20844628 Case Presentation Endometrial Cancer
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Transcript of 20844628 Case Presentation Endometrial Cancer
7/17/2019 20844628 Case Presentation Endometrial Cancer
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Case Presentation:
Endometrial Cancer Group 2
Fhaye Kristine Kaye LorenzoDaphne Barillo
Christie Marie Barillo Joy Jamili
Alevi AguilarVenancio avarro
Faith !acure
Karen Dollopac
Area of Exposure: ASMGH-OB Gyne WardPM Sift
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Bio!rapic "ata
ame" MJB
Age" #$yo%e&" Female
Civil %tatus" %ingle
A''ress" Bar(aza) Anti*ue
Birth place" Bar(aza) Anti*ue
Birth 'ate" July +) ,-..
/eligion" Aglipayan
ationality" Filipino
Date o0 A'mission" %eptem(er ,+)211-
Atten'ing !hysician" Dr Maria Ceilo %%ansolis
A'mitting Diagnosis" 3n'ometrial Cancer
4n0ormant" Client an' AJB
/elationship to the Client" %ister
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5his is the case o0 MJB) a #$year6ol' 0emale) single an'a resi'ent o0 Bar(aza)
Anti*ue presently a'mitte'at Angel %alazar MemorialGeneral 7ospital 8ith the
a'mitting 'iagnosis o03n'ometrial Cancer
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9vervie8What is Endometrial Cancer?
3n'ometrial carcinoma is a :in' o0 cancer that (egins inyour uterus 9nly 8omen have a uterus %o only 8omencan get this :in' o0 cancer Carcinoma re0ers to cancerthat (egins in tissues that 0orm linings throughout the
(o'y 5he en'ometrium is the lining o0 the insi'e o0 theuterus 3n'ometrial carcinoma is a cancer that 0orms0rom the inner lining o0 the uterus 5hroughout thissection) 8e re0er to it simply as en'ometrial cancer9ther :in's o0 cancer can 0orm in the uterus as 8ell
5hese are calle' uterine sarcomas 5hey are 'iscusse'in their o8n section 3n'ometrial cancer usually ta:esyears to 'evelop 4t most o0ten occurs in 8omen 8hohave alrea'y gone through menopause
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What causes Endometrial/Uterine cancer?
5he main cause o0 most en'ometrial canceris too much o0 the hormone estrogen compare' tothe (o'y;s progesterone level 3strogen ma:esthe lining o0 the uterus <en'ometrium= gro8
thic:er !rogesterone >opposes> estrogen6yourprogesterone level goes up then 'rops at the en'o0 each menstrual cycle) ma:ing the thic:en'ometrium layer she' a8ay 5his is 8hat you
:no8 as menstrual (lee'ing Wen tere is toomuc estro!en in te #ody$ pro!esteronecan%t do its &o#' (e endometrium !etstic)er and tic)er' O*er time$ teendometrium cells can #ecome cancerous'
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Cief Complaint"
A('ominal pain an' enlargemento0 the a('omen 2 8ee:s !5A
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History of te
Present Healt Concern
58o 8ee:s !5A) the patient ha'
tolera(le a('ominal pain an' mil'cramps 8ith enlargement o0 thea('omen !atient 'i' not ta:e any
me'ications to relieve the pain!atient symptoms persiste') thussought consultation an' 8asa'vise' 0or a'mission
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5he client 8as 0ully immunize' <,BCG)$D!5) $9!V) $ 7epa B an' ,measlevaccine= o :no8n allergies) <6= 0or
Bronchial Asthma) <6= 0or 7ypertension)an' <6= 0or Dia(etes Mellitus !atient isalso :no8n as an alcoholic 'rin:er)consumes 26$ (ottles o0 (eer a 8ee: Last
January 211+ the client) un'ergonesurgical operation) the removal o0 uterinemass
Past Healt
History
7/17/2019 20844628 Case Presentation Endometrial Cancer
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OB Gyne History
The client had her first
menstrual period (menarche) at theage of 15, with regular intervals
lasting for 3-5 days consuming
2pads a day. ravida-! and "arity-!.
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Pysical Assessment
A. General Survey:
#eight$ 5%&'
espiratory ate$ 2 *reaths+min (tachypnea)- due to
venous o*struction rachial "ulse$ 1&5 *eats+min (tachycardia)- physical
signs of pain.
Temperature+ailla$ 3./ degrees 0elsius
lood "ressure$ 1&!+1!!mm#gevel of 0onsciousness$ lethargic (drowsy, response
to uestion then fall
asleep) with *lunted affect.
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B. Skin, hair, and Nails Assessment
1. 4in$ tan, dry, and fairly hot to touch. 4in
fold returns to place after 2-3 seconds. he waspale and cachexic (s4in-*one results from the
increase meta*olic demand of the tumor). inimal
moles can *e seen on the face. 6o edema of the
face noted.2. #air$ *lac4, straight chin level and evenly
distri*uted hair. (-) for e*orrheic dermatitis and
"ediculusis capitis. 6o scalp lesions noted.
3. 6ails$ thic4, hard, well-trimmed nails. Thecondition of the nail *ed is smooth and firm. (-) for
0lu**ing or eau%s lines.
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C. Head and Neck Assessment
#ead$ symmetric, round and inmidline. 6o visi*le lesions noted.
6ec4$ symmetric without
masses, scars, pulsation, lymphnodes non-palpa*le. Trachea in
midline. Thyroid gland non-palpa*le
with strong *ounding (7&) carotid
pulse.
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D. Eyes: protruded eyes without lesion or edema.
clera is white without lesions noted. 8ye*rowssparse with eual distri*ution. "upil 8ual,
ound, eactive to ight and 9ccommodation
("89) .
E. Ears: esion noted at the right auricle.
(papule)
F. Nse and Sinuses: eternal structure without
deformity. ymmetrical and patent nares with noinflammation noted. 6asal septum midline without
*leeding perforation or deviation. :rontal and
maillary sinuses non-tender.
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G. !uth and "harynx: pale and dry lips. 0heilosis noted.
H. Cardiac Assessment: no vi*rations or pulsations noted.#. Breast Assessment: 6o discharges from the nipples.
6on-tender and no dimpling or retraction noted.
J. Abdominal Assessment: hard, tender abdomen.
Abdominal girth of 85 cm and fundal height of 33 cm
with palpable mass on the pelvic floor upon Internal
Eamination !IE". #isible veins noted due to abdominal
distention.
$. Geniturinary%re&rductive Assessment: with
palpa*le mass on the pelvic floor upon ;nternal 8amination(;8). <ith minimal vaginal *leeding. :oley 0atheter attached
to uro*ag draining to a yellowish urine.
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c !lanning ursing4ntervention
/ationale
Very severea('ominal pain r?t'irect tumor
involvement
%u(@ective Cues"Ga(ali:6(ali:sa:it :ang a:on(usong
9(@ective Cues"Facial grimacing!ain scale?,1<very severe pain=// 2 cpm!/ ,#E (pm
B! ,#1?,11mm7g
/e0erence" ursing Care!lans Documentation #th 3'ition Lin'a Moyet<pE+-=
General"A0ter 'ays o0
hospital
conHnement) thepatientpsychologicalattitu'e an'physical status 8ill(e a(le to cope8ith the situation
%peciHc" A0ter 7 o0nursingintervention)patient 8ill (e a(le
to", 5olerate painan' 8ill have apain scale o0 #2 7ave a vitalsigns 8ithin normalrange
4n'epen'ent",!er0orm painassessment each
time pain occursote speciHclocation an'intensity <16,1scale=2Monitor vitalsigns
Depen'ent", A'ministerme'ication asor'ere' an'in'icate'
especially 0or thepersistence o0pain <5rama'ol2Emg=
5o rule out8orsening o0un'erlyingcon'ition
5o relieve pain0elt (y the
patient
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,ursin!"ia!nosis
Plannin! ,ursin!nter*ention
.ationale
3nlargement o0 thea('omen r?t Flui'accumulation in
the peritonealcavity occurs 'ueto the 'irectpressure (y thetumor or venouso(struction
Su#&ecti*e Cue:Ga(ahol a:on(usong :ag 8ararn a:o :amus6onhalin :ang sarangsemana
O#&ecti*e cues:,3nlargement o0the a('omen 8ithFun'al 7eight" $$cmA('ominal Girth"
Ecm
General: A0ter 'ays o0hospital
conHnement) thepatientpsychologicalattitu'e an'physical status 8ill(e a(le to cope8ith the situation
Speci/c: A0ter 7 o0nursinginterventions)patient 8ill (e a(le
to"
,/eport 'ecreasein a('ominal sizean' 0un'al height
2 De0ecate
ndependent:,Monitor F7 an'A('ominal girth
'aily
2 Maintain (e'rest
$ Monitor 4nta:ean' 9utput <M49=
# Monitorrespiratory) (o8elan' (la''er0unction
"ependent:
E A'ministerme'ication asor'ere'
, 5hesemeasurements
help 'etect Iui'retention an'ascites2 4mmo(ilityre'uce' the ris: o0in@ury
$ Monitor lossescalculation
# Level cor'compressioninIuences
respiratory<cervical=) (o8el<lum(ar=) an'(la''er <lum(ar=0unctioning
E Ai's in theelimination o0 stool
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