responses benefits than unhealthy fears.

Discuss patient’s perceptions associated with both medical “Magpa- opera na lang ko kay
of feelings. Listen to patient’s and emotional conditions. gikinahanglan na jud na ko
concerns. Providing patient with usual Para ko maayo.” As verbalized
Provide information in verbal support persons can diminish by the patient.
form and speak in simple feelings of fear.
sentences and concrete terms. Promotes atmosphere of caring
Promote patient control and and permits correction of
help patient identify and accept misperceptions.
things over which control is not Facilitates understanding and
possible. retention of information.
Strengthens internal locus of

control.
CUES AND NURSING DX OUTCOME CRITERIA NURSING RATIONALE
EVIDENCES INTERVETION
Subjective :
Sakit akong tahi” as
Altered At the end of my  Perform a To assess

verbalized by the Comfort: Care my patient comprehensive precipitating

patient.
Objectives :
Pain will manifest assessment factors
Restlessness noted Related to decrease pain as Note location To know the
Facial Grimace Noted

Pain scale 7 out of 10

Surgical evidence by: of surgical presence of
10- highest pain incision Verbalized pain is incision pain
No pain

Fatigue
secondary tolerated Assess client’s complication

Weak to Post Absence of facial perception To evaluate

Undergone TAH

Vital Signs :
surgery. grimace  pain that
Pain scale <7 out Perform pain relate to
T - 37.1°c
PR - 66 bpm
RR- 19 cpm
of 10 assessment each client
Absence of fatigue time pain To role out
BP- 110/80 mmHg
Absence of body
 occurs worsening of
weakness underlying
condition
NURSING INTERVETION RATIONALE EVALUATION

 After my nursing
Accept clients To identify pain intervention the patient has
description of pain subject to patients been manifested decreased
Monitor vital sign experience pain as evidenced by:
Work with client to Usually altered pain

To assist to explore

prevent pain Verbalized pain is
Provide quiet method that controls tolerated(mas dili na kaayu
environment and calm pain sakit akong tahi” as
To alleviate pain
activities. verbalized by the patient.
Administer analgesic 

as prescribed 
Absence of facial grimace
Encourage adequate  As a pain medication Pain scale 5 out of 10
rest period 

 To prevent fatigue Absence of fatigue



Absence of body weakness

CUES AND NURSI OUTCOME NURSING INTERVETION RATIONALE EVALUATION
EVIDENCES NG DX CRITERIA
Subjective : Risk At the end of my Note risk factors for To assist
After my nursing
“ pamati nako mura for care, the patient occurrence of infection contributing
kog ge hilantan, bag- Infecti will manifest To assess skin condition factors intervention my
o raba ko ge on free from around incision To assess presence patient has been
operahan” as Related infection as Stress proper hand of infection manifested free from
verbalized by the to evidence by: washing technique by all To reduce existing
patient. surgica Verbalize care givers to the client risk factor infection as evidence
Objectives : l understanding Cleans incision daily and To prevent by:
Lack of knowledge Incisio Of causative prn with providione infection
regarding causative n factors iodine or other To reduce

factors seconda Identify appropriate solution infection “ ako paning paning

Unable to identify ry to interventions to Change dressing as needed For mobilization kamotan nga dili
preventive measures surgica prevent Encourage early of respiratory mainfection akong
Weak l infection ambulation, deep breathing, secretions
febrile operati Absence of body coughing and position To prevent
tahi” as verbalized by
Surgical inscision on. weakness change. infection the patient.
at hypogastric Afebrile Administer or monitor
Performed
region medication regimen
Undergone TAH
intervention to
Vital Signs : prevent infection
T - 37 . 6 ° C Absence of weakness
PR - 69bpm
RR - 20 cpm Afebriled
BP - 130 / 80 mmHG T = 36.6 degree C