SAINT LOUIS UNIVERSITYCOLLEGE OF NURSING

Baguio City

Case Presentation: Hydrosalpinx, Acute appendicitis

Presented to:

Mrs. Melody D. Baliang, RN

Presented by:

Ayugat, Roland

Alcantara, Nadine

Ceriaco, Chedan

Gonzales, Bianca

Macayan, Katrin

Rayray, Ciara

Date:

June 17, 2008

PATIENT PROFILE

Name: Mrs. M. T. M. (Initials for anonymity)Age: 42 years oldCitizenship: FilipinoBirth date: September 15, 1965Religion: Roman CatholicBirth Place: Baguio City, PhilippinesAddress: San Vicente, Baguio CityEducational Attainment: High School GraduateAdmitting Physicians: Dr. Bibat,

Dr. CatalanAttending Physician: Dr. MalinitDate and Time Admitted: June 13, 2008; 11:10AMRoom and Bed Number: Pay ward, 025

Impression Diagnosis: Adnexal Mass, Left, to consider ectopic pregnancy, G7P6 (6016)

Operations performed: SalpingectomyElective Appendectomy(Both done last June 14, 2008)

Final Diagnosis: Hydrosalpinx, Left, s/p sapingectomy, G7P6 (6016), Acute appendicitis, congestive s/p Appendectomy

HISTORY OF PRESENT ILLNESS

Patient’s condition started one month before admission, when she experienced profuse

vaginal bleeding with discharge amounting to approximately two fully soaked diapers and had been

diagnosed of threatened abortion 10 weeks AOG. She had then undergone completion curettage

last May 08, 2008 at the Sto. Nino Hospital, Baguio City. The bleeding was controlled but resumed

a few days after the curettage with discharge amounting to approximately 1 to 2 minimally soaked

pads. The patient had not taken any medications and verbalized to have no associated abdominal

pain, dysuria, or fever accompanying her existing condition.

Six days prior to admission, the patient complained of experiencing abdominal pain with an

intensity of 5 out of 10 and no radiation. No medications were taken and there had been no

accompanying symptoms such as fever, dysuria, nausea and vomiting.

About two days before admission, patient’s condition persisted, prompting her to seek

advice from a private physician. A complete blood count, urinalysis and pelvic ultrasound were then

requested for further diagnosis. The complete blood count revealed no significant health

deviations, while the urinalysis suggested the presence of a urinary tract infection and the Pelvic

ultrasound showed left adnexal mass, suspicious for ectopic pregnancy, mild hydrosalpingitis. Due

to these findings, the patient was advised for admission, hence admitted.

PAST MEDICAL HISTORY

The patient verbalized to have been previously hospitalized at Sto. Nino Hospital for her

completion curettage and named no other succeeding condition necessitating hospitalization apart

from her present admission at Saint Louis University - Hospital of the Sacred Heart. She also

claimed to have no existing allergies to food and drugs and has had no previous intake of

maintenance drug for any serious health complication.

Furthermore, she has had no history of ovarian carcinoma, dysfunctional uterine bleeding,

myoma, Hydatidiform mole, pelvic inflammatory disease, cervicovaginitis, or polycystic ovarian

syndrome.

FAMILY MEDICAL HISTORY

The patient claimed to have no existing history of heredofamilial disease conditions such

as hypertension, cerebrovascular diseases, asthma, diabetes mellitus, cancer, peptic ulcer

disease, hyperthyroidism, or arthritis. She has no family member with an existing contagious

disease such as with pulmonary tuberculosis.

COURSE OF CONFINEMENT

This nursing care plan presents the case of Mrs. M. T. M., 42 year-old female, Filipino, a

Roman Catholic, married, born on September 15, 1965, a resident of San Vicente, Baguio City,

with a chief complaint of flank pain and vaginal bleeding. This was her second hospitalization, but

had been admitted for the first time in Saint Louis University - Hospital of the Sacred Heart last

June 13, 2008 at 11:10 am by Dra. Catalan and Dra. Bibat, with an impression diagnosis of

Adnexal Mass, Left, to consider ectopic pregnancy, G7P6 (6016).

The patient was admitted with the following diagnostic tests: hematology dated June 11,

2008; complete blood count dated June 11, 2008; urinalysis dated June 11, 2008; whole abdominal

sonogram dated June 11, 2008; and a specimen histopathology that had been reported last May

18, 2008.

During the second day of hospitalization, June 14, 2008, the patient had undergone the

following operations: Salpingectomy, Elective Appendectomy both with duly accomplished consent

forms with proper pre-operative preparation.

During Hospitalization, the patient received the following medications: Nalbuphine (10mg);

Cefalozine (1gm); Metoclopramide (10mg); Ranitidine (50mg); Ketorolac (30mg) and Tranexamic

Acid (500mg). The patient had been infused with and consumed 2 bottles of D5LRS (1L) and 1

bottle of PLRS (1L).

DIAGNOSTICS AND IMPLICATIONS

Hematology (June 11, 2008)

Result: blood type “O” Rh positive

The hematology test was completed to identify the patient’s blood type and Rh blood

group. Laboratory technicians determine the patient’s blood type and then either cross

match it to the potential donor or screen it for the presence of antibodies; this is done to

avoid blood type mismatches which may trigger damaging antigen-antibody responses

(agglutination) or rupture of red blood cells (hemolysis).

Reference: Tortora, et. al.; Principles of Anatomy and Physiology; 11th edition

Complete Blood Count (June 11, 2008)

Normal values Patient ValueHgb 120-160 g/L 127 g/LHct 0.37-0.47 Vol % 0.38 Vol%Leukocyte 5-10 10^9/L 10.15 10^9/LNeutrophils 0.5-0.7 0.82Lymphocytes 0.2-0.4 0.17Eosinophils 0-0.07 0.01Platelet 150-440 x10^9/L 383 x 10^9/L

The complete blood count was done to identify if the patient’s active bleeding has taken

effect on the present level of blood components, apparently, no significant deviation is

seen.

Reference: Smeltzer, et. al.; Textbook of Medical Surgical Nursing; 10th edition

Urinalysis (June 11, 2008)Color: dark yellow Pus cells: 40-50/hpfAppearance: turbid RBC: 20-30/hpfReaction: acidic (ph6) Bacteria: some/hpfSpecific Gravity: 1.015 Yeast Cells: none foundAlbumin: (+) Mucus threads: loadedSugar: (-) Epithelial cells: some

Amorphous Urates/Phosphates: few

A urinalysis is a diagnostic physical, chemical, and microscopic examination of a urine

sample (specimen). Specimens can be obtained by normal emptying of the bladder

(voiding) or by a hospital procedure called catheterization. Red blood cells in the patient’s

urine can be due to bleeding in the genitourinary tract as a result of systemic bleeding

disorders or bacterial infections while pus in the urine may be indicative of urinary tract

infection.

Reference: http://www.healthatoz.com/healthatoz/Atoz/common/standard/transform.jsp?requestURI=/healthatoz/Atoz/ency/urinalysis.jsp

Ultrasound- whole abdominal Sonogram (June 11, 2008)

The uterus is midline, anteverted and normal in size, measuring 5.9 x 3.4 x 4.9 cm. It shows

homogenous echotexture. The endometrial stripe is thin (5.0mm). A complex mass is noted at the

left adnexal area adjacent to the ovary, measuring 3.0 x 2.3 cm. There is mild dilation of the right

fallopian tube which is fluid filled. The right ovary is intact. The cul-de-sac is clear.

IMPRESSION: Left adnexal mass, suspicious of ectopic pregnancy

Mild Hydrosalpingitis, Right

Unremarkable Sonogram of the liver, gallbladder, pancreas, spleen,

kidneys, urinary bladder

Medical sonography (ultrasonography) is an ultrasound-based diagnostic medical imaging

technique used to visualize muscles, tendons, and many internal organs, their size,

structure and any pathological lesions with real time tomographic images. An adnexal

mass is a lump in the tissues near the uterus, usually in the ovary or fallopian tube, which

usually include ovarian cysts, ectopic (tubal) pregnancies, and benign (noncancerous) or

malignant (cancerous) tumors. A hydrosalpinx is a distally blocked fallopian tube filled with

serous or clear fluid. The blocked tube may become substantially distended giving the tube

a characteristic sausage-like or retort-like shape.

References: http://en.wikipedia.org/wiki/Hydrosalpinx; http://en.wikipedia.org/wiki/Hydrosalpinx; http://en.wikipedia.org/wiki/Ultrasound

Histopathology (Submitted- May 12, 2008) (Reported- May 18, 2008)

Diagnosis: Abortion, incomplete, 11 weeks age of gestation, G8P7 (7016); status completion

curettage

Histopathologic Diagnosis: Uterine Curettings- Decidual tissues, chorionic villi, blood clots

Gross description: Specimen consists of irregular fragments of tan membranous and spongy

tissues admixed with blood clots forming an aggregate measuring 3 x 3 x 3 cm

Histopathology refers to the examination of a biopsy or surgical specimen by a pathologist,

after the specimen has been processed and histological sections have been placed onto

glass slides. This is the most important tool of the anatomical pathologist in routine clinical

diagnosis of cancer and other diseases. This was done to identify the tissues extracted

during the patient’s completion curettage. The test seems to have identified tissues

resembling the products of conception hence the identified diagnosis suggests an

incomplete abortion.

Reference: http://en.wikipedia.org/wiki/Histopathology

MEDICATION LIST

Ranitidine (50mg)

Histamine H2 receptor antagonist

Indication: Relief of heartburn associated with acid indigestion and sour stomach.

Treatment of GERD.

Action: competitively inhibits gastric acid secretion by blocking the effect of histamine on

H2 receptors. Both daytime and nocturnal basal gastric acid secretion, as well as food-

and pentagastrin – stimulated gastric acid are inhibited.

Contraindications: cirrhosis of the liver, impaired renal or hepatic function

Side effects: Headache, abdominal pain, consitipation, diarrhea, nausea and vomiting.

Nursing Considerations:

o Give antacids concomitantly for gastric pain although they may interfere with ranitidine

absorption.

o Assess stomach pain

o Avoid alcohol, aspirin – containing products, caffeine containing products (may

increase stomach acid)

Cefazolin (1gm)

First generation cephalosporin

Indication: UTI

Action: Antibacterial – interferes with the final step in cell wall formation, resulting into

unstable cell membranes that undergo lysis. Also, cell division and growth are inhibited

First generation – effective activity against gram – positive microorganisms (S. aureus) and

relatively mild activity against gram – negative microorganisms( E.coli).

Side effects: Diarhhea, N/V, abdominal pain, rash, fever

Nursing considerations:

o Take as directed/ complete subscription

o Report adverse effects

Tranexamic Acid (500mg)

Antifibrinolytic agent

Indication: Active vaginal bleeding

Action: Tranexamic acid is a competitive inhibitor of plasminogen activation, and at much

higher concentrations, a noncompetitive inhibitor of plasmin.

Contraindications: active intravascular clotting, acquired defective color vision, since this

prohibits measuring one endpoint that should be followed as a measure of toxicity

Side effects: Gastrointestinal disturbances, Hypotension

Nursing Considerations:

o Use cautiously on pregnant women

o Patients with a previous history of thromboembolic disease may be at increased

risk for venous or arterial thrombosis.

Nalbuphine (10 mg)

Brand name: Nubain

Drug Classification: Opioid analgesic

Indications: Management of moderate to severe pain. Also used as an analgesic during

labor, as a sedative prior to surgery, and as a supplement in balanced anesthesia.

Action: Binds to opiate receptors in the CNS. Alters the perception of and response to

painful stimuli, while producing generalized CNS depression. In addition, has a partial

antagonist property, which may result in opioid withdrawal in physically dependent

patients.

Contraindications: Hypersensitivity to nalbuphine or bisulfites. Patients who are physically

dependent on opioid analgesics and have not been detoxified (may precipitate withdrawal).

Caution: Head trauma, increased intracranial pressure; severe renal, hepatic, or

pulmonary disease; hypothyroidism; geriatric/debilitated patients.

Adverse reactions: Sedation, headache, dizziness, vertigo, respiratory depression, nausea

and vomiting, clammy feeling.

Nursing Considerations:

o Assess type, location, and intensity of pain.

o Assess BP, PR, and RR before and periodically during administration.

o Prolonged use may lead to physical and psychological dependence and tolerance.

o Patient teaching:

Instruct on how and when to ask for pain medication.

Advise to call for assistance when ambulating.

Ketorolac (30 mg)

Brand name: Toradol, Ketomed

Drug Classification: Non-opioid analgesic; NSAID

Indications: Short term management of pain. Management of ocular itching due to

seasonal allergic conjunctivitis.

Action: Inhibits prostaglandin synthesis producing peripherally mediated analgesia. It also

has an antipyretic and an anti-inflammatory property.

Contraindications: Cross-sensitivity with other NSAIDs may exist. Lactation.

Caution: History of GI bleeding, CVD, and renal impairment.

Adverse reactions: Drowsiness, abnormal vision, asthma, pallor.

Nursing Considerations:

o Assess pain, noting type, location, and intensity.

o Patients with asthma, aspirin-induced therapy, and those with nasal polyps are at

increased risk for developing hypersensitivity reactions.

o Patient Teaching:

Instruct on how and when to ask for pain medications.

Metoclopramide (10 mg)

Brand name: Plasil

Drug Classification: Anti-emetic

Indications: It is used short-term to treat heartburn caused by gastroesophageal reflux in

people who have used other medications without relief of symptoms. It is also used to treat

slow gastric emptying in people with diabetes (also called diabetic gastroparesis), which

can cause nausea, vomiting, heartburn, loss of appetite, and a feeling of fullness after

meals.

Action: Metoclopramide increases muscle contractions in upper digestive tract. This

speeds up the rate at which the stomach empties into the intestines.

Contraindications: In patients with a history of hypersensitivity to metoclopramide or any of

the components. In the presence of GI hemorrhage, mechanical obstruction, or

perforation. In those with pheochromocytoma, in epileptics and in those with

extrapyramidal reactions.

Caution: Pregnancy and lactation.

Adverse reactions: Restlessness, drowsiness, fatigue and lassitude. Less frequent

reactions are insomnia, extrapyramidal symptoms, headache, dizziness, nausea,

galactorrhea, gynecomastia, rash and urticaria, or bowel disturbances.

Nursing Considerations:

o Extract from history if the patient has epilepsy, GI perforation, pheochromocytoma,

or bleeding in the intestines.

o The drug can pass into the breast milk and may harm the baby.

o Metoclopramide is usually taken before meals and at bedtime.

o Patient Teaching:

Instruct to take with a full glass of water.

THIRTEEN AREAS OF ASSESSMENT

I. Psychological Status

Mrs. M. T. M. is 42 years old. She is an Igorot and was born and raised in San Vicente,

Baguio City. Her parents are also from San Vicente, Baguio City. Presently, her family is residing in

San Vicente, Baguio City. They live in an owned, concrete 1-storey house with two rooms. The

patient is a Roman Catholic and verbalized that she has no beliefs or practices that may hinder

health care rendered to her. She is married and was blessed with 6 children. She is a retailer of

ready-to-wear clothes or mostly commonly known as “wagwag”. According to her, she avails of the

dry goods from Manila.

The patient is accommodated at the Pay ward section of the OB ward of Saint Louis

University-Hospital of the Sacred Heart.

The patient is a mother to 6 children. She verbalized that they have good family

relationships. The patient’s second child is the one staying with her in the hospital. All in all, there

are 9 members of her family and they live together. Prior to hospitalization, she was independent;

however, during her confinement, her daughter had been assisting her in performing ADLs as the

patient’s condition necessitated dependency since the procedures performed rendered her to be

temporarily in need of assistance in doing activities she used to do alone. Her diversional activities

include taking care of her children, doing household chores, or managing in her business.

Her OB history is as follows:

*OB score-G7P6 (6016)

G1: 1984, home delivery, NSD, term baby boy

G2: 1989, home delivery, NSD, term baby boy

G3: 1991, home delivery, NSD, term baby boy

G4: 1996, home delivery, NSD, term baby girl

G5: 2001, home delivery, NSD, term baby boy

G6: 2006, home delivery, NSD, term baby girl

G7: 2008, spontaneous abortion, 12 weeks AOG

II. Mental and Emotional Status

The patient is awake and coherent, oriented to time, place, and person. She is a high

school graduate and is able to read, write, comprehend and follow directions.

Regarding her health problem, she is grateful in having undergone left salpingectomy and

appendectomy which afforded her relief from pain. She has no unusual beliefs about the cause of

her health problem. This is her second hospitalization.

Her chronological age is directly proportional to her developmental age as she is open and

approachable, and is able to converse with the student nurses without any observable signs or

significant inconsistencies such as speech defects, stuttering or inability to understand or follow the

conversational framework with difficulty.

III. Environmental Status

The patient is in need of assistance when standing and going to the comfort room.

There are two more patients in the room. There is adequate lighting and ventilation. The

comfort room is approximately less than 10 feet away from the patient’s bed. Side tables are

located at the right and left upper head of the bed where her things are readily accessible. There

was no presence of side rails but there are head and foot rails. The patient is with an intravenous

line on her right hand. An IFC was inserted last June 14, 2008 in preparation for her operation and

was ascetically removed after her surgery on June 15, 2008.

IV. Sensory Status

a. Visual status: the patient has no known visual deficits. She also has no unusual sensations

like blurring of vision. The patient does not use any corrective like contact lenses or

eyeglasses or prosthetic devices like artificial eyeballs. She has pale palpebral conjuctiva

and 2-3 mm pupils, equally round and reactive to light and accommodation. Her eyes are

normally symmetrical and in level with each other. There are also symmetrical eye

movements.

b. Auditory status: the patient is able to distinguish and respond to voices. She verbalized

that she has no known auditory deficits and unusual sensations like ringing or buzzing.

She has no auditory corrective devices. The patient’s pinnae are bilaterally symmetrical

with the lateral canthus of the eyes and in line with each other.

c. Olfactory status: the patient is able to discriminate odors and there are no unusual

sensations. The patient has no colds.

d. Gustatory status: the patient is able to discriminate sweet, salty, bitter and sour tastes. She

has no unusual sensations. She verbalized that there was no change in her appetite.

e. Tactile status: the patient is able to discriminate different tactile sensations and has no

unusual sensations.

f. Speech formulation and perception: the patient has intact speech organs. The patient

verbalized that her whole set of upper jaw teeth is a denture. The patient is able to

understand and initiate speech and has no deficits in phonation.

g. Sensory environment: the hospital setting and routine such as vital signs taking are

tolerated well by the patient.

V. Motor Status

Upon admission, the patient was weak. Upon assessment, the patient is unable to

ambulate properly and needs assistance when standing and going to the comfort room. There was

good body coordination as well as stability. The patient can tolerate range of motion exercises.

There are no muscular abnormalities and there is good muscle tone and mass. The patient’s

muscle strength is as follows:

5/5 5/5

4/5 4/5

The patient was instructed to remain flat on bed for a few hours after the

surgery. However, there were no further medical restrictions on activity and early ambulation was

encouraged. The patient has an abdominal binder over her wound dressing and is patient is right

handed.

VI. Nutritional Status

The patient usually has three main meals and two snacks. She prefers vegetables

(highland or lowland), coffee, and soda drinks particularly coke. She also prefers bread for snacks.

According to her, she has good appetite prior to and even during hospitalization. However, prior to

and after her surgery, she was on NPO. On the morning of June 15, 2008, she had already passed

flatus and stool. There was no further physician’s order regarding her diet.

The patient has a medium structured body. She has moist skin as well as moist

buccal cavity. She has good capillary refill and good skin turgor.

The patient has a denture. She has intact oral cavity. The patient is awake and is

able to swallow but was remained on NPO, a day after her surgery.

VII. Elimination Status

The patient has been diagnosed with urinary tract infection as seen and implied by

increased pus cells in her urinalysis. During her operation last June 14, 2008, she was inserted

with an IFC draining yellowish urine and is adequate with urine output of more than 30cc/hour. The

IFC was eventually removed on June 15, 2008 in the presence of flatus. During the night shift of

her 1st day post operatively, the patient was however observed to have decreased urinary output

and was then therefore referred to the resident on duty for further management. The patient had

remained on bed for a number of hours and was hesitant to ambulate due to the discomfort and

pain she felt hence reported that she had defecated once.

VIII. Fluid and Electrolyte Status

On average, she drinks for about 8-10 glasses of water a day. She also drinks additional

coffee and carbonated drinks. The patient was maintained on NPO after her operation but her

presence of flatus and that she already defecated may indicate progress on her nutritional intake.

The patient has good skin turgor.

IX. Circulatory Status

Pulse rate is of regular rhythm, ranging from 70 – 75 beats per minute. Blood pressure

range is from 110/70- 120/80. Her capillary refill was 2 seconds. Client manifests good, adequate

and effective circulation as seen by the absence of cyanosis and dizziness. In addition the client is

awake and alert which manifests good level of consciousness.

X. Temperature Status

Before and upon admission, patient’s temperature is within normal (range of 36.4 – 37.5

C). The patient’s temperature was stable during hospitalization; no fever was experienced.

XI. Integumentary Status

The patient has a fair complexion. The patient had a dry and intact binder over wound

dressing on the abdominal area due to her appendectomy and salphingectomy. No signs of muscle

wasting or clubbing nails were observed. The patient has a good skin turgor.

XII. Comfort and Rest Status

Normally, she sleeps for about 8 hours. During hospitalization, she verbalized that she

does not have any concern regarding her hours of sleeping but was observed to be awakened from

sleep on several occasions to converse with the other patient beside her. She was maintained flat

on bed immediately after her operation but already advised and assisted to be on her desired

comfortable position as ordered by her physician. She claimed to feel post-operative pain over her

abdomen. She described it to be non-radiating and of moderate intensity.

XIII. Respiratory Status

The patient has no problems regarding her respiratory status. Her respiratory rate has a

range of 20-25 breaths per minute. She has an effective airway clearance and has an effective

breathing pattern which provides adequate gas exchange and results to a good level of

consciousness and non-cyanotic peripheral status.

LIST OF PRIORITIZED PROBLEMS

Actual problems

1. Acute pain related to tissue trauma secondary to surgery

2. Impaired skin integrity related to trauma secondary to surgical incision

3. Impaired tissue integrity related to trauma to integumentary and subcutaneous tissues

secondary to abdominal surgery

4. Activity intolerance related to temporary immobility secondary to previous surgery

5. Impaired physical mobility related to discomfort upon movement secondary to surgery

6. Impaired transfer ability related to trauma and discomfort upon moving secondary to effects of

surgery

7. Self-care deficit: bathing/hygiene, and dressing related to discomfort upon moving secondary to

effects of surgery

8. Acute urinary retention may be related to use of a medication (opioid) with side effects of urinary

retention

9. Ineffective role performance related to physical health alterations

10. Interrupted family process related to situational changes secondary to physical health

alterations

11. Disturbed sleeping pattern related to interruptions for therapeutic, monitoring and other

generated awakening

Potential problems

1. Risk for constipation related to insufficient physical mobility

2. Risk for infection related to inadequate primary defenses (broken skin integrity)

3. Risk for injury related to altered mobility status secondary to surgery

4. Risk for imbalance nutrition: less than body requirements related to decreased volume of

ingested food during hospitalization

5. Risk for imbalanced body temperature related to trauma affecting temperature regulation

PRIORITIZATION OF PROBLEMS

Abraham Maslow (1954) attempted to synthesize a large body of research related to

human motivation. Prior to Maslow, researchers generally focused separately on such factors as

biology, achievement, or power to explain what energizes, directs, and sustains human behavior.

Maslow posited a hierarchy of human needs based on two groupings: deficiency needs and growth

needs. Within the deficiency needs, each lower need must be met before moving to the next higher

level. Once each of these needs has been satisfied, if at some future time a deficiency is detected,

the individual will act to remove the deficiency. The first four levels are:

1) Physiological: hunger, thirst, bodily comforts, etc.;

2) Safety/security: out of danger;

3) Belonginess and Love: affiliate with others, be accepted; and

4) Esteem: to achieve, be competent, gain approval and recognition.

According to Maslow, an individual is ready to act upon the growth needs if and only if the

deficiency needs are met. The fifth level is Self-actualization. It means to find self-fulfillment and

realize one's potential. Self-actualized people are characterized by: 1) being problem-focused; 2)

incorporating an ongoing freshness of appreciation of life; 3) a concern about personal growth; and

4) the ability to have peak experiences.

LIST OF PRIORITIZED PROBLEMS

PRIORITIZED PROBLEMSCLASSIFICATION

(Actual/Potential)

1. Acute pain related to tissue trauma secondary to surgery Actual

2. Impaired skin integrity related to trauma secondary to surgical

incisionActual

3. Impaired tissue integrity related to trauma to integumentary and

subcutaneous tissues secondary to abdominal surgeryActual

4. Activity intolerance related to temporary immobility secondary to

previous surgeryActual

5. Impaired physical mobility related to discomfort upon movement

secondary to surgeryActual

6. Impaired transfer ability related to trauma and discomfort upon

moving secondary to effects of surgeryActual

7. Acute urinary retention may be related to use of a medication

(opioid) with side effects of urinary retentionActual

8. Disturbed sleeping pattern related to interruptions for therapeutic,

monitoring and other generated awakeningActual

9. Self-care deficit: bathing/hygiene, and dressing related to

discomfort upon moving secondary to effects of surgeryActual

10. Ineffective role performance related to physical health alterations Actual

11. Interrupted family process related to situational changes

secondary to physical health alterationsActual

12. Risk for constipation related to insufficient physical mobility Potential

13. Risk for imbalance nutrition: less than body requirements related

to decreased volume of ingested food during hospitalizationPotential

14. Risk for infection related to inadequate primary defenses (broken

skin integrity)Potential

15. Risk for imbalanced body temperature related to trauma affecting

temperature regulationPotential

16. Risk for injury related to altered mobility status secondary to

surgeryPotential

NURSING CARE PLANS

Assessment Explanation of the problem Objectives Interventions Rationale Evaluation

P: s/p Salpingectomy, Elective Appendectomy

S: “ Complained to have pain felt over the abdominal; area, characterized as stabbing in nature, with no radiation, rated as 7/10, aggravated by movement, and alleviated by rest”

O: >Appears weak

>Confines self to bed and moves minimally

>Groans upon movement

>Hesitant to initiate movement

>Asks for assistance in ADL’s

>Facial Grimacing observed upon movement

> Seen holding abdomen

>Vital signs: BP: 110/70 mmHgRR: 25 cpmPR: 75 bpmT: 36.5 C

A: Acute pain related to tissue trauma secondary to

The patient had undergone an abdominal ultrasound with the following results: Left adnexal mass suspicious of ectopic pregnancy and Mild Hydrosalpingitis, Right

Salpingectomy, and Elective Appendectomy was performed to repair the assessed damage

A Surgical incision was done

Nociceptors or free nerve endings in the skin responded to the potentially damaging stimuli (surgical cutting)

Nociceptive actions are transmitted to the peripheral nervous system

The brain receives the stimuli and interprets pain depending the type of fiber delivering the impulse

LTO: After hospitalization, the patient will

a) assume ADLs without pain or discomfort

b) verbalize that she is completely pain free

STO: Within the shift the patient will be able to

a) identify and describe pain felt b )verbalize that her pain decreased from to

c) enumerate at least 3 strategies of pain relief correctly

d) perform deep breathing exercises for pain management correctly

Diagnostics:

1.Monitor vital signs

2. Use a pain assessment scale to Comprehensively assess and record pain using objective criteria such as location, characteristics, onset/duration, frequency, quality, severity and precipitating or aggravating factors before and after performing nursing interventions.

3. Note location of surgical Incisions

4. Assess patient perception and beliefs about pain felt

Therapeutics:

1. Inform patient that the health worker acknowledges that the patient’s pain is real by:

a. Listening to the patient’s subjective complaints

b. Conversing therapeutically with the patient

Diagnostics:

> For establishment of baseline data and an objective parameter/ indication of increasing pain.

> baseline for assessing changes in pain level and evaluating interventions

>Location of Surgical incisions can influence the amount of post operative pain felt, this also serves as a medium of comparison with the clients pain rating

> Identify factors influencing the pain responseTherapeutics:

>Promotes a feeling of assurance, therefore decreasing the burden

>Distracts the patient from concentrating on the pain

surgeryAcute pain related to tissue trauma secondary to surgery

Smeltzer, et. al.; Textbook of Medical Surgical

Nursing;10th edition

c. Anticipating and attending to the patient’s needs

d. Assisting in ADLs

2. Provide comfort measures by:

a. Clustering activities to provide periods of rest

b. Assisting to a comfortable position

c. Performing non pharmacologic nursing interventions ( back rub or massage)

3. Carry out pharmacologic interventions of pain as ordered:a) Nalbuphine (10 mg)

>Decreases the patient’s

> helps decrease movement that aggravates pain felt

>to afford rest to the client thereby promoting wellbeing and less preoccupation with pain

>reduces muscle tension by distributing pressure on all body parts thereby promoting comfort

>promotes relaxation and relieves pain episodes that last for a short interval of time

>Action: Binds to opiate

receptors in the CNS. Alters

the perception of and

response to painful stimuli,

while producing generalized

CNS depression. In addition,

has a partial antagonist

property, which may result in

opioid withdrawal in physically

b) Ketorolac ( 30mg)

dependent patients.

>Nursing Considerations:

i. Assess type, location,

and intensity of pain.

ii. Assess BP, PR, and

RR before and

periodically during

administration.

iii. Prolonged use may

lead to physical and

psychological

dependence and

tolerance.

iv. Patient teaching:

a. Instruct on

how and

when to ask

for pain

medication.

b. Advise to call

for assistance

when

ambulating.

>Action: Inhibits prostaglandin

synthesis producing

peripherally mediated

analgesia. Has antipyretic and

Educative interventions:

1. Discuss non therapeutic management of pain used by the patient such as

a. Bed rest

anti-inflammatory properties

>Nursing Considerations:

i. Assess pain, noting

type, location, and

intensity.

ii. Patients with asthma,

aspirin-induced

therapy, and those

with nasal polyps are

at increased risk for

developing

hypersensitivity

reactions.

iii. Patient Teaching:

a. Instruct on

how and

when to ask

for pain

medications.

Educative interventions

>Bed rest supports immobilization with its deleterious effects on bone,

b. Relaxation techniques like deep breathing exercises

2. Instruct deep breathing exercises.

3. Encourage to verbalize increasing pain.

connective tissue, muscle, and psychosocial well-being. Limited bed rest of less than 48 hours may be beneficial to allow for reduction of significant muscle spasm brought on with upright activity

> Reduces pain by relaxing tense muscles that contribute to the pain

> Ensures that the patient has seen the correct way of doing a correct technique

>gives the patient a sense of control over the pain as she can help be assured that the student nurse will be around to be of assistance in times that he feels pain

Reference: Smeltzer et. al.; Textbook of Medical Surgical Nursing;10th edition

Doenges et. al; Nurses Pocket Guide; 9th edition

Assessment Explanation of the problem Objectives Interventions Rationale Evaluation

P: s/p Salpingectomy, Elective Appendectomy

S: “Kakatapos lang ng operasyon ko kanina”

O : >Status post Salpingectomy, and Elective Appendectomy , day 1

>With dry and intact abdominal dressing and binder

> No foul odor noted in the surgical site >(+) facial grimace and guarding behavior noted when ambulating>Vital signs: BP: 110/70 mmHgRR: 25 cpmPR: 75 bpmT: 36.5 C

A: >Impaired skin integrity related to trauma secondary to surgical incision

>Impaired tissue integrity related to trauma to integumentary and subcutaneous tissues secondary to abdominal surgery

The patient had undergone an abdominal ultrasound with the following results Left adnexal mass suspicious of ectopic pregnancy and Mild Hydrosalpingitis, Right

Salpingectomy, and Elective Appendectomy was performed to repair the assessed damage

Surgical procedure required cutting into her skin and tissue and removing her appendix and affected fallopian tube Skin and Tissue trauma secondary to the surgery

Presence of abdominal wound (surgical site)

>Impaired skin integrity related to trauma secondary to surgical incision

>Impaired tissue integrity related to trauma to integumentary and

LTOAfter hospitalization: -the patient’s surgical site will not have any complications such as infection-the patient’s wound will heal normally and well approximated. STO:After 8 hours of nursing interventions: -the patient’s suture site will remain intact and free from contamination -the patient or a skilled significant other will be able to demonstrate at least 4-7 steps of proper wound dressing techniques

Diagnostics:

>Monitor for signs of infection

>Monitor vital signs every 4 hours

>Assess skin integrity

>Assess wound dressing for drainage

> Monitor dietary intake, and avoid irritant food and fluid intake

Therapeutics: >Avoid handling and placing direct pressure on the suture area

>Ensure safety by

Diagnostics: >infection, through production of toxins and wastes increases the probability of tissue damage.>Provides a baseline that allows quick recognition of deviations in subsequent measurements >Serves as baseline data to evaluate the efficiency of nursing intervention

>early recognition of undesirable signs and symptoms such as profuse bleeding is vital in preventing further complications

>these substances may cause irritation to the patient’s skin and oral mucous membranes and may cause complications in the healing process of the abdominal wound

Therapeutics: >pressure predisposes skin breakdown

>to maintain the patency

subcutaneous tissues secondary to abdominal surgery

REFERENCES:

Clinical Applications of Nursing

Diagnosis 4th edition, copyright 2002,

by Cox, Hinz, Lubno, Scott-Tilley,

Newfield, Slater , and Sridaromont.

Published by F.A. Davis company,

Philadelphia

www.medscape.com

Fundamentals of Nursing, 5th edition

by Kozier, Erb,Blais, Wilkinson,

published by the Addison-Wesley

company INC, copyright 1998

constantly checking on the patient and assisting when patient is ambulating

>Perform deep breathing and coughing exercises with the patient

>Perform passive exercises or have the patient perform active range of motion exercises >Use sterile technique when changing/ assessing dressing or performing invasive procedures

>Promote rest and comfort by clustering nursing interventions

> Wash hands thoroughly before and after each intervention

Educative interventions:

>Teach the patient and significant others about proper wound care

of the patient’s tubings like the Epidural catheter and IFC and prevent any complications that may arise if the tubes are disconnected

>Mobilizes static pulmonary secretions

>stimulates circulation, which provides nourishment and carries waste away, thus reducing the likelihood of skin breakdown.

>protects patient from exposure to pathogens

>adequate rest coupled with the right diet promotes faster wound healing

>prevents cross-contamination and nosocomial infections

Educative interventions:

>Basic care measures for impaired skin integrity are important toe prevent

>Teach and explain to the patient the benefits of early ambulation and how to ambulated using proper techniques to avoid trauma to the wound >Encourage patient to increase intake of food rich in protein such as organ meats and food rich in Vitamin C such as pineapple and oranges

>Teach the patient and family the purpose and techniques of universal precautions

infection >early ambulation prevents inadequate tissue perfusion to the surgical site which may lead to other complications >protein is needed for tissue building and wound healing and vitamin C enhances the absorption of protein and other nutrients needed for wound healing >protects the patient and the family from infection