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NURSING HISTORY

I.PERSONAL DATA

NAME: DSC

AGE: 57y/o

BIRTHDATE: Feb. 16, 1953

RELIGION: Roman Catholic

CIVIL STATUS: Single

MEDICAL DIAGNOSIS: Myoma Uteri

ROOM NO.: 432 B

DATE OF ADMISSION: Feb. 23, 2011

II. CHIEF COMPLAINT

Abdominal Enlargement

III. HISTORY OF PRESENT ILLNESS

4 mons PTA

 (-) hypogastric mass ,first in size , movable

 (-) hypogastric pain

 (-) vaginal bleeding

 Whole abdominal ultrasound done revealed adrenal mass

 Advised operation did not comply

1 mon PTA

 (+) hypogastric pain

 (-) pain

 TVS done revealed ONG & ovarian cyst, myoma uteri


 Advised operation did not comply

1 week PTA

 still with the same condition

IV.PAST HEALTH HISTORY

(+)hypertension

V. SOCIAL HISTORY

(-) alcohol drinker

(-) smoker

VI. FAMILY HISTORY

(+) DM

(+) HPN

Clinical Appraisal

1. Vital Signs

Temp: 37.8 C PR: 86bpm

BP: 120/80mmHg RR: 20cpm

2. General Appearance
 Receive patient lying on bed, conscious and coherent..

3. Speech

 Normal voice

4. Level of consciousness
 Patient is conscious and responsive

5. Condition of the skin


 Light to dark brown; smooth & soft

6. Head to Toe Inspection

 Eyes: Eyebrow and eyelashes are evenly distributed


Conjunctiva: Pale palpebral

 Head: Proportion to the body and skull is rounded.


 Hair: black in color
 Face: Normal as the color of complexion
 Ears: Color: same as facial color
Symmetry at the level of the eyes; No discharges

 Nose: No discharges
 Mouth and lips: Dry lips
 Neck: No Lymphnodes
 Heart/Lungs: HR: 82bpm
RR: 18cpm

 Upper Extremities: unilateral movement


 Lower Extremities: unilateral movement

ANATOMY AND PHYSIOLOGY


a. Broad Ligaments. Two wing-like structures that extend from the lateral margins
of the uterus to the pelvic walls and divide the pelvic cavity into an anterior and a
posterior compartment.

b. Corpus Luteum. The yellow mass found in the graafian follicle after the ovum
has been expelled.

c. Estrogen. The generic term for the female sex hormones. It is a steroid hormone
produced primarily by the ovaries but also by the adrenal cortex.

d. Fimbriae. Fringes; especially the finger-like ends of the fallopian tube.

e. Follicle. A pouch like depression or cavity.

f. Follicle Stimulating Hormone. The follicle stimulating hormone (FSH) is a


hormone produced by the anterior pituitary during the first half of the menstrual
cycle. It stimulates development of the graafian follicle.

g. Graafian Follicle. A mature, fully developed ovarian cyst containing the ripe
ovum.

h. Hormone. A chemical substance produced in an organ, which, being carried to


an associated organ by the bloodstream excites in the latter organ, a functional
activity.

i. Lactation. The production of milk by the mammary glands.

j. Luteinizing Hormone. A hormone produced by the anterior pituitary that


stimulates ovulation and the development of the corpus luteum.

k. Oocyte. A developing egg in one of two stages.

l. Ovum. The female reproductive cell.

m. Progesterone. The pure hormone contained in the corpora lutea whose


function is to prepare the endometrium for the reception and development of the
fertilized ovum.

n. Reproduction. The process by which an offspring is formed

PATHOPHYSIOLOGY

Etiology:
Predisposing Factors:
- Unknown
- Advancing Age
- Genetics
- Race
- Stress

Precipitating Factors:
- Over Weight
Disease Process
- Hyperestrogenic State
- Hypertension
- Nulliparity
- Multiparity
- Menopause
- Contraceptives
- Smoking

Benign tumors originating in the smooth muscular uterine tissue, though sometimes
they
originate in the smooth muscle of the uterine vessels
Stress within the myometrium
(Due to physical and mental means resulting from uterine contractions.
Multiple fibroids)
Simple proliferation (monoclonal) of smooth muscle cells
(Continuous development of group of cells from a single ancestral cell by repeated
cellular
replication; cell formation)
Development of Leiomyomas ( fibroid )
Fibroid Growth Increase

Estrogen-dependent tumors, their growth is related to their exposure to circulating
estrogens

Express maximal growth during the generativeage of a female, when estrogen
secretion is
at its highest, and growth curve is especially slope in the decade preceding
menopause
(probably as the consequence of anovulatory cycles with unopposed circulatory
estrogen)

sometimes grow during pregnancy, which is probably related to estrogen, as well as
an
increased blood flow in pregnancy and edema. Estrogen receptors are present in a
higher
concentration within myomas than in the adjacent myometrium.

DISCHARGE PLAN

Mefenamic Acid must be given TID O.D for pain.


M
Instruct the relative to follow medication regimen

E
Encourage the patient to have some exercise.

Educate and instruct the family of the patient of the proper taking of
T medications on time and the proper wound care to avoid contamination
and infection at the surgical site.
Encourage ambulation for her early recovery.

H
Inform the patient the importance of proper hygiene from head to toe.

Inform the family of the patient to have her checkup 2 weeks after
o discharge for the continuity of treatment.
Instruct the family of the patient to monitor if there is any sudden change
to the patient and report immediately.

Inform the family of the patient to have her checkup 2 weeks after
D discharge for the continuity of treatment.
Instruct the family of the patient to monitor if there is any sudden change
to the patient and report immediately.

Jean Watson’s theoretical of frame work

The ten primary carative factors


1. The formation of a humanistic- altruistic system of values.
2. The installation of faith-hope.
3. The cultivation of sensitivity to one’s self and to others.
4. The development of a helping-trust relationship
5. The promotion and acceptance of the expression of positive and negative
feelings.
6. The systematic use of the scientific problem-solving method for decision
making
7. The promotion of interpersonal teaching-learning.
8. The provision for a supportive, protective and /or corrective mental, physical,
socio-cultural and spiritual environment.
9. Assistance with the gratification of human needs.
10.The allowance for existential-phenomenological forces.