1
PERPETUAL HELP COLLEGE OF MANILA
1240 V. Concepcion St., Sampaloc, Manila
Submitted to:
Mrs. Josephine Dela Cruz, RN
Clinical Instructor
Submitted by:
Abordo, Nena Bell Jill - Physical Assessment & Nursing Care Plan
Alpecho, Kathreen Mae - Drug Study
Alunday, Radigundee - Medical and Surgical Management
Awat, Cassandra Von - Etiology or Risk Factors
Barzaga, Cristine - Diagnostic Procedure
Cabarrubias, Alvin Ray D. -Gordon’s Health Pattern, Pathophysiology,
Statement of Nursing Diagnosis & Nursing Care Plan
Canlas, Veronica - General Objectives, Nursing Care Plan & Discharge Plan
Changco, Mariaelis - Anatomy & Physiology
Commendador, Maritonee - Client’s Data & Health History
Corpuz, Nichael Bonn - Introduction

2
PERPETUAL HELP COLLEGE OF MANILA
Format for Case Presentation
I. Client’s Data
II. Health History
• Family Health History
i. Maternal Health History
ii. Paternal Health History
• History of Past and Present Illness
• Risk Factors Associated with Disease
i. Non- modifiable Factors
ii. Modifiable Factors
III. Physical Assessment
• Subjective- Gordon’s Health Pattern
• Objective- Kozier’s reference
IV. Definition of Disease/Introduction
V. Pathophysiology of the Disease
VI. Anatomy and Physiology
VII. Diagnostic Procedures done to Client
VIII. Medical/Surgical Management done
IX. Drug Study
X. Statement of nursing problems/nursing diagnosis based on grouped data(Gordon’s)
XI. Priority Nursing Problem/Nursing Care Plan
• Actual
• Potential
XII. Discharge Plan

3
PERPETUAL HELP COLLEGE OF MANILA
Table of Contents
I. Client’s Data………………………………………….………..… 1
II. Health History…………………………………………………… 2
• Family Health History…………………………………………… 2
iii. Maternal Health History…………………………….. 2
iv. Paternal Health History……………………………… 2
• History of Past and Present Illness………………….…....… 2
• Risk Factors Associated with Disease……………………… 3
iii. Non- modifiable Factors……………………………… 3
iv. Modifiable Factors…………………………………….. 3
III. Physical Assessment……………………………………………. 5
• Subjective- Gordon’s Health Pattern……………………….. 5
• Objective- Kozier’s reference…………….……………..…… 9
IV. Definition of Disease/Introduction…………………..…… 32
V. Pathophysiology of the Disease……………………………… 33
VI. Anatomy and Physiology……………………………….………. 34
VII. Diagnostic Procedures done to Client………………….…. 41
VIII. Medical/Surgical Management done……………….………. 46
IX. Drug Study………………………………………….……………. 50
X. Statement of nursing problems/nursing diagnosis
based on grouped data(Gordon’s)…………………...………. 62
XI. Priority Nursing Problem/Nursing Care Plan………...…... 63
• Actual
• Potential
XII. Discharge Plan…………………………………………………… 64

4
General Objectives:
 This study on myoma aims to look into the indispensible information
regarding the disease, its pathophysiology resulting to the theoretical
signs and symptoms and correlate them with those manifested by the
patient
 It is also aims to develop our skills, knowledge and attitude in providing
proper nursing care needed to have an effective nursing management and
list the criteria used for diagnosing myoma
 Develop good Nurse-Patient relationship
Specific Objectives:
In order to meet the general objective of the study, the ff intended to be done:
 To be able to acquire knowledge regarding myoma through research
 To be able to develop a better understanding on the use of medications
and its implication on the treatment of myoma
 To be able to implement the appropriate plan of nursing management for
patients with myoma

5
I. Client’s Data
Name- De Luna, Rima Mejica
Age – 32
Chief complaint: VAGINAL BLEEDING
Diagnosis -AUB problem sec. to prolapsed submucosal myoma. G4P4
Time admitted – 6:10 PM
Ward- OB GYNE
Address- 417 NBB Navotas
B-day – 11/19/78
Religion- Roman Catholic
Father name- Loreto Dulay
Mother name- Crisanda Mejica
Husband name- Dante de Luna
Admitting physician – Dr. Macasadia
Pertinent physical findings:
BP 100/80 HR 89 RR 20 TEMP. 37
WT 44.5 kgs HT 1.43 BMI 21.76 kg/m2
Slightly pink palpebral conjunctivas SCF clear BS. A dynamic pericardium WRRR (-)
murmurs inspection + fleshy mass at introiter + moderate bleeding submucus. IE
10x5x5 cm prolapsing mass with stalked abnormal
Personal and social history:
Alcohol- occasional
B-GYNE history:
Menarche 15year old interval 28-30 duration 3days

6
Cornstarches 19 year old symptom- dysmenorrheal
OB score
G1 2000 male NSD del. Midwife (-) complication
G2 2006 female NSD del. Midwife (-) complication
G3 2007 preterm (7mos)
G4 2008 female NSD del. Midwife (-) complication
No. of sexual partner – 1 partner
Previous pap smear – NONE
Method of contraceptive (+) 2008 trust pills

7
II. Health History
•Family Health History
i. Maternal Health History
(+) hypertension
ii. Paternal Health History
(+) hypertension, (+) diabetes mellitus
•History of Past and Present Illness
2 months PTA patient noted increase menstruation duration and amount
for 5 days. No inter menstrual bleeding noted. 1 day PTA, patient while
strains during defecations. (+) bleeding during defecation. She strained and
noted prolapsed mass at urination and prompted consult.
• Risk Factors Associated with Disease
v. Non- modifiable Factors
-Anovulatory bleeding
-Midcycle bleeding associated with ovulation
-High levels of unopposed estrogen
vi. Modifiable Factors
-Complications of an early, undiagnosed pregnancy
-Breakthrough bleeding while they are taking oral
contraceptives
-Genetic abnormalities, race, and related to age of
menarche, obesity, and parity

8
• Classification of Myomas
1. Intramural. Found in the uterine wall, surrounded by myometrium. Clinical
manifestations include increased uterine size, vaginal bleeding between menses and
dysmennorrhea
2. Submucosal. Located directly under the endometrim, involving the endometrial cavity.
May become pedunculated (grow on a stalk). Clinical manifestations include prolonged
vaginal bleeding and cramps and the tumor may be seen protruding through the cervix.
3. Subserosal. Found on the outer surface (under the serosa) of the uterus. Tends to
become pedunculated, to wander, and to be multiple and large. Clinical manifestations
include backache, constipation and bladder problems.
4. Wandering or parasitic. A pedunculated leiomyoma that twists on its pedicle, breaks
off, then attaches to other tissues, particularly the omenum.
5. Intraligamentary. Implants on the pelvic ligaments. May be displace the uterus or
involve the ureters.
6. Cervical. Occur infrequently and may obstruct the cervical canal

9
III. Physical Assessment
• Subjective- Gordon’s Health Pattern
Health
Patterns
Before Hospitalization
During
Hospitalization Analysis
1. Health
perception -
Health
management
Pattern
- Pt had abnormal uterine
bleeding for almost 4 days.
Pt is a non smoker and a
occasional alcohol drinker. Pt
have the family illness of
hypertension and diabetes.
Mrs. D doesn’t have regular
medical check-ups and only
seeks medical attention when
the need arises. Whenever
she had headaches, she rest
for a while and take
paracetamol when needed.
Pt. perceived her menstrual
cycle was regular until the
fourth day of excessive
bleeding and presence of
mass when she urinated.
- during her
hospitalization,
she’s was rushed
to the emergency
room & a vaginal
myomectomy was
done. after that
operation, she still
feels weak
probably because
of losing too much
blood. She’s
anxious if the
mass that was
taken is
cancerous or not.
- She only
seeks medical
help whenever
needed.
The patient is
anxious if the
fibroid is
cancerous or
not.
2. Nutritional
– Metabolic
Pattern
- According to Mrs. D., she
eats three times a day. He
usually eats vegetables, fish
and meat whenever they
have extra money. The
patient verbalized that she
seldom eat fruits.
In terms of fluid intake, the
client stated that he
consumes at an average of
5-6 glasses of water per day,
distributed at around 2
glasses in the morning, 3 at
noon and 1 glass at evening
before hospitalization. She is
- during her
hospitalization, the
doctor ordered
NPO until the third
day wherein she
was on soft diet.
- Normal eating
pattern is at on
the minimum of
3 times per
day, depending
upon metabolic
need and
demands. Fluid
intake is on the
average of 8 to
10 glasses per
day.
- She have to
increase her
fluid intake. In

10
the one who always prepare
their food.
Patient’s WT 44.5 kgs HT
1.43 BMI 21.76 kg/m2
Normal BMI range:
<18.5…………...underweight
18.5-24.9………..healthy
25.0-29.9…………overweight
30≥……………………obesity
terms of her
food intake and
frequency,
There are no
remarkable
deviations
3. Elimination
Pattern
- Bowel Habits: Mrs. D
defecates once a day with a
brownish stool.
Bladder Habits: She voids 3-
5 times a day with amber
colored urine in small
amount. Pt urinates not more
than 1000ml per void.
- During
hospitalization,
since the patient
was on NPO,
there were
changes on her
bowel and bladder
habits. She was
on indwelling foley
catheter.
- Normal bowel
movement is 1
to 3 times a
day and
voiding at 1200
to 1500ml/day.
- Mrs. D’s
bowel and
bladder habits
has changed
during
hospitalization.
4. Activity
Exercise
Pattern
- Mrs. D usually does walking
when she gets bored before
her hospitalization. Pt is a
housewife. She usually do
household choirs and she’s
proud to say that it’s a good
form of exercising.
- She stop taking
walks during her
hospitalization
because it is
contraindicated in
operation
performed.
So, she only do
bed rest and tries
to turn on each
side because she
always wake up.
- Well
described bout
her activities in
daily living like
exercising. She
is well informed
that doing
household
choirs is a
simple way of
exercise.
5. Sleep –
Rest Pattern
- before the Pt was
hospitalized, she mostly
- during her
hospitalization,
- Based from
Kozier

11
sleep 7pm or 8pm at night
and wakes up at 8 in the
morning. When she don’t
have anything to do after
lunch, he usually have a nap.
The pt had stated
that he
experienced sleep
difficulties. She
always wake up in
different intervals.
Before going to
sleep she always
think about the
mass that was
taken out of her if
it’s benign or
malignant.
Fundamentals
of Nursing, 8-
10 hours of
sleep is
needed to have
an adequate
rest and an
environment
that is
conducive to
health is
necessary to
provide comfort
to an individual.
- The client has
an abnormal
state of sleep
and rest.
Frequent
thinking about
her situation is
the primary
cause of sleep
deprivation.
6. Cognitive-
perceptual
pattern
- Patient does not have any
hearing problems.
She is oriented to time and
place and can recall past
events. Patient is a high
school graduate. Mrs. D is
able to understand, and
communicate with others and
make decisions on her own.
She is able to see, feel, hear,
smell, taste by testing him
like pinching, giving some
sentence to read and saying
words that she have to repeat
it after we said it.
- during her
hospitalization,
there is no
significant change
in the status and
perception of his
five senses.
- There is no
symptoms of
pain while we
are doing an
interview.
7. Self-
perception
and self
- Patient described herself as
a hardworking person. She
claimed her happiness and
- during in her
hospitalization,
she never think
- pt is being a
positive thinker
despite of what

12
concept
pattern
contentment will be more felt
if only his illnesses were
absent. Pt is contented to
have provided her family with
good life.
negative things
that will make her
down while
recovering with
her illness.
happened to
her health
8. Role
Relationship
pattern
- Patient described himself as
a loyal wife to her husband
as well a responsible mother
to her kids. Her husband
comes home every weekend
from work as a contractual
carpenter. She takes care of
her kids and do the cooking
and laundry form them. She
send them to school
everyday.
- during her
hospitalization,
her husband is
aware of her
current situation.
She is worried
about her kids if
they’re doing well
without her. She is
also concerned if
they’re eating well.
- pt is still being
a good mother
to her kids
despite of her
current health
status.
9. Sexuality –
Reproductive
pattern
- Patient had her 1st
menstruation at the age of
15. She used to use pills
Patient claims to have no
history of STD or UTI. She
doesn’t have any problem
with her sexual intercourse.
- during her
hospitalization,
she clearly
describe the
patterns of
satisfaction and
dissatisfaction
with sexuality.
- The Pt.
analyzed
clearly about it
and able to
understand the
physical and
psychological
effects of his
current health
status on her
sexual
expression.
10.Coping
and Stress
Tolerance
- Defines stress as something
that can make someone tired.
Currently stressed because
of current physical condition.
Long term stressor include
financial problems, and short
term stressor include the
problems in the community
and family. Goes to
neighbors and friends to
relieve stress and she shares
her problem them.
Sometimes she brings her
- during her
hospitalization,
she doesn’t
change her
perception toward
her situation.
She’s aware that
being hospitalized
is a stressful
situation. She tries
to get well
because she
misses her kids.
- Able to
describe
general coping
pattern and
effectiveness of
the pattern in
terms of stress
tolerance.

13
kids to shopping malls to
stroll and in that way her
stress is relieved.
11.Value –
Belief Pattern
- Patient is a Roman Catholic
and goes to church on
Sundays with her kids and
claims to pray everyday. She
values health
and sees it as a wealth.
Patient does not have any
superstitious beliefs.
- during her
hospitalization,
there is no change
with her religious
life. She believes
God will help her
recover faster
- able to
determine the
patterns of
values and
beliefs(spiritual)
or goals that
guides his
choices and
decisions.
.
• Objective- Kozier’s Reference
Vital signs
Vital signs
Normal Actual
Findings
Analysis Interpretation
Blood
pressure 120/80 160/90
On the disease
process, any condition
that may affect the
cardiac output, blood
volume, blood viscosity
has direct effect on the
blood pressure.
The patient was in
distress during the
assessment.
(Kozier, B. (2004).
Cardiac output will often
affect the delivery of oxygen
to the cells of the body and
when the system or tissues
does not get the required
oxygen for the metabolic
process cellular function will
be altered.

14
Fundamentals of
Nursing p. 510).
Temperature 36.5-
37.5
39.4
Inflammation is a local,
nonspecific defensive
response of the tissues
to an injurious or
infectious agent. It is an
adaptive mechanism
that destroys or dilutes
the injurious agent,
prevents further spread
of the injury, and
promotes the repair of
damaged tissue.
Patient has an
increased WBC count
of 12.3% (August 23,
2010)
(Kozier, B. (2004).
Fundamentals of
Nursing p. 634).
Febrile
The rate of loss depends
primarily on the surface
temperature of the skin
which is intern a function of
skin blood flow. The blood
flow of the skin varies in
response to changes in the
body core temperature and
to changes in temperature
of the external environment.
Pulse rate 60-100 92
Normal Range
(Kozier, B. (2004).
Fundamentals of
Nursing p. 496).
Pulse wave represents the
stroke volume output or the
output or the amount for
blood that enters the
arteries with each
ventricular contraction.
Respiratory 16-20 24
Several factors that
increase respiratory
The effectiveness of
respiration is important for

15
rate rate include stress and
increase environmental
temperature.
(Kozier, B. (2004).
Fundamentals of
Nursing p. 506).
the uptake of oxygen from
the air into the blood and
release carbon dioxide from
the blood into expired air.
Skin
PARTS METHOD NORMAL
FINDINGS
ACTUAL
FINDINGS
ANALYSIS INTERPRETATION
Skin Inspection
Palpation
Skin color
varies from
light to deep
brown; from
ruddy pink to
light pink,
from yellow
overtimes to
olive.
Generally
uniform
except in
areas
exposed to
sun; areas of
lighter
pigmentation
(palms, lips
Fair
complexion
with dry and
flaky skin.
Pale in
appearance.
No edema,
abrasions,
lesion.
Temperature
is higher
than normal
There is a
decrease in
hemoglobin
because of
blood loss
The skin is dry and
flaky because
sebaceous and sweat
glands are less active.
Dry skin is more
prominent over the
extremities. Pallor is
the result of
inadequate circulating
blood. Normal blood
circulation relies on
muscle activity.
Immobility impedes
circulation and
diminishes the supply
of nutrients to specific
area. Pressure ulcers

16
nail beds) in
dark skin
people.
No edema,
abrasions,
lesion.
Temperature
is uniform
and w/in
normal range
range. are due to localized
ischemia, a deficiency
in the blood supply to
the tissue.
Generalized edema is
most often an
indication of impaired
venous circulation and
in some cases reflects
cardiac dysfunction
and venous
abnormalities.
Increase temperature
from the normal level
maybe due to tissue
destruction, pyrogenic
substances, or
dehydration on the
hypothalamus.
( Fundamentals of
Nursing by Kozier,
pp.529, 535,540,576,
1071)
Nails Inspection Convex
curvature;
angle of nail
plate about
160o
- with smooth
Convex,
smooth in
texture,
pallor,
capillary refill
is 4-5
Patient’s nail
beds are pale
may be due to
decreased
oxyhemoglobin
level on the
Pallor may reflect poor
arterial circulation due
to diminished
circulating blood
volume.

17
texture
- color is
highly
vascular&
pink in light
skinned
clients; dark
skinned
clients may
have brown
or black
pigmentation
in
longitudinal
streaks
with intact
epidermis on
tissue
surroundings
- blanch test-
prompt return
of pink or
usual color
(gen. <3 sec)
seconds on
the hands.
Nail bed
color is pale
on both
lower and
upper
extremities.
blood.
(Fundamentals of
Nursing by Kozier,
p542)
Head
PARTS METHOD
NORMAL
FINDINGS
ACTUAL
FINDINGS ANALYSIS INTERPRETATION
Each hair

18
Hair Inspection
Palpation
Evenly
distributed hair
over the scalp
with thickness,
variable
amount of
body hair. No
infection or
infestation.
Hair is black,
thin and evenly
distributed over
the scalp. No
infection or
infestation
noted.
It is dry and
sticky.
grows from a
single, live
follicle has its
own roots in
the
subcutaneous
tissue of the
skin. Oil
glands next to
hair follicle
provides gloss
and, to some
degree water
proofing of the
hair.
(Kozier, B.
(2004).
Fundamentals
of Nursing p.
541)
Poor hygiene due
to impaired
physical mobility.
The injury limits her
activities of daily
living. No
significant relative
is there to help her
manage her poor
hygiene.
Scalp Inspection
Palpation
White, clean,
free from
masses, lumps
scars, lice, nits,
dandruff, and
lesions no area
of tenderness
Dry scalp.
Clean, free from
masses, lumps
scars, lice, nits,
dandruff, and
lesions no area
of tenderness
Normal Findings
Skull Inspection
Palpation
Rounded(
normocephalic)
& symmetrical,
with frontal,
parietal,
occipital,
prominences)
smooth,
Round
(normocephalic),
smooth skull
contour.
Smooth,
absence of
nodules or
masses.
Normal
findings
(Fundamentals
of Nursing by
Kozier page
544.)
Normal findings

19
uniform,
absence of
modules or
masses
Eyes
PARTS METHOD
NORMAL
FINDINGS
ACTUAL
FINDINGS ANALYSIS INTERPRETATION
Eyebrows Inspection Symmetrically
aligned.
Equally
distributed,
curled slightly
outward
Symmetricall
y aligned
and equal
movement.
Hair evenly
distributed.
Normal
findings.
(Kozier, B.
(2004).
Fundamentals
of Nursing p.
732).
Normal findings
Eyelashes Inspection Equally
distributed,
Curled slightly
outward
Eyelashes
are equally
distributed
and curled
slightly
outward.
Normal
findings.
(Kozier, B.
(2004).
Fundamentals
of Nursing p.
1152)
Normal findings
Eyelids Inspection The skin is
intact, no
Lids closes
symmetricall
Normal
findings
Normal findings

20
discharge and
no
discoloration.
The lids close
symmetrically
blinks
involuntary
and with
bilateral
blinking.
y, bilateral
blinking and
no visible
sclera above
corneas
when lids
are open
(Kozier, B.
(2004).
Fundamentals
of Nursing p.
548
Sclera &
Conjunctiva
Inspection Shiny, smooth
& pink or red
in color
Pale
conjunctiva,
smooth and
shiny.
Patient has
decreased
hemoglobin
level of 10.2
g/dl.
(September 6,
2010)
Pallor may reflect
poor arterial
circulation due to
diminished
circulating blood
volume
(Kozier, B. (2004).
Fundamentals of
Nursing p. 554).
Cornea Inspection transparent,
shiny &
smooth,
details of the
iris are visible
transparent,
shiny &
smooth,
details of the
iris are
visible
Normal
Findings
Normal Findings
Pupils and
Iris
Inspection Black in color,
equal in size,
Iris black in
color, equal
Normal
findings.
Normal findings

21
normally 3-7
mm in
diameter,
sound-
smooth border
iris flat &
sound. Pupils
constrict when
looking at near
object and
dilate when
looking at far
objects.
in size and
round in
shape. Iris is
flat and
round. Pupil
diameter is
3mm.
Pupils
constrict
when light is
directed
towards it,
and dilate
when light is
removed.
(Kozier, B.
(2004).
Fundamentals
of Nursing p.
554).
Visual
Acuity
Inspection Able to read
newsprint with
20/20 vision
on snellen
chart.
Able to read
newsprint
with 20/20
vision on
snellen
chart.
Normal
Findings
Normal Findings
Ears
PARTS METHOD NORMAL
FINDINGS
ACTUAL
FINDINGS
ANALYSIS INTERPRETATION
Auricles Inspection The color is
the same as
Auricles
aligned at the
Normal
Findings
Normal Findings

22
Palpation
facial skin,
symmetrical,
the auricles
aligned with
outer canthus
of the eye
Mobile, firm
and not
tender, pinna
recoils after it
is folded.
outer canthus
of the eyes,
symmetrical
and color is
the same as
the facial skin.
Ear
Canal
Inspection Distal third
contains hair
follicles and
glands. Dry
cerumen,
grayish-tan
color or sticky,
wet cerumen
in various
shades of
brown.
Distal third
contains hair
follicles and
glands. Dry
cerumen.
Normal
findings.
(Kozier, B.
(2004).
Fundamentals
of Nursing p.
556-557)
Normal findings.
Hearing
Acuity
Inspection Normal voice
tones audible.
Sound is
Normal Voice
tones audible.
Normal
findings
Normal findings

23
heard in both
ears or
localized at
the center of
the head
(Weber
Negative).
Air conducted
hearing is
greater than
bone
conducted
hearing
(positive
Rinne)
According to
Kozier page
597.
Nose
PARTS METHOD NORMAL
FINDINGS
ACTUAL
FINDINGS
ANALYSIS INTERPRETATION
Nose Inspection Symmetric
and straight
No
discharge in
flaring
Uniform in
color
Not tender,
Symmetric and
straight
No discharge in
flaring
Uniform in
color
Not tender, no
lesion
Normal
Findings
Normal Findings

24
no lesion
Facial
Sinuses
Palpation No
tenderness
No tenderness
noted.
Normal
findings
(Kozier, B.
(2004).
Fundamental
s of Nursing
p. 561)
Normal findings.
Septum Inspection Air moves
freely as the
client
breathes
through the
nares. Nasal
septum
intact & in
midline
Nasal septum
intact and in
midline.
Normal
findings
Kozier page
560-561
Normal findings
Mouth
PARTS METHOD NORMAL
FINDINGS
ACTUAL
FINDINGS
ANALYSIS INTERPRETATION
Lips Inspection
Palpation
Uniform pink
color
Soft, moist,
Pale, Dry Paleness is
due to
decrease in
Blood loss decrease
hemoglobin level and
since the patient isn’t

25
smooth
texture
Symmetry of
contour
Ability to
purse lips
hemoglobin
and dry
because of
dehydration
allowed to take any
liquids
Buccal
mucosa
Inspection Uniform pink
color
Soft, moist,
smooth
texture
Presence of
foul breath
odor.
Immobility
related to
invasive
procedure
done
Foul breath odor is
due to poor self
hygiene and lack of
motivation from others
Gums Inspection Pink gums,
moist, firm
texture to
gums.
Pinkish gums,
no retraction,
moist and firm.
Normal
findings.
(Fundamental
s of Nursing
by Kozier,
p603)
Normal findings.
Tongue Inspection
Palpation
Central
position
Pink color,
moist,
slightly
rough; then,
whitish
Pink in color,
moist, no
lesions,
tenderness and
nodules.
Tongue is on
the middle.
Normal
Findings
(Fundamental
s of Nursing
Normal Findings

26
coating
Smooth;
lateral
margins; no
lesions
Raised
papillae
Moves
freely, no
tenderness
Smooth
tongue base
with
prominent
veins.
Client was able
to move tongue
from side to
side and up
and down.
by Kozier,
p603)
Teeth Inspection 32 adult
teeth
smooth,
white, shiny
tooth enamel
pink gums
moist.
Without
dentures and
incomplete
teeth, yellowish
in color with
pink gums. 4
teeth on upper
and 7 on lower.
Tooth loss
occurs as a
result of
dental
disease but is
preventable
with good
dental
hygiene.
(Fundamental
s of Nursing
by Kozier
p566)
Normal findings

27
Uvula Inspection Soft, moist,
smooth
texture Pink
and smooth.
Soft, moist, and
pink
Normal
findings.
(Fundamental
s of Nursing
by Kozier
p604)
Normal findings.
Tonsils Inspection No
discharge.
Tonsils of
normal size.
Pink and
smooth
posterior
wall.
No discharge.
Pinkish in
color. normal
size
Normal
findings.
(Fundamental
s of Nursing
by Kozier
p604)
Normal findings.
Neck
PARTS METHOD NORMAL
FINDINGS
ACTUAL
FINDINGS
ANALYSIS INTERPRETATION
Neck Inspection Proportional
to size of the
head,
symmetrical
and straight.
Freely
Proportionate
to the size of
head and
symmetrical.
Unable to
move.
Muscles in
the neck like
sternocleido
mastoid and
trapezius
draw the
Normal Findings

28
Palpation
movable
without
difficulty.
No palpable
lumps or
tenderness
The trachea
is in the
Central
placement in
midline of
neck, spaces
are equal on
both sides.
There are no
palpable lymph
nodes. Head
cannot easily
flex and rotate.
Trachea is in
the central
placement and
no indication of
possible neck
tumor or
thyroid
enlargement.
head to the
side and
elevate the
chin and
elevate the
shoulders to
shrug them.
(Fundamental
s of nursing
by Kozier p5)
Thorax
PARTS METHOD NORMAL
FINDINGS
ACTUAL
FINDINGS
ANALYSIS INTERPRETATI
ON
Chest
size and
shape
Inspection Anteroposterior
to transverse
chest is
symmetrical.
Anteroposterior
to transverse in
ratio of 1:2,
chest is
symmetrical
Normal
findings.
(Fundamentals
of nursing by
Kozier p549)
Normal findings

29
Breath
sounds
Auscultation Bronchovesicular
breathe sound.
Patient has a
clear,
bronchovesicular
breath sound.
Normal
Findings
(Fundamentals
of Nursing by
Kozier p549)
Normal findings
Posterior Palpation
Percussion
Full and
symmetric chest
expansion.
Premitus tactile
most clearly at
the apex of the
lungs
Quiet, rhythmic
and effortless
respiration.
Vesicular and
bronchovesicular
breath sound.
Notes resonate,
except over
scapula, the
lowest point of
resonance is at
the diaphragm.
Full and
symmetric chest
expansion. Quiet
and rhythmic,
and effortless
breathing.
Resonant except
on the scapula,
there is lowest
point of
resonance over
scapula.
Normal
findings
(Fundamentals
of nursing by
Kozier p549)
Normal findings
Anterior Inspection Quiet, rhythmic
and effortless
Effortless
Respiration.
Normal
Findings
Normal findings

30
Palpation
respiration.
Full and
symmetric chest
expansion.
Same as
posterior vocal
fremitus, fremitus
is normally
decreased over
heart and breast
tissue.
Full and
symmetric chest
expansion.
(Fundamentals
of nursing by
Kozier p549
box 29—5;
p617)
Breast
PARTS METHOD NORMAL
FINDINGS
ACTUAL
FINDINGS
ANALYSIS INTERPRETATIO
N
Breast Inspection
Palpation
No masses and
lumps
n/a. The patient
refused to be
assessed
The patient
refused to be
assessed
Areola Inspection
Palpation
Dark in color in
contrast to
surrounding skin.
No masses,
lumps and
lesions.
n/a The patient
refused to be
assessed
The patient
refused to be
assessed

31
Nipples Inspection
Palpation
Size is
proportional. No
discharged or
secretions.
n/a The patient
refused to be
assessed
Abdomen
PARTS METHOD NORMAL
FINDINGS
ACTUAL
FINDINGS
ANALYSIS INTERPREATTION
Skin
integrity
Inspection Unblemished
skin, uniform
in color.
Unblemished
skin, uniform
in color
Normal
findings
According to
Kozier page
592-598
Normal findings
Contour
and
Symmetry
Inspection Flat,
rounded.
Symmetric
contour.
Distended Abdomen is
distended
due to
uterine
fibroids
Uterine fibroids
creates pressure to
the bladder and
rectum
Movement Inspection Symmetric
movements
caused by
respiration.
Symmetric
movement
caused by
respiration,
no visible
Normal
findings
Normal findings

32
vascular
pattern.
According to
Kozier page
592-598
Bowel
sounds
Auscultation Audible
bowel
sounds.
Normal
bowel
sounds = 5-
35 per
minute
Audible bowel
sounds.
hypoactive
Bowel
sounds= 4
per minute
Normal
Findings
Normal Findings
Umbilicus Inspection
Clean Clean Normal
findings
According to
Kozier page
592-598
Normal findings
Bladder Palpation Not palpable Not palpable Normal
findings
According to
Kozier page
592-598
Normal findings
Liver Palpation May not be No Normal Normal findings

33
palpable.
Border feels
smooth
enlargement.
Not palpable
findings
According to
Kozier page
592-598
Urogenitalia System
METHOD NORMAL FINDINGS ACTUAL
FINDINGS
ANALYSIS INTERPRETATION
Inspection
Pubic hair evenly
distributed, pubic skin
intact, no lesions
n/a
Foley catheter
intact.
The Patient
refused to be
assessed
The Patient refused
to be assessed.
Foley catheter is
due to patient’s
inability to void by
herself.
Inspection Skin of vulva area is
slightly darker than the
rest of the body, labia
round full and relatively
symmetric
n/a
The Patient
refused to be
assessed
The Patient refused
to be assessed
Inspection Clitoris does not
exceed 1cm in width
and 2cm in length, no
inflammation, swelling
or discharge
n/a
The Patient
refused to be
assessed
The Patient refused
to be assessed
Palpation No enlargement and
tenderness n/a
The Patient
refused to be The Patient refused

34
assessed to be assessed
Musculoskeletal System
PARTS METHOD NORMAL
FINDINGS
ACTUAL
FINDINGS
ANALYSIS INTERPRETATION
Upper
Extremities
Inspection
Palpation
Equal in
size on
both sides.
Equal in
strength,
coordinated
movement.
Able to
tolerate
wide range
of motion.
No difficulty
upon
bending
and
stretching.
No lesions,
no scars
and no
deformity.
Equal in size
on both
sides.
Equal in
strength,
coordinated
movement.
Able to
tolerate wide
range of
motion. No
difficulty
upon
bending and
stretching.
No lesions,
no scars and
no deformity.
Normal
Findings
(Fundamentals
of Nursing by
Kozier p1068)
Normal Findings
Lower
Extremities
Inspection Equal in
size on
Equal in size
on both
Normal
Findings
Normal Findings

35
Palpation
both sides.
Able to
tolerate
wide range
of motion.
No difficulty
upon
bending
and
stretching.
No lesions,
no scars
and no
deformity.
sides.
Able to
tolerate wide
range of
motion. No
difficulty
upon
bending and
stretching.
No lesions,
no scars and
no deformity.
(Fundamentals
of Nursing by
Kozier p1068)
Peripheral
pulse
Palpation Symmetric
full
pulsation
Weak pulse
on right and
left dorsalis
pedis pulse
A weak pulse
both feet
indicates
reduced
capillary
perfusion
(Fundamentals
of Nursing by
Kozier, p496)
Patient has edema
and may be due to
reduced blood
circulation.

36
IV. Definition of Disease/Introduction
Myomatous or fibroid tumors of the uterus are estimated to occur in 20%
to 40% of women during their reproductive years. It is thought that women are
genetically predisposed to develop this condition, which is almost always
benign. Fibroids arise from the muscle tissue of the uterus and can be solitary
or multiple, in the lining (intracavitary), muscle wall (intramural), and outside
surface (serosal) of the uterus. They usually develop slowly in women
between 25 and 40 years of age and may become quite large. A growth spurt
with enlargement of the fibroid tumor may occur in the decade before
menopause, possibly related to anovulatory cycles and high levels of
unopposed estrogen. Fibroids are a common reason for hysterectomy
because they often result in mennorrhagia, which can be difficult to control.

37
V. Pathophysiology of the Disease
Benign Tumors of the Uterus
Fibroids
(leiomyomas, Fibromyomas, myoma)
Anovulatory Cycles High levels of unopposed estrogen
Intermingled varying amounts of
fibrous connective tissue
Resembling the muscles in
the walls of the organ
Usually multiple and vary
from pea-sized to masses
Located in the Located lower In the body of Close beneath
Lower uterus down on the cervix uterus its lining membrane
Pedunculated Intramural Intramural Protruding Intracavitary
Intracavitary myomas myomas myoma
Myoma Pedunculated serosal
myoma
Danger during press upon the
Childbirth bladder & rectum
Urinary problems Mennorrhagia
Constipation Metrorrhagia
Bloating

38
VI. Anatomy and Physiology
Ovaries
The paired ovaries (o-vah-rez) are pretty much the size and shape of almonds.
An internal view of an ovary reveals many tiny saclike structures called ovarian
follicles. As a developing egg within a follicle begins to ripen or mature, the follicles
enlarges and develops a fluid-filled central region called an antrum. At this stage, the
follicle , called a vesicular or Graafarian follicle, is a mature and the developing egg
is ready to be ejected from the ovary, an even called ovulation. After ovulation, the
ruptured follicle is transformed into a very different-looking structure called corpus
luteum, which eventually degenerates. Ovulation generally occurs every 28 days,
but can occur more or less frequently in some women. In older women, the surfaces

39
of the ovaries are scarred and pitted, which attests to the fact that many eggs have
been released.
Duct System
The uterine (fallopian) tubes, uterus, and vagina form the duct system of the
female reproductive tract.
Uterine (Fallopian) Tubes
The uterine (u’ter-in), or fallopian (fal-lo’pe-an) tubes form the initial part of the
duct system. They receive the ovulated oocyte and provide a site where fertilization
can occur. Each of the uterine tubes is about 10 cm (4 inches) long and extends
medially from an ovary to empty into the superior region of the uterus. Like the
ovaries, the uterine tubes are enclosed and supported by the broad ligament. Unlike
in the male duct system of the testes there is little or no actual contact between the
uterine tubes and the ovaries. The distal end of each uterine tube expands as the
funnel-shaped infundibulum, which has fingerlike projections called fimbrae (fim’bre-
e) that partially surround the ovary. As an oocyte is expelled from an ovary during
ovulation, the waving fimbrae create fluid currents that act to carry the oocyte into
the uterine tube, where it begins its journey toward the uterus. (obviously, however
many potential eggs are lost in the peritoneal cavity) The oocyte is carried toward
the uterus by a combination of peristalsis and the rhythmic beating of cilia. Because
the journey to the uterus takes 3 to 4 days and the oocyte is visible for up to 24
hours after ovulation, the usual site of fertilization is the uterine tube. To reach the
oocyte, the sperm must swim upward through the vagina and uterus to reach the

40
uterine tubes. This is a difficult journey. Because they must swim against the
downward current created by the cilia, it is rather like swimming against the tide.
Uterus
The uterus (u’ter-us “womb”), located in the pelvis between the urinary bladder
and rectum, is a hollow organ that functions to receive, retain and nourish a fertilized
egg. In a woman who has never been pregnant, it is about the size and shape of a
pear. (During pregnancy, the uterus increases tremendously in size to accommodate
the growing fetus and can be felt well above the umbilicus during the latter part of
pregnancy) The uterus is suspended in the pelvis by the broad ligament and
anchored anteriority and posterior by the round and uterosacrial ligaments,
respectively.
The major portion of the uterus is referred to as the body. Its superior rounded
region above the entrance of the uterine tubes is the fundus, and its narrow outlet,
which protrudes into the vagina below, is the cervix.
The wall of the uterus is thick and composed of three layers. The inner layer or
mucosa is the endometrium (en-do-me’tre-um). If fertilization occurs, the fertilized
egg (actually the young embryo the time it reaches the uterus) burrows into the
endometrium of the uterus (this process is called implantation) and resides there for
the rest of its development. When a woman is not pregnant, the endometrial lining
sloughs off periodically, usually about every 28 days, in response to changes in the
levels of ovarian hormones in the blood. This process is called menses.

41
Vagina
The vagina (vah-ji-nah) is a thin-walled tube 8 to 10 cm (3 to 4 inches) long. It
lies between the bladder and rectum and extends from the cervix to the body
exterior. Often called the birth canal, the vagina provides a passageway for the
delivery of an infant and for the menstrual flow to leave the body. Since it receives
the penis (and semen) during sexual intercourse, it is the female organ of copulation.
The distal end of the vagina is partially closed by a thin fold of the mucosa called
the hymen (hi-men). The hymen is very vascular and tends to bleed when it is
ruptured during the first sexual intercourse. However, its durability varies. In some
females, it is torn during a sports activity, tampon insertion, or pelvic examination.
Occasionally, it is so tough that it must be ruptured surgically if intercourse is to
occur.
Menstrual cycle
Although the uterus is the receptacle in which the young embryo implants and
develops , it is receptive to implantation only for a very short period each month. Not
surprisingly this brief interval coincides exactly with the time when a fertilized egg would
begin to implant, approximately 7 days after ovulation. The events of the menstrual, or
uterine cycle are the cyclic changes that the endometrium, or mucosa of the uterus,
goes through month after month as it responds to changes in the levels of ovarian
hormones in the blood.
Since the cyclic production of estrogens and progesterone by the ovaries is, in
turn, regulated by the anterior pituitary gonadropic hormones, FSH and LH, it is

42
important to understand how these “hormonal pieces” fit together. Generally speaking,
both female cycles are about 28 days long (a period commonly called a lunar month),
with ovulation typically occurring midway in the cycles, on or about day 14. The three
stages of menstrual cycle are described next.
• Days 1-5: Menses. During this interval, the functional layer of the thick
endometrial lining of the uterus is sloughing off, or becoming detached from the uterine
wall. This is accompanied by bleeding for 3 to 5 days. The detached tissues and blood
pass through the vagina as the menstrual flow. The average blood loss during this
period is 50 to 150 ml (or about ¼ to ½ cup). By day 5, growing ovarian follicles are
beginning to produce more estrogen.
• Days 6-14: Proliferative stage. Stimulated by rising estrogen levels produced
by the growing follicles of the ovaries, the basal layer of the endometrium regenerates
the functional layer, glands are formed in it, and the endometrial blood supply is
increased. The endometrium once again becomes velvety, thick, and well vascularized.
(ovulation occurs in the ovary at the end of this stage in response to the sudden surge
of LH in the blood.)
• Days 15-28: Secretory stage. Rising levels of progesterone production by the
corpus lutuem of the ovary act on the estrogen-primed endometrium and increase its
blood supply even more. Progesterone also cause the endometrial glands to increase in
size and to begin secreting nutrients into the uterine cavity. These nutrients will sustain
a developing embryo (if one is present) until it has been implanted. If fertilization does
occur, the embryo produces a hormone very similar to LH, which causes the corpus
luteum to continue producing its hormones. If fertilization does not occur, the corpus

43
luteum begins to degenerate towards the end of this period as LH blood levels decline.
Lack of ovarian hormones in the blood causes blood vessels supplying the functional
layer of the endometrium to go into spasm and kink. When deprived of oxygen and
nutrients, those endometrial cells begin to die, which sets the stage for menses to
begin again on day 28.
Although this explanation assumes a classic 28-day cycle, the length of the
menstrual cycle is quite variable it can be as short as 21 days or as long as 40 days.
Only one interval is fairly constant in all females; the time from ovulation to the
beginning of menses is almost always 14 or 15 days.
Hormone production by the Ovaries
As the ovaries become active at puberty and start to produce ova, production of
ovarian hormones also begins. The follicle cells of the growing and mature follicles
produce estrogen, which causes the appearance of the secondary sex characteristics
in the young woman. Such changes includes:
• Development of the breasts
• Appearance of axillary and pubic hair
• Enlargement of the accessory organs of the female reproductive systems
(uterine tubes, uterus, vagina, external genitalia)
• Increased deposit of fat beneath the skin in general, and particularly in
the hips and breasts
• Widening and lightening of the pelvis
• onset of menses, or the menstrual cycle

44
The second ovarian hormone, progesterone, is produced by a special glandular
structure of the ovaries, the corpus luteum. As mentioned earlier, after ovulation occurs
the ruptured follicle is converted to the corpus luteum which looks like and acts
completely different from the growing mature follicle. Once formed, te corpus luteum
produces progesterone (and some estrogen) as long as LH is still present in the blood.
Generally speaking, the corpus luteum has stopped producing hormones by 10 to 14
days after ovulation. Except for working with estrogen to establish the menstrual cycle,
progesterone does not contribute to the appearance of the secondary sex
characteristics. Its other major effects are exerted during pregnancy, when it helps
maintain the pregnancy and prepare the breasts for milk production. (however, the
source of progesterone during pregnancy is the placenta, not the ovaries.)

45
VIII. Medical/Surgical Management
Book-based
Treatment of uterine fibroids may include medical or surgical intervention and
depends to a large extent on the size, symptoms and location as well as the woman’s
age and her reproductive plans. Fibroids usually shrink and disappear during
menopause, when estrogen is no longer produced. Simple observation and follow-up
may be all the management that is necessary. The patient with minor symptoms is
closely monitored. If she plans to have children, treatment is as conservative as
possible. As a rule, large tumors that produce pressure symptoms must be removed
(myomectomy).
Medical Management
Asymptomatic leiomyomas can be observed every 6 months a practitioner if (1)
the client is not pregnant, (2) there is no excessive bleeding or pressure on the bladder,
bowel, or uterus and (3) the tumor is not rapidly growing.
Medications (e.g., leuprolide [lupron]) or other gonadotropin releasing hormone
(GnRH) analogues, which induce a temporary menopause like environment, may be
prescribed shrink the fibroid. This treatment consists of monthly injections, which may
cause hot flashes and vaginal dryness. Treatment is usually short term9ie, before
surgery) to shrink the fibroids, allowing easier surgery, and no alleviate anemia, which
may occur as a result of heavy menstrual flow. This treatment is used on a temporary
basis because it leads to vasomotor symptoms and loss of bone density.

46
Antifibrotic agents are under in investigation for long term treatment of fibroids.
Mifepristone, a progesterone antagonist, has also been prescribed; it appears to be
effective.
Surgical Management
Surgical treatment may involve cutting off the blood supply to the fibroid with
uterine artery embolization, laser surgery or myomectomy (removal of a tumor without
removal of the uterus).these procedures preserve the reproductive organs and
reproductive capability. Large leiomyomas may require hysterectomy.
Hysterectomy
Indications: three types of hysterectomy may be performed:
1. Total hysterectomy is a removal of the uterus and cervix, and can be performed
either abdominally or vaginally.
2. Total hysterectomy with bilateral salpingooophorectomy (TAH-BSO) is the
removal of uterus, cervix, fallopian tubes, and ovaries. Can be performed
abdominally or vaginally.
3. Radical hysterectomy same as a TAH-BSO plus removal of the lymph nodes,
upper third of the vagina, and parametrium. Usually performed if a malignant
tumor is found.
Contraindications: The only contraindication to hysterectomy is any heath
condition that prevents surgery.

47
Complications. Hemmorrhage and infection are the primary complications.
Outcomes. It is expected that the client will return home in 2 to 4 days and
resume regular activities within 4 to 6 weeks, depending on the type of
hysterectomy performed. Pain, abdominal bleeding, and anemia, if present, will
cease. For all procedures except myomectomy, menstruation ends.
Several other alternatives to hysterectomy have been developed for treatment of
excessive bleeding due of fibroids. These include the following:
 Hysteroscopic resection of myomas: a laser is used through a hysteroscope
passed through the cervix; no incision or overnight stay is needed.
 Laparoscopic myomectomy: removal of a fibroid through a laparoscope
inserted through a small abdominal incision
 Laparoscopic myolysis: a laser or electrical needles are used to coagulate the
fibroid
 Laparoscopic cryomyolysis: electric current is used to coagulate the fibroid
 Uterine artery embolization (UAE): polyvinyl alcohol or gelatin particles are
injected into blood vessels that supply the fibroid via the femoral artery, resulting
in infarction and resulting shrinkages. This percutaneous image-guided therapy
offers an alternative to hormone therapy or surgery.UAE may result in infrequent
but serious complications such as pain, infection, amenorrhea, necrosis and
bleeding. A although rare deaths and ovarian failure may occur. Women need to
weigh the risk and benefits carefully, especially if they have not completed

48
childbearing, this procedure has been found to cause fewer complications than
hysterectomy, but women may need further treatment in future.
 Magnetic resonance-guided focused ultrasound surgery (MRgFUS):
ultrasonic surgery is passed through the abdominal wall to target and destroy the
fibroid. Although not yet widely used, this noninvasive procedure is approved by
the U.S .food and drug administration for premenopausal women with bother
some symptoms due to fibroids and who do not want more children .it is an
outpatient treatment
Surgical Management
Client-based
Vaginal myomectomy involves removing fibroids through the vagina; as with
hysteroscopic myomectomy, therefore, there are no external scars. This operation is done when
the fibroids are moderate in size but too deep or numerous for hysteroscopic or laparoscopic
myomectomy. It is easier in women who have children as there tends to be more space in the
pelvis for this type of surgery.
The procedure is easiest when the fibroid(s) are at the back of the uterus, and most
difficult when they are mainly at the top; in that situation, laparoscopic myomectomy may be
preferred. Because conventional instruments are used, Vaginal myomectomy generally takes
less time than laparoscopic myomectomy and the repair of the uterus is stronger. Recovery in
terms of hospitalisation and return to normal activities is similar, and faster than with
laparotomy.

49
X. Statement of nursing problems/nursing diagnosis based on grouped
data (Gordon’s)
1. Activity Intolerance related to bed rest
2. Acute pain related to injury agents as manifested by trauma to tissues
3. Acute pain related to surgical procedure
4. Anxiety related to change in role status
5. Constipation or Risk for constipation related to decreased activity
6. Disturbed sleep pattern related to pain, lack of sleep privacy
7. Disturbed body image related to treatments
8. Hygiene self care deficit related to pain
9. Hyperthermia related to trauma as manifested by increase in body
temperature
10.Ineffective health maintenance related to lack of social support
11.Nausea related manipulation of GI tract, postsurgical anesthesia
12.Risk for infection related invasive procedure
13.Risk for loneliness related to affection deprivation
14.Self-care deficit related to weakness and tiredness
15.Urinary retention related to pain, fear

50
XI. Priority Nursing Problem/Nursing Care Plan
• Actual
Assessment Nursing Dx Inference Planning Intervention Rationale Evaluation
Subjective:
The patient
verbalizes:
“I felt pain on
my surgical
incision”
Objective:
- Reported
pain
with the pain
scaleof 8 (pain
scale from 1–
10)
- Facial
Grimacing
- Guarding
behavior
Acute pain
secondary to
surgical
procedure
(hysterectomy)
as evidence by
reported
pain with the
pain scale of
8 (pain scale
from 1 – 10),
limited range of
motion and
sleep
disturbance
pattern
Hysterectomy
↓
Breaking in
the
continuity of
the skin
↓
Imflamation
process
triggered
↓
Nerve ending
compression
↓
Pain
After 8 hours of
rendering nursing
intervention, the patient
w illbe able to:
- Decrease pain
scale of 8 to 4 as
evidence by
stable vital signs.
Independent:
1. Evaluate pain
regularly noting
characteristic,
location intensity (0-10).
2. Identify specific
activity limitations.
3. Reposition as
indicated.
4. Encourage of
relaxation
technique like deep
breathing exercise.
5. Monitor vital signs
DEPENDENT:
1.Administer analgesic
medication: Ketorolac
IVTT x 4 doses q 8
hours
as prescribe by the
physician.
1. Provide
information about
need for or
effectivenessof
intervention.
2. Prevents undue
strain on operative
site.
3. May relieve pain
and enhance
circulation
4. Relieves muscle
and emotional
tension.
5. Changes in vital
signs may be used
for rough estimate
of pain.
DEPENDENT:
1. To relieve mild or
moderate pain.
After 8º of
rendering
nursing care,
the goalswas
met partially
asevidenced
by:
- Decreased
pain scale to
the
level of 5.

51
• Actual
Assessment Nursing Dx Inference Planning Intervention Rationale Evaluation
Subjective
“kanina pa po
siya nilalagnat”
as verbalized by
the patient’s
relative
Objective
> T – 39.4% C
> Chilling
> Clammy Skin
> Skin warm to
touch
Hyperthermia
related to
trauma as
manifested by
In body
temperature of
39.4 oC
Tumors of the
uterus
Located in
the body of
the uterus
Invasive
procedure
Removal of
tumors
Damage of
the tissues
Trauma of
tissue
Hyperthermia
In body
temperature
After 30 min. of
nursing
intervention,
the patient
manifest
thermo
regulating as
evidenced by:
> Skin
temperature in
expected
range
> Body
temperature
w/in normal
limits
> describes to
prevent or
minimize inc. in
body temp
> describe
proper
measures
during TSB
1. Render TSB
2. Fluid intake
3. Removal of
excessive clotting
4. Put cold
compress to
forehead neck,
axilla, and groin.
5. Every 5
minutes check for
temperature if the
temp. is w/in
normal range
6. Teach the
relative proper
TSB techniques
like avoiding long
strokes and only
patting the wet
towel on the skin
> To body
heat
evaporation
has a cooling
effect
>To
circulation of
blood
> To promote
heat loss
> To absorb
heat in said
areas. Thus,
heat loss
>to determine
if the temp. is
w/in normal
range
>Long strokes
creates
friction to the
skin and it
produces
heat.
After 30 min.
of nursing
intervention,
the body of
the patient is
able to reach
the normal
range of body
temperature.
> the patient
is able to
verbalize
understanding
of techniques
of proper TSB

52
• Potential
Assessment Nursing Dx Inference Planning Intervention Rationale Evaluation
Subjective
“hindi ako
mapalagay kasi
baka hindi ako
gumaling
agad.naaawa
ako mga anak
ko.”As
verbalized by
the patient
Objective
>Irritability
>poor eye
contact
>Expressed
concerns due to
change in life
events
>dry mouth
Anxiety related
to change in
Health status as
manifested by
irritability
Changes in
physiologic
status
Worsening of
case
Hospitalization
Anxiety due to
thoughts of
not able to
recover
After
continuous
nursing
intervention,
the client will
be able to:
-Verbalize
appropriate
range of
feeling.
-encourage
verbalization of
concerns
-assist patient in
expressing
feelings by active
listening
-provide accurate
and concrete
information about
what is being
done
-provide a calm
and peaceful
environment
-encourage
relaxation
techniques
-encourage to
project a positive
and realistic
attitude
- this aids
comfort by
improving
the patients
attitude
toward the
situation.
-relieves
discomfort
and pain.
After
continuous
nursing
intervention,
the client
was able to:
-verbalized
appropriate
range of
feelings.

53
XII. Discharge Plan
M- medication
 Advise the client to comply with the prescribe treatment regimen.
 Explain in a manner that can be understand as to name, actions, side effects
etc.
 Emphasize that strict compliance of treatment should be observed to prolong
life.
E- exercise Deep Breathing exercises.
 Keep emotional stress under control by using relaxation techniques such as
muscle relaxation exercises.
T- treatment
 Provide Rest periods between activities.
 Provide adequate ventilation and a quiet calm environment.
H- health teaching
 Instruct the client in energy saving activities.
 Instruct the patient to eat healty foods.
 Advise family to provide emotional support.
O- OPD
 Advise patient to comply with clinic follow up.
 Advise patient to comply with treatments.
D- diet
 Eat in small frequent meals of high nutritional value.
 Drink plenty of water at least 8 times a day.
S- spiritual
 Advise the significant others to guide and support the Patient by uplifting her
spiritual being.
 Maintain positive outlook in life.

54
Reference Books
Brunner & Suddarth, 2010,Textbookof Medical and Surgical Nursing
12th
Ed., Lippincott & Willliams
Joyce M. Black, 2005,Mediccal-SurgicalNursing: Clinical
Management for Positive Outcomes 7th
Ed., Elsevier Inc.
Marguerrete Kinney, 1988,AACN’s Clinical Reference forCritical-
Care Nursing 2nd
Ed., Mosby
Harold Shyrock, 1985,Modern Medical Guide
McCane & Huether, 2008 Understanding Pathophysiology4th
Ed.,
Mosby
Elaine M. Marieb, 2004,Essentials of Human Anatomy & Physiology
7th
Ed., Pearson Education South Asia PTE LTD
Judith M. Wilkinson, 2005,Prentice Hall Nursing Diagnosis Handbook
with NIC interventions and NOC outcomes 7th
Ed., Pearson
Education South Asia
Stanly Loeb,1992,Nursing 92 Drug handbook, Springhouse
Corporation
Clayton and Stock, 2001,Basic Pharmacologyfor Nurses 12th
Ed.,
Mosby
Images
http://images.search.yahoo.com/images

55
Math homework help
https://www.homeworkping.com/