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COLLEGE OF NURSING
Baguio City
Case Presentation:
Hydrosalpinx, Acute appendicitis
Presented to:
Mrs. Melody D. Baliang, RN
Presented by:
Ayugat, Roland
Alcantara, Nadine
Ceriaco, Chedan
Gonzales, Bianca
Macayan, Katrin
Rayray, Ciara
Date:
June 17, 2008
PATI EN T P ROFI LE
Patient’s condition started one month before admission, when she experienced profuse
vaginal bleeding with discharge amounting to approximately two fully soaked diapers and had been
diagnosed of threatened abortion 10 weeks AOG. She had then undergone completion curettage
last May 08, 2008 at the Sto. Nino Hospital, Baguio City. The bleeding was controlled but resumed
a few days after the curettage with discharge amounting to approximately 1 to 2 minimally soaked
pads. The patient had not taken any medications and verbalized to have no associated abdominal
pain, dysuria, or fever accompanying her existing condition.
Six days prior to admission, the patient complained of experiencing abdominal pain with an
intensity of 5 out of 10 and no radiation. No medications were taken and there had been no
accompanying symptoms such as fever, dysuria, nausea and vomiting.
About two days before admission, patient’s condition persisted, prompting her to seek
advice from a private physician. A complete blood count, urinalysis and pelvic ultrasound were then
requested for further diagnosis. The complete blood count revealed no significant health
deviations, while the urinalysis suggested the presence of a urinary tract infection and the Pelvic
ultrasound showed left adnexal mass, suspicious for ectopic pregnancy, mild hydrosalpingitis. Due
to these findings, the patient was advised for admission, hence admitted.
The patient verbalized to have been previously hospitalized at Sto. Nino Hospital for her
completion curettage and named no other succeeding condition necessitating hospitalization apart
from her present admission at Saint Louis University - Hospital of the Sacred Heart. She also
claimed to have no existing allergies to food and drugs and has had no previous intake of
maintenance drug for any serious health complication.
Furthermore, she has had no history of ovarian carcinoma, dysfunctional uterine bleeding,
myoma, Hydatidiform mole, pelvic inflammatory disease, cervicovaginitis, or polycystic ovarian
syndrome.
The patient claimed to have no existing history of heredofamilial disease conditions such
as hypertension, cerebrovascular diseases, asthma, diabetes mellitus, cancer, peptic ulcer
disease, hyperthyroidism, or arthritis. She has no family member with an existing contagious
disease such as with pulmonary tuberculosis.
COU RS E OF C ONF IN EM EN T
This nursing care plan presents the case of Mrs. M. T. M., 42 year-old female, Filipino, a
Roman Catholic, married, born on September 15, 1965, a resident of San Vicente, Baguio City,
with a chief complaint of flank pain and vaginal bleeding. This was her second hospitalization, but
had been admitted for the first time in Saint Louis University - Hospital of the Sacred Heart last
June 13, 2008 at 11:10 am by Dra. Catalan and Dra. Bibat, with an impression diagnosis of
Adnexal Mass, Left, to consider ectopic pregnancy, G7P6 (6016).
The patient was admitted with the following diagnostic tests: hematology dated June 11,
2008; complete blood count dated June 11, 2008; urinalysis dated June 11, 2008; whole abdominal
sonogram dated June 11, 2008; and a specimen histopathology that had been reported last May
18, 2008.
During the second day of hospitalization, June 14, 2008, the patient had undergone the
following operations: Salpingectomy, Elective Appendectomy both with duly accomplished consent
forms with proper pre-operative preparation.
During Hospitalization, the patient received the following medications: Nalbuphine (10mg);
Cefalozine (1gm); Metoclopramide (10mg); Ranitidine (50mg); Ketorolac (30mg) and Tranexamic
Acid (500mg). The patient had been infused with and consumed 2 bottles of D5LRS (1L) and 1
bottle of PLRS (1L).
The hematology test was completed to identify the patient’s blood type and Rh blood
group. Laboratory technicians determine the patient’s blood type and then either cross
match it to the potential donor or screen it for the presence of antibodies; this is done to
avoid blood type mismatches which may trigger damaging antigen-antibody responses
(agglutination) or rupture of red blood cells (hemolysis).
Reference: Tortora, et. al.; Principles of Anatomy and Physiology; 11th edition
The complete blood count was done to identify if the patient’s active bleeding has taken
effect on the present level of blood components, apparently, no significant deviation is
seen.
Reference: Smeltzer, et. al.; Textbook of Medical Surgical Nursing; 10th edition
Reference: http://www.healthatoz.com/healthatoz/Atoz/common/standard/transform.jsp?requestURI=/healthatoz/Atoz/ency/urinalysis.jsp
The uterus is midline, anteverted and normal in size, measuring 5.9 x 3.4 x 4.9 cm. It shows
homogenous echotexture. The endometrial stripe is thin (5.0mm). A complex mass is noted at the
left adnexal area adjacent to the ovary, measuring 3.0 x 2.3 cm. There is mild dilation of the right
fallopian tube which is fluid filled. The right ovary is intact. The cul-de-sac is clear.
IMPRESSION: Left adnexal mass, suspicious of ectopic pregnancy
Mild Hydrosalpingitis, Right
Unremarkable Sonogram of the liver, gallbladder, pancreas, spleen,
kidneys, urinary bladder
Diagnosis: Abortion, incomplete, 11 weeks age of gestation, G8P7 (7016); status completion
curettage
Histopathologic Diagnosis: Uterine Curettings- Decidual tissues, chorionic villi, blood clots
Gross description: Specimen consists of irregular fragments of tan membranous and spongy
tissues admixed with blood clots forming an aggregate measuring 3 x 3 x 3 cm
Reference: http://en.wikipedia.org/wiki/Histopathology
MEDI CATION LI ST
Indication: Relief of heartburn associated with acid indigestion and sour stomach.
Treatment of GERD.
Action: competitively inhibits gastric acid secretion by blocking the effect of histamine on
H2 receptors. Both daytime and nocturnal basal gastric acid secretion, as well as food-
and pentagastrin – stimulated gastric acid are inhibited.
Contraindications: cirrhosis of the liver, impaired renal or hepatic function
Side effects: Headache, abdominal pain, consitipation, diarrhea, nausea and vomiting.
Nursing Considerations:
o Give antacids concomitantly for gastric pain although they may interfere with ranitidine
absorption.
o Assess stomach pain
o Avoid alcohol, aspirin – containing products, caffeine containing products (may
increase stomach acid)
Cefazolin ( 1gm)
First generation cephalosporin
Indication: UTI
Action: Antibacterial – interferes with the final step in cell wall formation, resulting into
unstable cell membranes that undergo lysis. Also, cell division and growth are inhibited
First generation – effective activity against gram – positive microorganisms (S. aureus) and
relatively mild activity against gram – negative microorganisms( E.coli).
Side effects: Diarhhea, N/V, abdominal pain, rash, fever
Nursing considerations:
o Take as directed/ complete subscription
o Report adverse effects
V. Motor St atus
Upon admission, the patient was weak. Upon assessment, the patient is unable to
ambulate properly and needs assistance when standing and going to the comfort room. There was
good body coordination as well as stability. The patient can tolerate range of motion exercises.
There are no muscular abnormalities and there is good muscle tone and mass. The patient’s
muscle strength is as follows:
5/5 5/5
4/5 4/5
The patient was instructed to remain flat on bed for a few hours after the
surgery. However, there were no further medical restrictions on activity and early ambulation was
encouraged. The patient has an abdominal binder over her wound dressing and is patient is right
handed.
The patient usually has three main meals and two snacks. She prefers vegetables
(highland or lowland), coffee, and soda drinks particularly coke. She also prefers bread for snacks.
According to her, she has good appetite prior to and even during hospitalization. However, prior to
and after her surgery, she was on NPO. On the morning of June 15, 2008, she had already passed
flatus and stool. There was no further physician’s order regarding her diet.
The patient has a medium structured body. She has moist skin as well as moist
buccal cavity. She has good capillary refill and good skin turgor.
The patient has a denture. She has intact oral cavity. The patient is awake and is
able to swallow but was remained on NPO, a day after her surgery.
On average, she drinks for about 8-10 glasses of water a day. She also drinks additional
coffee and carbonated drinks. The patient was maintained on NPO after her operation but her
presence of flatus and that she already defecated may indicate progress on her nutritional intake.
The patient has good skin turgor.
Pulse rate is of regular rhythm, ranging from 70 – 75 beats per minute. Blood pressure
range is from 110/70- 120/80. Her capillary refill was 2 seconds. Client manifests good, adequate
and effective circulation as seen by the absence of cyanosis and dizziness. In addition the client is
awake and alert which manifests good level of consciousness.
Before and upon admission, patient’s temperature is within normal (range of 36.4 – 37.5
C). The patient’s temperature was stable during hospitalization; no fever was experienced.
The patient has a fair complexion. The patient had a dry and intact binder over wound
dressing on the abdominal area due to her appendectomy and salphingectomy. No signs of muscle
wasting or clubbing nails were observed. The patient has a good skin turgor.
The patient has no problems regarding her respiratory status. Her respiratory rate has a
range of 20-25 breaths per minute. She has an effective airway clearance and has an effective
breathing pattern which provides adequate gas exchange and results to a good level of
consciousness and non-cyanotic peripheral status.
LIS T O F P RI OR ITIZ ED P RO BL EM S
Actual problems
1. Acute pain related to tissue trauma secondary to surgery
2. Impaired skin integrity related to trauma secondary to surgical incision
3. Impaired tissue integrity related to trauma to integumentary and subcutaneous tissues
secondary to abdominal surgery
4. Activity intolerance related to temporary immobility secondary to previous surgery
5. Impaired physical mobility related to discomfort upon movement secondary to surgery
6. Impaired transfer ability related to trauma and discomfort upon moving secondary to effects of
surgery
7. Self-care deficit: bathing/hygiene, and dressing related to discomfort upon moving secondary to
effects of surgery
8. Acute urinary retention may be related to use of a medication (opioid) with side effects of urinary
retention
9. Ineffective role performance related to physical health alterations
10. Interrupted family process related to situational changes secondary to physical health
alterations
11. Disturbed sleeping pattern related to interruptions for therapeutic, monitoring and other
generated awakening
Potential problems
1. Risk for constipation related to insufficient physical mobility
2. Risk for infection related to inadequate primary defenses (broken skin integrity)
3. Risk for injury related to altered mobility status secondary to surgery
4. Risk for imbalance nutrition: less than body requirements related to decreased volume of
ingested food during hospitalization
5. Risk for imbalanced body temperature related to trauma affecting temperature regulation
According to Maslow, an individual is ready to act upon the growth needs if and only if the
deficiency needs are met. The fifth level is Self-actualization. It means to find self-fulfillment and
realize one's potential. Self-actualized people are characterized by: 1) being problem-focused; 2)
incorporating an ongoing freshness of appreciation of life; 3) a concern about personal growth; and
4) the ability to have peak experiences.
CLASSIFICATION
PRIORITIZED PROBLEMS
(Actual/Potential)
1. Acute pain related to tissue trauma secondary to surgery Actual
2. Impaired skin integrity related to trauma secondary to surgical
Actual
incision
3. Impaired tissue integrity related to trauma to integumentary and
Actual
subcutaneous tissues secondary to abdominal surgery
4. Activity intolerance related to temporary immobility secondary to
Actual
previous surgery
5. Impaired physical mobility related to discomfort upon movement
Actual
secondary to surgery
6. Impaired transfer ability related to trauma and discomfort upon
Actual
moving secondary to effects of surgery
7. Acute urinary retention may be related to use of a medication
Actual
(opioid) with side effects of urinary retention
8. Disturbed sleeping pattern related to interruptions for therapeutic,
Actual
monitoring and other generated awakening
9. Self-care deficit: bathing/hygiene, and dressing related to
Actual
discomfort upon moving secondary to effects of surgery
10. Ineffective role performance related to physical health alterations Actual
11. Interrupted family process related to situational changes
Actual
secondary to physical health alterations
12. Risk for constipation related to insufficient physical mobility Potential
13. Risk for imbalance nutrition: less than body requirements related
Potential
to decreased volume of ingested food during hospitalization
14. Risk for infection related to inadequate primary defenses (broken
Potential
skin integrity)
15. Risk for imbalanced body temperature related to trauma affecting
Potential
temperature regulation
16. Risk for injury related to altered mobility status secondary to
Potential
surgery
NU RS IN G C ARE P LAN S
Assessment Explanation of the problem Objectives Interventions Rationale Evaluation
LTO : After hospitalization, Diagnostics: Diagnostics:
P: s/p Salpingectomy, The patient had undergone an the patient will
Elective Appendectomy abdominal ultrasound with the 1.Monitor vital signs
following results: Left adnexal a) assume ADLs without pain > For establishment of
S: “ Complained to have mass suspicious of ectopic or discomfort baseline data and an objective
pain felt over the pregnancy and Mild parameter/ indication of
abdominal; area, Hydrosalpingitis, Right b) verbalize that she is increasing pain.
characterized as stabbing completely pain free 2. Use a pain assessment scale to
in nature, with no radiation, Comprehensively assess and > baseline for assessing
rated as 7/10, aggravated record pain using objective criteria changes in pain level and
by movement, and Salpingectomy, and Elective ST O : Within the shift the such as location, characteristics, evaluating interventions
alleviated by rest” Appendectomy was performed patient will be able to onset/duration, frequency, quality,
to repair the assessed damage severity and precipitating or
O: >Appears weak a) identify and describe pain aggravating factors before and
felt after performing nursing
>Confines self to bed and interventions.
moves minimally A Surgical incision was done b )verbalize that her pain
decreased from to 3. Note location of surgical
>Groans upon movement Incisions >Location of Surgical incisions
c) enumerate at least 3 can influence the amount of
>Hesitant to initiate strategies of pain relief post operative pain felt, this
movement Nociceptors or free nerve correctly also serves as a medium of
endings in the skin responded to comparison with the clients
>Asks for assistance in the potentially damaging stimuli d) perform deep breathing pain rating
ADL’s (surgical cutting) exercises for pain 4. Assess patient perception and
management correctly beliefs about pain felt > Identify factors influencing
>Facial Grimacing the pain response
observed upon movement Therapeutics: Therapeutics:
Nociceptive actions are
> Seen holding abdomen transmitted to the peripheral 1. Inform patient that the health
nervous system worker acknowledges that the
>Vital signs: patient’s pain is real by:
BP: 110/70 mmHg
RR: 25 cpm a. Listening to the patient’s >Promotes a feeling of
PR: 75 bpm The brain receives the stimuli subjective complaints assurance, therefore
T: 36.5 C and interprets pain depending decreasing the burden
the type of fiber delivering the
impulse b. Conversing >Distracts the patient from
A: Acute pain related to therapeutically with the concentrating on the pain
tissue trauma secondary to patient
surgery
Acute pain related to tissue
trauma secondary to surgery c. Anticipating and attending >Decreases the patient’s
Reference: Smeltzer et. al.; Textbook of Medical Surgical Nursing;10th edition
Doenges et. al; Nurses Pocket Guide; 9th edition
Assessment Explanation of the problem Objectives Interventions Rationale Evaluation
P: s/p Salpingectomy, The patient had undergone an LTO Diagnostics: Diagnostics:
Elective Appendectomy abdominal ultrasound with the After hospitalization:
following results Left adnexal >Monitor for signs of >infection, through
S: “Kakatapos lang ng mass suspicious of ectopic -the patient’s surgical site will not have any infection production of toxins and
operasyon ko kanina” pregnancy and Mild complications such as infection wastes increases the
Hydrosalpingitis, Right -the patient’s wound will heal normally and well probability of tissue
O : >Status post approximated. damage.
Salpingectomy, and >Monitor vital signs every >Provides a baseline that
Elective Appendectomy , ST O: 4 hours allows quick recognition
day 1 Salpingectomy, and Elective After 8 hours of nursing interventions: of deviations in
Appendectomy was performed subsequent
>With dry and intact to repair the assessed damage -the patient’s suture site will remain intact and measurements
abdominal dressing and free from contamination
binder >Assess skin integrity >Serves as baseline data
-the patient or a skilled significant other will be to evaluate the efficiency
> No foul odor noted in Surgical procedure required able to demonstrate at least 4-7 steps of proper of nursing intervention
the surgical site cutting into her skin and tissue wound dressing techniques
and removing her appendix >Assess wound dressing >early recognition of
>(+) facial grimace and and affected fallopian tube for drainage undesirable signs and
guarding behavior noted symptoms such as
when ambulating profuse bleeding is vital in
>Vital signs: preventing further
BP: 110/70 mmHg complications
RR: 25 cpm Skin and Tissue trauma
PR: 75 bpm secondary to the surgery > Monitor dietary intake, >these substances may
T: 36.5 C and avoid irritant food and cause irritation to the
fluid intake patient’s skin and oral
mucous membranes and
Presence of abdominal wound may cause complications
A: >Impaired skin integrity (surgical site) in the healing process of
related to trauma the abdominal wound
secondary to surgical
incision