Liceo de Cagayan University

College of Nursing

NCM501202
A Care Study

Submitted to

As Partial Requirement for NCM501202

Submitted by
 TABLE OF CONTENTS

Page
I. Introduction 3
A. Overview of the Case 3
B. Objective of the Study 3
C. Scope and Limitation of the Study 4
II. Health History 5
A. Profile of Patient 5
B. Family and Personal Health History 7
C. History of Present Illness 7
D. Chief Complain 7
III. Developmental Data 8
IV. Medical Management 11
A. Medical Orders and Laboratory Results 11
B. Drug Study 16
V. Pathophysiology with Anatomy and Physiology 23
VI. Nursing Assessment 29
(System Review and Nursing Assessment II)

VII. Nursing Management 33

A. Ideal Nursing Management (NCP) 33
B. Actual Nursing Management (SOAPIE) 36
VIII. Referrals and Follow-up 39
IX. Evaluation and Implications 39
X. Documentation 40
A. Documentation of evidence of care for 1 week rotation 40
B. Organization/ Grammar/ Bibliography 41
XI. Rating Scale 41

2
 I. Introduction

A. overview

What is an ovarian cyst?

An ovarian cyst is a fluid-filled sac in or on the ovary. Many ovarian cysts are
noncancerous cysts that occur as a result of ovulation (the release of an egg
from the ovary). These are called functional cysts. Functional cysts normally
shrink on their own over time, usually in about 1 to 3 months. Often functional
cysts do not cause any symptoms (you may not even know you have one), but
other times they can cause abdominal pain, menstrual irregularities, nausea and
vomiting. If you have a functional cyst, your doctor may want to check you again
in 1 to 3 months to make sure the cyst has gotten smaller. If you develop
functional cysts often, your doctor may want you to take birth control pills so you
won't ovulate. If you don't ovulate, you won't form functional cysts.

If you do have a cyst, your doctor will probably want you to have a sonogram so
he or she can look at the cyst. What your doctor decides to do after that depends
on your age, the way the cyst looks on the sonogram and if you're having
symptoms such as pain, bloating, feeling full after eating just a little, and
constipation.

f you are menopausal and are not having periods, you shouldn't form functional
cysts, but it is possible for you to form other types of ovarian cysts. You should
call your doctor if you experience any of the symptoms of an ovarian cyst.

3
 B. Scope of the Study

 The study focuses on Medical Ward patient, admitted at Cagayan de Oro

Medical Center , Cagayan de Oro City, having the diagnosis of Pulmonary
Tuberculosis.
 Nature, causes, signs & symptoms, pathophysiology, medical
management, nursing management, and prognosis of the disease.
 Involves the ideal and actual nursing intervention appropriate to address
the needs of Mr. X’s, the drug study of the medications given to her, the
health teachings as well as referrals for Mr. X.
 Assessment of Mr. X’s personal health history, and history of present
illness.

C. Limitation of study

 Limited only to the history of the patient which is comprised of the patient’s
profile, family and personal health history, chief complaint and history of
present illness.
 Information being collected from the patient during the patient assessment
and from his watchers.
 The patient was only taken cared of for 2 days, starting from the 1 st day of
his admission at Cagayan de Oro Medical Center, Cagayan de Oro City.

 Other relevant information was kept confidential including his true identity
to protect his privacy.

4
II. Health History

A. Patient’s Profile

Client’s Name:

Age: 28 Years old

Address: ,

Civil Status: Single

Sex: Female

Nationality: Filipino

Religion:
Educational Attainment: College Graduate

Height: 4’10’’

Weight: 65 kg

Occupation: Govt Employee

Income: 13000/monthly

Informant: Cousin

Date of Admission: August 4, 2008

5
Time of Admission: 3:15 pm

Chief Complaint: Irregular Menses, Left Adnexal cyst

Admitting Diagnosis: Para-ovarian cyst

Attending Physician:

Re-admission date:

Re-admission Chief Complaint:

Attending Physician:

6
History of Present Illness

Chief Complaint : Irregular Menses, Left Adnexal cyst

a 28 years old, female, UCCP, a government employee, currently residing
at ------------- was admitted in Polymedic General Hospital for the first time last
August 4, 2008 at 3:15 pm.
On follow up ultrasound (UTZ) noted increase in size of mass thus
advised surgery.

Personal Health History

In relation to the health history of the ---------- family, Ms.

------------------------ has not undergone any previous hospitalization.

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III DEVELOPMENTAL THEORY

 Erik Erikson’s Theory of Psychosocial Development

Erik H. Erikson (1963-1964), adapted and expanded Freud’s theory of
development to include the entire lifespan, believing eight stages of
development.
Erikson envision life as a sequence of levels of achievement. Each stage
signals a task that must be achieved. The resolution of task can be complete,
partial, or unsuccessful. Erikson believes that the greater the task achievement,
the healthier the personality of the person; failure to achieve a task influence s a
person’s ability to achieve the next task. These developmental tasks can be
viewed as a series of crises, and successful resolution of these crises is
supportive to the person’s ego. Failure to resolve the crises is damaging to the
ego.
Erikson’s eight stages reflects both positive and negative aspect of the
critical life periods. The resolution of the conflicts at each stage enables the
person to function effectively in society. Each phase has kits own developmental
task, and individual must find a balance between.
According to Erik Erikson’s developmental task. Mr N.S , 65 years old,
belongs to developmental task of older age, with a central task of integrity versus
despair. As I observed, he was kin the positive resolution of development at his
stage because according to his daughter he has a good relationship with his
parent’s, brothers and sisters and most especially with his wife and children, he
had raised them well and really tried his best to support his children, he was a
loving father and even though he experienced an illness on his older stage of life,
still he was able to show courage and strength while admitted in the hospital. He
has a positive coping mechanism skill especially in participating during
administration of medication.
 Robert J. Havighurst Developmental Task Theory
Havighurst (1900-1991) theorized that the developmental task one must
accomplish throughout life. He described developmental task as doing those

8
things that make up health and satisfactory growth kin society. The task are
organically and socially determined. Accomplishing task at a lower level, or at an
earlier stage, is the first step in the progression toward accomplishing task at
later age.
A developmental task is a task which arises at or about a certain period in
the life of individual, successful achievements of which leads to his happiness
and to success with later task, while failure leads to unhappiness in the
individual, disapproval by society, and difficulty with later task.
According to Havighurst developmental theory, Mr.N.S 65 years of age,
belongs to a period of middle age which was achieving adult civic and social
responsibility since at his age he has his own income for being a punong
baranggay graduate which he would received an amount of twenty five thousand
a month as his salary, also he has his own farm “durian Farm” and according to
his daughter her father was really happy with his life and as I observed during
the interview and assessment Mr. N.S was really satisfied with his achievements
and success in life.
 Jean Piaget Cognitive Developmental Task Theory
Piaget’s believes that cognitive structures are complete during the formal
operations period, from roughly 11 to 15 years. From the time formal operations
characterize thinking throughout adulthood and are applied to more areas.
Egocentrism continue to decline; however these changes in its content and
stability.
Some may use post-formal operations strategies to assist them in
understanding the contradictions that exist in both personal and physical aspects
of reality. The experiences of the professional, social and personal life in the
middle-aged persons will be reflected in their cognitive performance. The middle-
aged adult can imagine, anticipate, plan and hope.
In relation to our patients, his cognitive and intellectual abilities change
very little. As a punong barangay in there area, He uses his intellectual abilities in
dealing with problems related to his position. But there were also times that he
gave opinions as well as solutions to his people, but there were times that he

9
experienced failure and received pessimistic opinions from other people. Some
dragged him down but he never losses hoping in helping others. Even though,
He did’nt allow the idea he could not help served other people. According to
these treats made him strong and he learned more.
 Sigmund Freud Psychosocial Developmental Task.
Psychosocial Development refers to the development of personality. It can
be considered se the outward expression of the inner self. It encompasses a
persons temperament, feelings, character, traits, independence, self-esteem, self
concept, behavior, ability to interact with others, and ability to adapt to life
changes.
The culminating stage of Psychosocial Development is Genital Stage ( 13
years and after ) were energy is directed toward attaining a mature sexual
relationship. This stage involves a reactivation of the pregenital impulses. These
impulses are usually displaced and the individual passes are usually displaced
and the individual passes to the genital stage or maturity. An inability to resolve
conflicts can result in sexual problems, such as frigidity, impotence and the
inability to have satisfactory sexual relationship.
Our patients 65 years old, in his age right now, he encountered many things that
made him strong.
He was blessed with a loving wife and 4 children where he offers all his
achievements. All her children graduated from college. But unfortunately, his 2
children migrated here in CDO to work and live. He hates the idea of being away
from his children but he still accepted it. According to him, “ it’s a part being a
parent”.
He was also engaged in politics where his socialization, decision making and
being an achiever was practiced. But because of his illness, his turn or position
being a Barangay Captain was transferred to another official. According to his
wife, he then became moody. If you need something or you will ask something,
he got easily irritated.

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IV. Medical Management

A. Doctor’s Order
August 4, 2008
Please admit under the service of Dr. To provide care and close monitoring
Paano-Go
NPO To prepare for surgery
Labs; CBC, FBS, SGPT, HepBAg, To obtain baseline data’s and to know
chest x-ray, PA, ECG 12 L any abnormalities
For pelvic lap on 8/5/08 Removal of ovarian cyst
Secure consent For documentation
Inform OR For preparation
Inform me once patient is admitted To start the surgery

Pre Operative
August 4, 2008
Please start D5LR 1L regulated @ 30 To maintain fluid and electrolytes
gtts/min tomorrow @ 6:30 am
Emergency order and body hygiene
HepB precaution To protect and prevent infection
Cefuroxime 750 mg IV ++ ANST (-) to To prevent infection
begin 1 hour before surgery

11
 Post Operative

August 5 2008 9:30 AM

NPO To prevent irritation of the intestinal
wall
Post spinal care To give comfort
Monitor vital signs every 15 mins x 2, To monitor patients condition after
every hour x 4 hours every shift until surgery
stable
General liquid diet To prevent irritation in GIT
May turn to side To prevent bed sore and promote blood
circulation
May give Nalbuphine

August 6 2008 6:30 AM

DAT To give adequate nutrition to the
patient
Remove FBC and refer if unable to Provide comfort
urinate 6 hours after
Discontinue Famotidine
Multivit 1 tab 2x/day To nourish the patient
Ferrous sulfate (feosol), 1 tab OD To supplement iron intake of the patient
May sit up on bed To promote blood circulation and
ambulation
Regulate IVF at KVO To keep vein open

9:00 AM
D5LR 1L at KVO To maintain fluids and electroytes
Give paracetamol 500mg 1 tab every 4 To prevernt fever and relief to any pain
hours RTC
Discontinue Nalbuphine

August 7 2008 10:30 AM

Discontinue IVF when dry mouth
Discontinue Cefuroxime IV Prevent occurrences of side effects
Cefuroxime 500mg every 12 hours PO Prevent antiterrorist

12
Discontinue Nalbuphine For healing
May ambulate

Laboratory Results
August 4 2008

Result Normal range Rationale

Fasting Blood Sugar 89.95 60-100mg/dL within normal limit

Sero and Immuno .107 1.0 nonreactive reactive HBeAg

HbeAg

Hematology
Test Results Normal Range
Clotting time 3:49 mins 3-7 mins
Bleeding time 2.05 mins 1-3 mins

Complete Blood count

Test Results Normal range
WBC +10.82 x10/L 5-10
RBC 4.80 x10/L 3.69-5.90
Hemoglobin 13.5 g/dL 11.70-14
Hematocrit 40.7 % 34.10-44
Differential Count 53.6 % 55-62
Neutrophils 34.8 % 20-40
Lymphocytes 8.7 % 4-10
Monocytes 2.8 % 1-6
Eosinophils 0.1 % 0-1
Basinophils 13.1 % 11.5-14.5

Chemistry
Test Results Normal range
SGPT (ALT) 28.98 U/L 9-36

13
Potassium 4.33 meq/L 3.50-5.50
Sodium 138.60 meq/L 135-155
Creatinine 1.06 mgs/dL .07-1.30

Radiology Request Form

Request Examination: ECG 12 L
Request by: Dr. Paano-Go

Radiologic Report
Lungs are clear. Heart is not enlarged. Midline structures are displaced.
The CP sulci and hemidiaphrams are intact. The rest of the included structures
are all unremarkable
Normal chest findings

Pelvic (endovaginal) sonogram

Impression:
Increase in size of the previously noted non-septated pelvic cystic mass,
as described.
Normal size uterus with endometrial thickness of 1.5 cm
Sonographically normal right ovary, adnexal and urinary bladder non
visualized left ovary.
Well defined non-septated left Para ovarian cyst (7.2 x 6.6 x 6.3 cm)
Normal sized uterus with endometrial thickness of 1.6 cm
Tiny Nabothian cyst
Normal sized urinary bladder

14
 Generic name Brand Date Classification Dose/ Mechanism Specific Contraindication Side effects Nsg
name ordered Frequency/ of action Indication Precautions
Route
Cefuroxime 8-4-08 Antibiotic 750 mg IV Bactericidal; Parenteral: Allergy to Headache, Renal
Cephalosphori ANST ( - ) inhibits the Lower cephalosphorin or dizziness, Failure,
n give 1 hour growth of respiratory penicillin lethargy, lactation,
before baterial cell infections Nausea, pregnancy
surgery wall, causing caused by S. vomiting,
death pyogenes diarrhea,
Dermatoligi abdominal
c Infection pain, pain,
UTI’s infection at
Septicemia the
Meningitis injection
Preoperative site
prophylaxis
B. Drug Study

15
 Generic name Brand Date Classification Dose/ Mechanism Specific Contraindication Side effects Nsg
name ordered Frequency/ of action Indication Precautions
Route
Ranitidine 8-5-08 Antihistamine 20 mg IV Blocks Short-term Allergy to Headache, Hepatic and
renal
, every 12 daytime and treatment of ranitidine and malaise,
dysfunction.
gastrointestina hours nocturnal active lactation dizziness,
l Agent basal gastric duodenal somnolence pregnancy

acid ulcer; , insomnia,

secretion maintenance vertigo,
stimulated therapy for mental
by histamine duodenal confusion,
and reduces ulcer patient agitation,
gastric acid after healing depression,
release in of acute hallucinatio
response to ulcer;short- ns in older
food, term adults.
pentagastrin, treatment of
and insulin. active,
Shown to benign
inhibit 50% gastric
of the ulcer;
stimulated treatment of
gastric acid pathologic
secretion.

16
 Post Operative medications
Generic name Brand Date Classification Dose/ Mechanism Specific Contraindication Side effects Nsg
name ordered Frequency/ of action Indication Precautions
Route
Cefuroxime 8-5-08 Antibiotic 7 50 mg IV Bactericidal; Parenteral: Allergy to Headache, Renal
Cephalosphori every 12 inhibits the Lower cephalosphorin or dizziness, Failure,
n hours growth of respiratory penicillin lethargy, lactation,
baterial cell infections Nausea, pregnancy
wall, causing caused by S. vomiting,
death pyogenes diarrhea,
Dermatoligi abdominal
c Infection pain, pain,
UTI’s infection at
Septicemia the
Meningitis injection
Preoperative site
prophylaxis

17
 Generic name Brand Date Classification Dose/ Mechanism Specific Contraindication Side effects Nsg
name ordered Frequency/ of action Indication Precautions
Route
Famotidine 8-5-08 Histamine 2 20 mg IV Competitiv Short-term Contraindicated CNS: Use
(H2) ely blocks treatment with allergy to Headache, cautiously
every 12
and famotidine; renal malaise, with
receptor hours
the action maintenance failure; lactation. dizziness, pregnancy,
antagonist of of duodenal somnolence renal or
histamine ulcer , insomnia hepatic
at the Short-term Dermatolo dysfunction.
histamine treatment of gic: Rash
benign GI:
(H2) gastric ulcer Diarrhea,
receptors Treatment constipatio
of the of n, anorexia,
parietal pathologic abdominal
cells of the hypersecreto pain
ry Other:
stomach; conditions Muscle
inhibits Short-term cramp,
basal treatment of increase in
gastric GERD, total
acid esophagitis bilirubin,
due to sexual
secretion
GERD impotence
and OTC: Relief
chemically of
induced symptoms
gastric of
heartburn,
acid
acid
secretion. indigestion,
sour
stomach

18
 Generic name Brand Date Classification Dose/ Mechanism Specific Contraindication Side effects Nsg
name ordered Frequency/ of action Indication Precautions
Route
Nalbuphine 8-5-08 CENTRAL 5 mg IV Analgesic Symptomati History of Hypertensi History of
NERVOUS action that c relief of hypersensitivity on, emotional
every 10
SYSTEM relieves moderate to to drug. Safety hypotensio instability or
(CNS) hours moderate to severe pain. during pregnancy n, drug abuse;
AGENT; severe pain Also (category C) or bradycardia head injury,
ANALGESIC with preoperative lactation is not , increased
; NARCOTIC apparently sedation established. tachycardia intracranial
(OPIATE) low potential analgesia Prolonged use , flushing. pressure;
AGONIST- for and as a during pregnancy GI: impaired
ANTAGONIS dependence supplement could result in Abdominal respirations;
T to surgical neonatal cramps, impaired
anesthesia withdrawal. bitter taste, kidney or
nausea, liver
vomiting, function; MI;
dry mouth. biliary tract
surgery.

19
 Generic name Brand Date Classification Dose/ Mechanism Specific Contraindication Side effects Nsg
name ordered Frequency/ of action Indication Precautions
Route
Celecoxib 8-5-08 CENTRAL 400 mg OD Reduces or Relief of Severe hepatic Body as a
NERVOUS eliminates S&S of impairment; Whole: Patients who
cap P.O
SYSTEM the pain of osteoarthriti hypersensitivity Back pain, are P450 2C9
AGENT; rheumatoid s and to celecoxib; peripheral poor
ANALGESIC and rheumatoid asthmatic patients edema. GI: metabolizers;
; osteoarthritis arthritis. with aspirin triad; Abdominal patients who
NONSTEROI Treatment advanced renal pain, weigh <50
DAL ANTI- of acute pain disease; diarrhea, kg; moderate
INFLAMMA and primary concurrent use of dyspepsia, hepatic
TORY DRUG dysmenorrh diuretics and flatulence, impairment;
(NSAID); ea. ACE inhibitors; nausea. renal
COX-2; anemia; CNS: insufficiency
ANTIPYRETI pregnancy Dizziness, ; aspirin use;
C (category D) in headache, prior history
third trimester; insomnia. of GI
lactation Respirator bleeding or
y: peptic ulcer
Pharyngitis disease;
, rhinitis, asthmatics;
sinusitis, pregnancy
URI. Skin:
Rash..

20
 Intravenous Fluids
Date Ordered Solution
8-5-08 #1 D5LR 1L @ 30 gtts/min post op
8-5-08 + 50 mg omdis
8-6-08 #2 D5LR 1L @ KVO
8-6-08 #3 D5LR 1L @ KVO

21
Anatomy and Physiology
Female Reproductive System

The female reproductive anatomy includes internal and external structures.

The female reproductive system contains two main parts: the vagina and uterus,
which act as the receptacle for the male's sperm, and the ovaries, which produce the
female's ova. All of these parts are always internal; the vagina meets the outside at the
vulva, which also includes the labia, clitoris and urethra. The vagina is attached to the
uterus through the cervix, while the uterus is attached to the ovaries via the Fallopian
tubes. At certain intervals, the ovaries release an ovum, which passes through the
fallopian tube into the uterus.

If, in this transit, it meets with sperm, the sperm penetrate and merge with the egg,
fertilizing it. The fertilization usually occurs in the oviducts, but can happen in the uterus
itself. The zygote then implants itself in the wall of the uterus, where it begins the
processes of embryogenesis and morphogenesis. When developed enough to survive
outside the womb, the cervix dilates and contractions of the uterus propel the fetus
through the birth canal, which is the vagina.

The ova are larger than sperm and are generally all created by birth. Approximately
every month, a process of oogenesis matures one ovum to be sent down the Fallopian
tube attached to its ovary in anticipation of fertilization. If not fertilized, this egg is
flushed out of the system through menstruation.

The function of the external female reproductive structures (the genital) is twofold: To
enable sperm to enter the body and to protect the internal genital organs from infectious
organisms. The main external structures of the female reproductive system include:

Labia majora: The labia majora enclose and protect the other external reproductive
organs. Literally translated as "large lips," the labia majora are relatively large and
fleshy, and are comparable to the scrotum in males. The labia majora contain sweat
and oil-secreting glands. After puberty, the labia majora are covered with hair.

Labia minora: Literally translated as "small lips," the labia minora can be very small or
up to 2 inches wide. They lie just inside the labia majora, and surround the openings to
the vagina (the canal that joins the lower part of the uterus to the outside of the body)
and urethra (the tube that carries urine from the bladder to the outside of the body).

Bartholin's glands: These glands are located next to the vaginal opening and produce
a fluid (mucus) secretion.

Clitoris: The two labia minora meet at the clitoris, a small, sensitive protrusion that is
comparable to the penis in males. The clitoris is covered by a fold of skin, called the

22
prepuce, which is similar to the foreskin at the end of the penis. Like the penis, the
clitoris is very sensitive to stimulation and can become erect.

The internal reproductive organs in the female include:

Vagina: The vagina is a canal that joins the cervix (the lower part of uterus) to the
outside of the body. It also is known as the birth canal. The vagina is the tubular tract
leading from the uterus to the exterior of the body in female mammals, or to the cloaca in female
birds and some reptiles. Female insects and other invertebrates also have a vagina, which is the
terminal part of the oviduct.

The vagina is the place where semen from the male is deposited into the female's body at the
climax of sexual intercourse, commonly known as ejaculation.

Uterus (womb): The uterus is a hollow, pear-shaped organ that is the home to a
developing fetus. The uterus is divided into two parts: the cervix, which is the lower part
that opens into the vagina, and the main body of the uterus, called the corpus. The
corpus can easily expand to hold a developing baby. A channel through the cervix
allows sperm to enter and menstrual blood to exit. The uterus or womb is the major female
reproductive organ of humans. One end, the cervix, opens into the vagina; the other is connected
on both sides to the fallopian tubes.

A pictorial illustration of the female reproductive system.

The uterus mostly consists of muscle, known as myometrium. Its major function is to accept a
fertilized ovum which becomes implanted into the endometrium, and derives nourishment from
blood vessels which develop exclusively for this purpose. The fertilized ovum becomes an

23
embryo, develops into a fetus and gestates until childbirth. If the egg does not embed in the wall
of the uterus a woman gets her period and the egg is flushed away.

Ovaries: The ovaries are small, oval-shaped glands that are located on either side of
the uterus. The ovaries produce eggs and hormones. The ovaries are the place inside the
female body where ova or eggs are produced. The process by which the ovum is released is
called ovulation. The speed of ovulation is periodic and impacts directly to the length of a
menstrual cycle.

After ovulation, the ovum is captured by the oviduct, where it travelled down the oviduct to the
uterus, occasionally being fertilised on its way by an incoming sperm, leading to pregnancy and
the eventual birth of a new human being.

The Fallopian tubes are often called the oviducts and they have small hairs (cilia) to help the
egg cell travel.

Fallopian tubes: These are narrow tubes that are attached to the upper part of the
uterus and serve as tunnels for the ova (egg cells) to travel from the ovaries to the
uterus. Conception, the fertilization of an egg by a sperm, normally occurs in the
fallopian tubes. The fertilized egg then moves to the uterus, where it implants to the
uterine wall.

The cervix is the lower, narrow portion of the uterus where it joins with the top end of the
vagina. It is cylindrical or conical in shape and protrudes through the upper anterior vaginal wall.
Approximately half its length is visible; the remainder lies above the vagina beyond view.

24
Oviducts

The Fallopian tubes or oviducts are two very fine tubes leading from the ovaries of female
mammals into the uterus.\

On maturity of an ovum, the follicle and the ovary's wall rupture, allowing the ovum to escape
and enter the Fallopian tube. There it travels toward the uterus, pushed along by movements of
cilia on the inner lining of the tubes. This trip takes hours or days. If the ovum is fertilized while
in the Fallopian tube, then it normally implants in the endometrium when it reaches the uterus,
which signals the beginning of pregnancy

25
 Pathophysiology of Ovarian cyst

Ovary
\\\

Produces Graafian Follicles

Release of a mation

Oocyts becomes the

curpu lutuem

No fertilization She know of fertilization

Curopose luteum
Ocytes undergone fibrosis initiliably, decrease in
size ang thendrually
them

Enlargement of the corpus luteum

Ovarion Cyst

26
27
VI. NURSING ASSESSMENT
NURSING SYSTEM REVIEW CHART
Name:____Mara Nova C. Lapeceros________________________________________ Date
Temp.:_39.5 C____ Pulse Rate:_92bpm___ Height:_50cm___ Weight:_7 kgs_____
INSTRUCTIONS: Place an [X] in the area of abnormality. Comment at the space provided. Indicate the location of the problem in
the figure using [X].

EENT:
[X] impaired vision [ ] blind [ ] pain __________________
[ ] reddened [ ] drainage [ ] gums __________________
[ ] hard of hearing [ ] deaf [ ] burning B __________________
[ ] edema [ ] lesion [ ] teeth _Dizzy_____________
Assess eyes, ears, nose throat for abnormalities. __________________
[ ] no problem __________________
__________________
RESPIRATORY: __________________
[ ] asymmetric [ ] tachypnea [ ] apnea __________________
[ ] rales [ ] cough [ ] barrel chest X Incision site_________
[ ] bradypnea [ ] shallow [ ] rhonchi Pain upon exertion or_
[ ] sputum [ ] diminished [ ] dyspnea movement__________
[ ] orthopnea [ ] labored [ ] wheezing __________________
[ ] pain [ ] cyanotic D5LR 1L @ 30 gtt/min
Assess resp. rate, rhythm, pulse blood breath sounds, comfort __________________
[ x] no problem __________________
__________________
CARDIOVASCULAR: __________________
[ ] arrhythmia [ ] tachypnea [ ] numbness __________________
[ ] diminished pulses [ ] edema [ ] fatigue __________________
[ ] irregular [ ] bradycardia [ ] murmur __________________
[ ] tingling [ ] absent pulses [ ] pain __________________
Assess heart sound, rate, rhythm, pulse, blood pressure. __________________
circulation, fluid retention, comfort __________________
[X] no problem __________________
__________________
GASTROINTESTINAL TRACT: __________________
[ ] obese [ ] distention [ ] mass __________________
[ ] dysphagia [ ] rigidity [X] pain __________________
Assess abdomen, bowel habits, swallowing bowel sounds, comfort. __________________
[ ] no problem __________________
__________________
GENITO-URINARY AND GYNE: __________________
[ ] pain [ ] urine color [ ] vaginal bleeding __________________
[ ] hematuria [ ] discharge [ ] nocturia _____________ _____
assess urine frequency, control, color, odor, __________________
comfort, gyne bleeding, discharge __________________
[x] no problem __________________
__________________
NEURO: ___ _______________
[ ] paralysis [ ] stuporous [ ] unsteady __________________
[ ] seizures [ ] lethargic [ ] comatose __________________
[ ] vertigo [ ] tremors [ ] confused __________________
[X] vision [ ] grip __________________
assess motor, function, sensation, LOC, strength __________________
grip, gait, coordination, speech ___ _ _____________
[ ] no problem __________________
__________________
MUSCULOSKELETAL AND SKIN: __________________
[ ] appliance [ ] stiffness [ ] itching __________________
[ ] petechiae [ ] hot [ ] drainage __________________
[ ] prosthesis [ ] swelling [ ] lesion __________________
[ ] poor turgor [ ] cool [ ] deformity __________________
[X] wound [ ] rash [ ] skin color
[ ] flushed [ ] atrophy [x] pain
[ ] ecchymosis [ ] diaphoretic [ ] moist
assess mobility, motion, gait, alignment, joint function
skin color, texture, turgor, integrity
[ ] no problem

28
NURSING ASSESSMENT II
SUBJECTIVE OBJECTIVE
COMMUNICATION: [ ]Glasses [ ]
[ ]Hearing loss Comments “lipong pa languages
[x]Visual changes siya, bag-o paman [ ]Contact lenses [ ] hearing
[ ]Denied siya ni gawas sa OR aid
Verbalized by the R L
cousin of the Pupil size 2-3 mm □speech difficulties
patient Reaction Pupil equally round but not
reactive to light accommodation
OXYGENATION:
[ ]Dyspnea Comments: “Wala Resp. [x] regular [ ]irregular
may Described: Breathing are regular
[ ]Smoking history problema sa iyang
pag- R equal expansion to left lung
[ ]Cough ginhawa” as L equal expansion to right lung
verbalized
[ ]Sputum by her cousin
[x]denied
CIRCULATION: Heart rhythm [x] regular □ irregular
[ ]Chest pain Comments: “wala man Ankle edema ___none_________
[ ]Leg pain ngsakit iyang dughan” Pulse Car. Rad. DP. Fem*
[ ]Numbness of as verbalized by the R + + + +
Extremities patient’s cousin L + + + +
[X]Denied Comments: all pulse are palpable
*If applicable
NUTRITION:
Diet NPO_ [ ]Dentures [ x ]none
[X]N [X]V Comments:
Character ”wala paman pud Full partial with
[ ] Recent change in siya nagkaon” patient
Weight, appetite As verbalized by Upper [x] [ ] [ ]
the Lower [x] [ ] [ ]
[ ]Swallowing patient’s cousin
Difficulty
[x]denied
ELIMINATION:
Usual bowel pattern urinary frequency Comments Bowel sounds
1 x a day________ diaper_____ Patient has not audible
[ ]Constipation [ ]urgency elimination bowel Abdominal
Remedy [ ]dysuria distension
None [ ]hematuria since the surgery
date of last BM [ ]Inconsistence Present □yes □no
08-03-08 [ ]Polyuria Urine* (color,
[ ]Diarrhea [ ] foly in place consistency, Odor)
Character [x ]denied Urine is yellow drainig

29
Well into the the FBC

If foley is in place

30
 Bfiefly described the patient’s ability to
MGT. OF HEALTH & ILLNESS: follow treatments (diet, meds, etc.) for
[ ]Alcohol [x]denied chronic health problems (if present)
(amount frequency) The patient is closely monitored and
______none_____________ compliant to medications.
□SBE Last Pap Smear n/a
LMP__n/a__________
SKIN INTEGRITY:
□Dry Comments “wala man Dry cold pale
□Itching sad kapangatul ang Flushed x warm
□Other iyang lawas ”as Moist cyanotic
□denied by the patients *rashes, ulcers, decubitus(described
Cousin size, location, drainage) superficial
partial thickness burn.
ACTIVITY/SAFETY:
[ ]Convulsion Comments: LOC and orientation patient is
[X]Dizziness Lipong paman unconscious and not oriented to time
siya Galt: [ ]walker [ ]cane [ ]
[x]Limited motion dili paman gani pa- others
Of joints istoryahon sa [x]Steady [ ]unsteady_______
doctor” [ X]Sensory and motor losses in face or
Limitation in verbalized by the extremities
ability to patients cousin No sensory or motor losses in
[x]ambulate extremities
[x]bathe self [ ]ROM limitations Patient has limited
[ ]other range of motion due to loss of sensory
[ ]denied
COMFORT/SLEEP/AWAKE:
[x]Pain Comments: “sakit [x]Facial grimaces
(location) Lagi daw iyang [X]Guarding
opera” [x]Other signs of pain:______________
Frequency verbalized by the [ ]Siderail release form signed (60+
Remedies) patients cousin years)
[ ]Nocturia Not applicable
[ ]Sleep difficulties
[X ]denied
COPING:
Occupation Government Employee Observed non-verbal behavior
Members of Household 6 patient is compliant to this treatment
Most supportive person father plan

the person and his contact number that

can be reach any time Cousin

31
32
 SPECIAL PATIENT INFORMATION
___________ daily weight none PT/OT N/A
___________ BP q Shift none Irradiation
Not taken Neuro vs Urinalysis Urine test routine
urinalysis
Not taken CVP/SG. Reading N/A none 24 hour urine collection
Date Diagnostic/Laboratory Date Date I.V: Date
ordered Exams done ordered Fluids/Blood Disc.
08-04-08 Complete blood 08-04-08 08-04-08 #1 D5LR 08-05-08
count
08-04-08 HepBeAg 08-04-08

33
VII Nursing Management
A. Ideal Nursing Care Plan

1. NURSING DIAGNOSIS: Acute Pain related tissue trauma secondary to abdominal

surgery
Independent Interventions:
1. Investigate pain reports, noting 1. Changes in location/intensity are
location, duration, intensity, (1-10 not uncommon but may reflect
scale), and characteristics ( e.g. dull, developing complications. Pain
sharp, constant). tends to become constant, more
intense, and diffuse over the
entire abdomen as inflammatory
process accelerates; pain may
localize if an abscess develops
2. Maintain semi-fowler’s position as 2. facilitates fluid/ wound drainage
indicated
by gravity , reducing
diaphragmatic irritation and
abdominal tension , thereby
reducing pain.
3. Move client slowly and deliberately,
3. reduces muscle tension/
splinting painful area.
guarding, which may help
minimize pain of movement
4. Provide comfort measures e.g. 4. promote relaxation and may
massage, back rubs, deep breathing.
enhance client’s coping abilities
Instruct in relaxation/ visualization
exercises. Provide diversional by refocusing attention.
activities.
5. reduces nausea and vomiting,
5. Provide frequent oral care. Remove
noxious environmental stimuli which can increase
intraabdominal pressure/pain.

34
Dependent Intervention
1. Administer medication as
1. reduces metabolic rate and
indicated:
Analgesic, narcotics; intestinal irritation from
circulating/local toxins, which aid
in relied and promote healing.
Note: pain is usually severe and
may require narcotic pain
control. Analgesics may be
withheld during initial diagnostic
process because they can mask
signs/ symptoms.

2.Nursing Diagnosis : Risk for Constipation risk factors may include physical factors:
abdominal surgery.
Independent Interventions:
1. Auscultation bowel sounds. Note 1. Indicators of presence /
abdominal distention, presence of resolution of ileus, affecting
nausea / vomiting. choice of interventions.
2. Assist client with sitting on the edge 2. Early ambulation helps
of the bed and walking. stimulate intestinal function and
return of peristalsis.
3. Encourage adequate fluid intake, 3. promotes softer stools, may aid
including fruits juices, when oral is in stimulating peristalsis.
resumed
4. provide sitz bath 4. promotes muscle relaxation,
minimizes discomfort.

Dependent Intervention:
1. Adminster medications e.g. stool 1. Promote formation/ passage of softer
softeners, mineral oil, laxative, PRN stools

35
3. Nursing Diagnosis : Risk for ineffective tissue perfusion risk factors may include
postoperative tissue trauma.
Independent Interventions:
1. Indicators of adequacy of
1. Monitor Vital signs, palpate
systemic perfusion, fluid/ blood
peripheral pulses note capillary refill,
needs, and developing
assess urinary output,/ characteristics,
complications.
evaluate changes in mentation
2. Inspect dressings and perineal pads,
2. Proximity of large blood vessels
noting color, amount, and odor of
to operative site and/ or potential
drainage. Weigh pads and compare
for alteration of clotting
with dry weight if client is bleeding
mechanism ( e.g. cancer )
heavily.
increase risk of postoperative
hemorrhage.

3. Prevents stasis of secretion and

3. Turn client and encourage frequent
respiratory complication.
coughing and deep breathing
exercises.
4. Creative vascular stasis by
4. Avoid high Fowlers position and
increasing pelvic congestion and
pressure under the knees or crossing
pooling of blood in the
of legs.
extremities, potentiating risk of
thrombus formation.
5. Assist with/ instruct in foot and legs
5. Movement enhance circulation
exercises and ambulate as soon as
and prevents stasis
able.
complications.

6. may be indicative of
6. Note erythema, swelling of extremity,
development of
or reports of sudden chest pain with
thrombophlebitis/ pulmonary
dyspnea
embolus

Dependent Intervention
1. Replacement of blood losses
1. Administer IVF, blood products PRN
maintains circulating volume and tissue
perfusion.

36
B. Actual Nursing Care Plan
1st Priority

S “sakit akong tiyan kung mulihok ko” as verbalized by the patient

O  Facial grimace
 Guarding
A Acute Pain related tissue trauma secondary to abdominal surgery
P Short term: At the end of 15-30 minutes, the patient will be able report pain
is relieved
Long term: At the end of 8 hours, the patient will be able to demonstrate
relaxation skills, other methods to promote comfort.
I Independent:
1. Provide palliative measures e.g. reading books, watching T.V, to
divert the patient’s attention
2. Provide comfort measures e.g. massage, back rubs, deep
breathing, provide comfort
3. move client slowly, minimize the feeling of pain
4. ambulate patient PRN, to promote blood circulation thus facilitate
healing
Dependent:
1. Administer medication as needed e.g. Analgesics, relieve pain

E After 15 minutes, the patient was relieved from feeling of pain

37
 2nd Priority

S “Wala pako nakalibang pag abot nako dinhi” as verbalized by the patient
O  No bowel movement for 3 consecutive days
 Dry skin
 Less movement
A Constipation related to pain in surgical area
P Short term: At the end of 1 day, the patient will reestablish normal patterns
of bowel functioning
Long term: pass stool of soft/semiformed consistency without straining
I Independent:
 Note abdominal distention and auscultate bowel sounds,
observe the patient’s condition
 Provide privacy, promotes psychologic comfort
 Encourage early ambulation, facilitates passage of flatus
 Offer bed pan, to encourage patient to defecate

Dependent:
2. Administer medication e.g. Laxatives, stool softener PRN, softens
stools

E After 1 day the patient’s normal bowel movement was reestablished

38
 3rd Priority

S “ma lipong ko basta mutindog ko” as verbalized by the patient

O  Disoriented to person, place and time
 Change in usual response to stimuli
 Impaired ability to concentrate, reason, make decision
A Disturbed sensory perception related to hypoxia
P Short term: At the end of 15-30 minutes, the patient will recognize
limitations and seek assistance as PRN
Long term: at the end of 1 hour the patient will regain usual level of
consciousness
I Independent:
 Speak in normal, clear voice, without shouting, being aware of what
you are saying Minimize discussion of negatives (e.g. clients
personal problems) within clients hearing. Explain procedures and
environmental events even client those not seem aware
 Use bed rail padding, medical protective devices PRN

 Secure Parenteral line ( ET tube, catheter, if present, and check for

patency)

 Maintain quite, calm environment

Dependent:
Refer to physician for alternate care option
E At the end of 30 minutes the patient recognizes limitations and seek
assisstance

39
VIII Referrals and Follow ups

For the health problems of Ms. Lapeceros, who has undergone through surgery
for the removal of her ovarian cyst, she should be referred accordingly to any hospital institution
whenever symptoms of complication and/or infection occur. Patient should contact to her
physician for immediate management of her condition if any unusualities occur. Patient should
instructed to have her follow-up check up with her physician in the exact day at the exact time
of schedule, even if she doesn’t feel better, after being discharged from the hospital.

XI Evaluation and Implications

During the 2nd day nursing care of the patient, Ms Lapeceros was able to

manifest stable vital signs and signs and symptoms that may lead to the progress of the

physical well-being.

After rendering health care service and doing necessary interventions to the

patient. An improvement of Ms Lapeceros’s health status was observed as evidenced

by normal vital signs and verbalization of normal breathing pattern.

At the end of the shift, the interventions and procedures done to the patient were

successful and the patient was able to participate actively to the treatment regimen.

The condition of the patient implies that the surgery was reliable for reliance as

the last resort of any condition. In this case, through Ms. Lapeceros’s experience proved

that surgery is still trustworthy and that health is very importance to maintain in order to

prevent ourselves from getting sick or getting ill.

40
X Documentation

a) Documentation of evidence of care for 1 week rotation

Assessing Ms. Lapeceros

41
b. Organization/Grammar/ Bibliography

Douges, M.E. et.al., (2002). Nurse’s pocket guide: diagnosis, interventions &

rationales. (8th Edition). Philadelphia: F.A. Davis Company.

Douges, M.E. et.al., (2002). Nursing care plan: guidelines for individualizing

patient care (6th Edition) Philadelphia: F.A. Davis Company.

Gulandick, M. et.al., Nursing care plan. (3rd Edition)

Ignatavicius, D.D. & Workman, M.L. (2006). Medical-surgical nursing: critical

thinking for collaborative care. (5th Edition). St. Louis, Missouri: Elsevier Saunders.

Kozier, B. et.al., (2004). Fundamentals of nursing: concepts, process & practice.

(7th Edition). Philippines: Pearson Education South Asia PTE Ltd.

Smeltzer, S.C. & Bare, B.G. (2004).Textbook of medical-surgical nursing(10th

Edition, Volume 2). Philadelphia: Lippincott Williams and Wilkins. pp 553-538.

Spratto, G.R. & Woods, A.L. (1994). Nurse’s drug reference. USA: Delmar

Publishers Incorporated.

Ulrich & Canale. (2005). Nursing care planning guides. (6th Edition).

42
 LICEO DE CAGAYAN UNIVERSITY
COLLEGE OF NURSING
NCM501202
A CARE STUDY
Mara Nova C. Lapeceros
Name of Client
Submitted to
Mrs. Gina Batasin-in, RN
Name of faculty
As Partial Requirement for NCM501202
Submitted by
Michael Angelo D. Simyunn Jr.
Name of Student
RATING SCALE
A. Written WEIGHT RATING
I. introduction 5
a. overview of the case
b. objective of the study
c. scope and limitation of the study
II. Health History 5
a. profile of patient
b. family and personal health history
c. history of patients illness
d. chief complain
III. developmental data 5
IV. medical management 20
a. medical orders and rationale (10)
b. drug study (10)
V. Pathophysiology with anatomy and physiology 10
VI. Nursing assessment 10
VII. Nursing Management 30
a. Ideal nursing management (NCP) (10)
b. actual nursing management (SOAPIE) (20)
VIII. referral and follow-up 5
IX. Evaluation and implication 5
X. documentation 5
a. documentation of evidence of care for 1 week rotation
b. organization/grammar/bibliography
TOTAL SCORE 100
EQUIVALENT GRADE

43
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