Lionheart Lemery Presentation

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All Rights Reserved @ Lionheart 2009 /09279074641 www.Lionheart.co.nr

A Case Presentation

In Partial Fulfillment of the Requirementsin

NCM 104 Curative and Rehabilitative Nursing (RLE)


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PROGRAM

III. Introduction Anna Riza F. MagtiraIV. Patients Data Mc Richard V. PaglicawanV. Nursing Health History Lovely Naden NavarroVI. Physical Assessment 1 Jenilyn MercadoVII.Physical Assessment 2 Shanelle Erika MarquezVIII.Patterns of Functioning Mc Richard V.

PaglicawanIX. Laboratory Results Carmela Ruah C. PalerX. Anatomy and Physiology Jesse NomosXI. Pathophysiology Lovely Naden Navarro

XII.Nursing Care Plan Mc Richard V. Paglicawan Jesse Nomos Federico Magat


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EAC BSN IV Section 27 Group C

Magat, Federico Jr.

Magtira, Anna Riza F.Marquez, Shanelle Erika M.Mercado, Jenilyn

Moncayo, MichelleNavarro, Lovely

Nomos, JessePaglicawan, Mc Richard V.

Paler, Carmela Ruah C.

January 08, 2009


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Submitted to

Anthony E. Estolas R.N.


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I. INTRODUCTION

We, the fourth year nursing students of EmilioAguinaldo College, Manila - Section 27 have prepareda clinical study utilizing the NURSING PROCESS.

This is a case of NAD, a 44 year old woman. Shechose not to establish her private life for publicconsumption. She belongs to a very simple and

extended type of family

She and her family believe in the assumption of proper roles, and for them, the family to functionnormally, they see to it that:

1. They shared different ideas and ways of childrearing responsibilities.2. Their family communicates openly with the othermembers of the family.3. Their family members are satisfied with their roles,and how the decisions are made.


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She was admitted at the Metro Lemery Medical Center onthe 9 th of December 2008 due to vaginal bleeding.

Upon admission, the patient was diagnosed with:

Hydatiditum Mole (H-Mole), (+)palpable mass @ CAR

She went through different laboratory procedures suchas CBC, Hematology, Compatibility Testing and Blood CrossMatching. After getting the results of the laboratory examsshe was advised for TAHBSO the following day.


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GOALS AND OBJECTIVES :

3. Ewan4. Basta


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II. PATIENTS DATA


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D. Family Medical History

The patient has a history of hypertension onthe mothers side. 3 of her 8 siblings are sufferingfrom hypertension and 1 has Diabetes Mellitus.


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E. Social and Personal History

The patient is a full time housewife spendingher time of the day only in the house. She has 6children and most of them have their own families.She is the one responsible preparing the foods forher family and cleaning the house. Her family is anexample of a Roman Catholic not active of attending the weekly church or any activities in thecommunity.


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F. Occupational History

She stays home all day to do her daily householdchores and prepare for breakfast, lunch and dinner of thefamily. Her husband is the one responsible for supplying forfood allowance of the family. Any other needs of the familywere given by her other children.

G. Developmental History

Cooking the food and cleaning the house is her dailychores. Washing the dishes and the clothes was theresponsibility of her daughter in law. After finishing thehousehold chores, the patient enjoys playing mahjong andtong-its with their neighborhood. H. Psychosocial History

The patient is not an active member in the communityor any groups. She only finished 3 rd year high school andwas married to her husband. She onl ex resses her


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IV. PHYSICAL ASSESMENT A. General Appearance

The patient is conscious and coherent during ourinterview.

B. General Survey- Pink palpebral conjuctiva, moist lips, moist oral

mucosaNo crackles, no wheezes

Regular rate and rhythm of the pulse and therespiratory rateCold and clammy


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Measurement / Vital Signs

HeightNot taken.

Weight

Not taken.

Temperature @R Axilla36.4C

Cardiac Rate

70bpm

Pulse Rate68 bpm

PD = CR PR = 70 68 = 2

Respiratory Rate (Regular Rhythm)

18 cpm

Blood Pressure (L arm)

90/60 mmHg Plan:

Diet : DATIVF : D5LR @ R arm 28 gtts/min


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V. PHYSICAL ASSESSMENT


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VII. LABORATORY RESULTS


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All Rights Reserved @ Lionheart 2009 /09279074641 www.Lionheart.co.nrSpecimen from the patient


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VIII. ANATOMY AND PHYSIOLOGY The Female Reproductive System

Sexual characteristics are divided into two types. Primary

characteristics are directly related to reproductive and included thesex organs (genitalia). Secondary sexual characteristics areattributes other than the sex organs that generally distinguish onesex from the other but are not essential to reproduction. The Female Sexual Anatomy and Physiology

The Female External Reproductive Organs


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Mons pubis/ veneris mountain of Venus, a pad of fattytissues that lies over the symphysis pubis covered by skinand at puberty covered by pubic hair that serves as acushion or protection to the symphysis pubis

Labia Majora large lips, longitudinal fold from pereniumto pubis symphysisLabia Minora AKA Nymphae, soft and thin longitudinalfold created between labia majora

Clitoris key, pea shaped erectile tissue composedof sensitive nerve endings; sight of sexual arousal in

femalesFourchet tapers posteriorly of the labia majora. Sitefor episotomy

- Sensitive to manipulation, torn duringpregnancyVestibule almond shaped area that contains the hymen,

vaginal orifice and batholenes glandUrinary Meatus small opening of urethra/ openingfor urinationSkenes Gland aka Paraurethral Gland, 2 smallmucus secreting glands for lubricationHymen membranous tissue that covers the vaginal

orificeVaginal Orifice external opening of the vagina


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Bartholenes Gland paravaginal gland, secretesalkaline substance, neutralizes acidity of the vagina

Doderleins Bacillus responsible for vaginal acidityParumculae Mystiformes healing of a hymen

Perenium muscular structure in between lower vaginaand anus


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Parts of the Uterus

Fundus upper cylindrical layerCorpus/ Body upper triangular layerCervix lower cylindrical layer

Isthmus lower uterine segment during pregnancy Muscular Composition: 3 main Muscles makingpossible expansion in all directionEndometrium - muscle layer for mensesMyometrium

Power of laborSmooth muscles is considered to be Living Ligature(muscles of delivery, capable of closing) of the bodyLargest portion of the uterusPeremetriumProtects the entire uterus

Ovaries 2 female sex glandalmond shapeFxn: Ovulation,production of 2 hormones( estrogen andprogesterone)


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Fallopian Tube2 3 inches long that serves as a passageway of the sperm from the uterusto the ampulla or the passageway of the mature ovum or fertilized ovum fromthe ampulla to the uterus5 significant segments

Infundibulum most distal part, trumpet shape, has fimbriaeFimbriae finger like structures that collects the mature ovum from theovaryAmpulla outer 3 rd or 2 nd half, site of fertilization, common site forectopic preg.Isthmus site for sterilization, site for BTL


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6 Major Parts of the Ovaries

Germinal Epithelium layers of epithelium that covers the surface of thebody

Tunica Albuginea whitish capsule of dense connective tissue located deep in

the germinal epitheliumStroma region of tissue deep to thetinuca albugineaOvarian Follicle the sack or bag thatcovers the ova during ovulationGrafan Follicle follicle that surrounds

the ova during expulsion of theunfertilized egg out of the ovaryCorpus Luteum a yellow endocrinegland found in the ovary formed whenthe follicle is discharged its secondaryoocyte which secretes progesterone,

estro en, and relaxin.


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OOGENESIS process of maturation of ovum30 weeks AOG 6 million immature ovum@ birth 1 million immature oocytes@ puberty 300 400 immature oocytes@ 13 y/o 300 400 mature oocytes

@ 23 y/o 180 280 mature ovum@ 33 y/o 60 160 mature ovum@ 36 y/o 24 124 mature ovum@46 y/o 4 mature ovum

Functions of Estrogen and ProgestinESTROGEN hormone of woman

Primary functionResponsible for the development of secondary characteristics infemalesinhibit production of FSH

Other functionHypertrophy of the myometriumSpinnbarkeit and Ferning Pattern (Billings Method)Ductile structure of the breastOsteoblastic bone activity (causes increased in height)Early closure of the epiphysis of the boneSodium retentionIncreased sexual desireResponsible for vaginal lubrication


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PROGESTERONE Hormone of the mother

Primary function prepares the endometriumfor implantation making it thick and tortousSecondary Function inhibit uterinecontractibilityOthers

Inhibit LH (hormone of ovulation)

productionGI motilityPermeability of kidneys to lactose and

dextrose causing + 1 sugar in urineMammary gland development

BBT


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The Ovarian Cycle

The follicles are then ready to complete their maturation aspart of the ovarian cycle, a 28 day cycle that includes follicle

maturation, ovulation and the subsequent release of hormonesby the remaining follicle cells. Each of these phases lastsapproximately 14 days and the changes in follicle structurethat occur as part of the ovarian cycle. Until this time, the primary oocyte has been suspended in

prophase of meiosis I. as the development of the tertiaryfollicle ends, rising LH levels prompt the primary oocyte tocompkete meiosis I. The completion of the first meiotic divisionproduces a secondary oocyte. The secondary oocyte beginsmeiosis II but stops short of dividing. Meiosis II will not becompletedunless fertilization occurs.

Generally, on day of 14 of a 28-day ovarian cycle, thesecondary oocyte and its surrounding follicular cells lose theirconnections with the follicular wall and float within the antrum.

The follicular cells surrounding the oocyte are now known asthe corona radiata.

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The Follicular Phase At the start of each ovarian cyclean ovary contains only few secondaryfollicles destibned for further development; by day 5 of the cycle, there isusually only one. Stimulated by FSH, that follicle forms a tertiary follicle ormature Graafian Follicle, roughly 15-20mm in diameter. The tertiaryfollicle is formed by days 10-14 of the ovarian cycle. Its large size createsa prominent bulge in the surface of the ovary. The Oocyte and its coveringof follicular cells projects into the expanded central chamber of thefollicle, the antrum.

Ovulation At ovulation, the tertiary follicle releases the secondary oocyte. Thedistended follicular wall then ruptures, releasing the follicular contents,including the secondary oocyte, into the pelvic cavity. The sticky follicularfluid keeps the corona radiata attached to the surface of the ovary nearthe ruptured wall of the follicle. Contact with projections of the uterinetube or with fluid currebnts established by its ciliated epithelium thensweeps the secondary oocyte into the uterine tube.

The Luteal Phase

The 14 day luteal phase of the ovarian cycle begins at ovulation. Theempty follicle collapses, an the remaining follicular cells invade theresulting cavity and multiply to create an endocrine structure known ascorpus luteum. Unless fertilization occurs, the corpus luteum begings todegenerate roughly 12 days after ovulation. The disintegration of thecorpus luteum marks the end of an ovarian cycle. A new ovarian cyclebegings with the selection of another secondary follicle and its formation


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IX. PATHOPHYSIOLOGY


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X. NURSING CARE PLAN


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