Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

61996341 case-study-myoma


Published on

homework help,online homework help,online tutors,online tutoring,research paper help,do my homework,

Published in: Education
  • Your program is absolutely a miracle. I am on day 15, using your method. I am completely OFF ALL MEDICATIONS. I have absolutely no negative side effects. My liver functions are normal, my blood sugar is normal, my energy is higher than it has been in years and I feel great. Your e-book has changed my life. ♥♥♥
    Are you sure you want to  Yes  No
    Your message goes here
  • Here's How YOU Can Stake Out Your Personal Claim In Our EIGHT MILLION DOLLAR GOLDMINE... ★★★
    Are you sure you want to  Yes  No
    Your message goes here
  • Fibroids Miracle! Cure Uterine Fibroids , end your PCOS related symptoms and regain your natural inner balance ... Guaranteed! -- Discover how Amanda Leto has taught thousands of women worldwide to achieve Uterine Fibroids freedom faster than they ever thought possible... Even if you've never succeeded at curing your Uterine Fibroids before... Right here you've found the Uterine Fibroids freedom success system you've been looking for! ■■■
    Are you sure you want to  Yes  No
    Your message goes here
  • Holistic Uterine Fibroids Secrets, Eliminate Uterine Fibroids Fast, Natural cure e-book reveals all.. ◆◆◆
    Are you sure you want to  Yes  No
    Your message goes here
  • The "Magical" Transformation That Happens When You Combine Two Of The Best Brain Reprogramming Technologies ★★★
    Are you sure you want to  Yes  No
    Your message goes here

61996341 case-study-myoma

  1. 1. 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. 2. 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. 3. 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. 4. 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. 5. 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. 6. 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. 7. 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. 8. 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. 9. 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. 10. 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. 11. 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. 12. 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. 13. 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. 14. 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. 15. 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. 16. 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. 17. 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. 18. 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. 19. 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. 20. 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. 21. 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. 22. 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. 23. 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. 24. 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. 25. 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. 26. 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. 27. 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. 28. 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. 29. 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. 30. 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. 31. 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. 32. 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. 33. 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. 34. 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. 35. 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. 36. 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. 37. 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. 38. 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. 39. 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. 40. 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. 41. 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. 42. 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. 43. 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. 44. 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. 45. 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. 46. 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. 47. 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. 48. 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. 49. 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. 50. 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. 51. 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. 52. 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. 53. 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. 54. 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
  55. 55. 55 Math homework help