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An abdominal mass is a growth or swelling in the abdomen. An abdominal mass can have
a variety of causes, ranging from innocuous to life-threatening.
The majority of abdominal masses are discovered during routine physical examinations.
They frequently develop slowly, and you may not notice them. Based on the location of the mass
and your symptoms, your doctor will be able to narrow down the possible causes.This may
located in Right upper quadrant & lower quadrant, left upper quadrant & lower quadrant,
epigastric, which is just below your ribcage in the center of your abdomen and periumbilical,
which is the area around your belly button.
Abdominal masses can be caused by a lot of different conditions, including the following.
Cancers
Colon cancer
Stomach cancer
Liver cancer
Kidney cancer
Neuroblastoma, a type of cancer that usually occurs in children
Gallbladder cancer
Uterine sarcoma
Endometrial cancer
Cysts. Cysts are sacs that can form almost anywhere on your body. They can be filled with
semi-solid material or fluid. They are usually not cancerous. In rare cases, they can be. The types
of cysts that can cause abdominal masses include:
Ovarian cysts
Pancreatic pseudocysts, which is a fluid-filled sac but not a true cyst
Pancreatic abscess, which is a type of infected cyst
A benign, or harmless, cyst called a Peritoneal inclusion
Abdominal aortic aneurysm. The aorta is the largest blood vessel in your body. It runs from
your heart down the center of your chest and abdomen. An aneurysm is a bulge in the wall of an
artery where there is a weak spot. A ruptured abdominal aortic aneurysm can be a life-
threatening complication.
Enlarged liver. Your liver is usually behind your right rib cage and can't be felt. If your
doctor can feel it, it may mean you have hepatomegaly. This is a liver that is bigger than normal.
It can be caused by many different conditions, such as:
Nonalcoholic fatty liver disease
Alcoholic liver disease
Blockage of the gallbladder or bile ducts
Leukemia
Lymphoma
Heart failure
A blockage in the veins that drain the liver
Liver cancer
Enlarged spleen. Your spleen is about the size of a fist. Like your liver, it normally can't be
felt during an exam. There are a lot of conditions that can cause an enlarged spleen, which is
called splenomegaly. Some of these are:
Hemolytic anemia, which is when your spleen destroys too many red blood cells
Liver disease
Leukemia
Infections caused by a virus, bacteria, or fungus
Gallbladder inflammation. This condition is called cholecystitis. It's usually caused by a
gallstone blocking a duct. Cholecystitis can either be acute or chronic. Acute cholecystitis
happens suddenly with severe pain in your upper abdomen. Chronic cholecystitis is long-lasting
and can damage your gallbladder. In either case, the treatment is usually removing your
gallbladder.
Crohn's disease. This is a type of inflammatory bowel disease that causes chronic
inflammation of your gastrointestinal (GI) tract. Your GI tract refers to all of the organs involved
in digesting your food. Crohn's disease can affect any part of it. But, it typically affects the end
of the small bowel and the beginning of the colon.
Uterine fibroids.Fibroids can be large enough to distend a woman’s uterus or so small that
they are microscopic. These are noncancerous growths in the uterus. Most women will have
them at some point during their childbearing years. You may not have any symptoms or you may
have any of the following:
Periods that last longer than a week
Heavy bleeding during your period
Pressure in your pelvic area
Pain in your back or legs
Constipation
Frequent urination
An abdominal mass may vary in different symptoms like abdominal pain,
diarrhea, constipation, bleeding from your rectum, blood in your urine, weight
loss, and fullness in the abdomen. The doctor may diagnose abdominal mass based
on the test request like blood tests, urine tests, abdominal ultrasound, computed
tomography (CT) scan, and magnetic resonance imaging (MRI) scan. The
treatment for your abdominal mass will depend on its underlying cause. Some of
them are surgery, medicine, chemotherapy, and lifestyle changes.
MEDICAL MANAGEMENT
Hormonal management is considered the first line of medical therapy for patients with acute
abdominal uterine bleeding without known or suspected bleeding disorders. Treatment options
include IV conjugated equine estrogen, combine oral contraceptives and oral progestin.
Combined oral contraceptives and oral progestin, taken in multi-dose regimens, also are
commonly used for acute abdominal uterine bleeding. Food and drug administration labeling
information can be helpful in determining which patients may or may not be treated with oral
contraceptives or progestin alone. Other oral contraceptives and progestin formulations and dose
schedules may be equally effective.
Antifibrinolytic drugs, such as tranexamic acid, work by preventing fibrin degradation and are
effective treatments for patients with chronic abdominal uterine bleeding. They have shown to
reduce bleeding in these patients b 30-55%. Tranexamic acid effectively reduces intraoperative
bleeding and the need for transfusion in surgical patients and is likely effective for patients with
acute abdominal acute bleeding. Experts recommended using either oral or IV tranexamic acid
for treatment of acute abdominal uterine bleeding. Intrauterine tamponade with a 26F Foley
catheter infused with 30 ml of saline solution has been reported to control bleeding successfully
and also may be considered.
Patients with known or suspected bleeding disorders ma responded to the hormonal and non-
hormonal management options listed earlier in this section. Consultation with a hematologist is
recommended for these patients, especially if bleeding is difficult to control or the gynecologist
is unfamiliar with the other options for medical management. Desmopressin may help treat
abdominal uterine bleeding in patients with non Willebrand disease if the patient is known to
respond to that agent. It may be administered by intranasal, inhalation, intravenously, or
subcutaneously. This agent must be used with caution because of the risk of fluids retention and
hyponatremia and should not be administered to patients with massive hemorrhage who are
receiving IV fluid overload. Recombinant factor VIII and von Willebrand factor also are
available and may be required to control severe hemorrhage. Other deficiencies may need factor
specific replacement.
Patients with bleeding disorder or platelet function abnormalities should avoid non-steroidal anti-
inflammatory drugs because of their effect of platelet aggregation and their interaction with
drugs that might be affect liver function and the production of clotting factors.
DIAGNOSTIC EXAM
IMPRESSION:
Upper limit liver size with diffuse parenchymal disease
Gallbladder polyp. Follow-up after 3 months is suggested
Splenomegaly
Nephromegaly with pelvocaliectasia, bilateral, which can be due to cysto-ureteral reflux
Unremarkable pancreas
Enlarged-sized uterus with lobulated contour and heterogenous parenchymal echopattern.
Clinical correlation is suggested to rule in the possibility of endometriosis.
Lobulated, heterogenous mass, anterior uterine body. Uterine myoma vs. uterine neoplasm.
Thickened endometrial stripe, which can be due to intercurrent endometritis. However the
possibility of endometrial neoplasm is not totally ruled out
Cystic structure, right adnexa such can represent an ovarian cyst.
Complex, predominantly csytic mass, left adnexa, which can be endometrioma or cystic ovarian
neoplasm.
Negative for para-aortic lymphadenopathy
Ascites
Chest x-ray and Endocervical biopsy- Waiting for result
Transvaginal and Abdominal Ct scan with contrast - Differ
Laboratory Results
Jan 5 Jan 8
Hemoglobin 49 89 120-60g/L
DEVELOPMENTAL TASK
Patient X is a married woman with one daughter. She is 45 years old and has the task of
developing generativity according to Erik Erikson's developmental theory. The patient and her
husband have been together for 11 years, and the patient verbalizes that she had a joyful and
energetic childhood. After her school activities, they played with her schoolmates. She stated
also that she did not suffer from any childhood diseases, except for chicken pox and mumps, but
she cannot recall the dates. When she was 12 years old, her first menstruation cycle came with
regularity (up to 3–5 days), as she stated, and she experienced the enlargement of breast and
pubic hairs all over the body. Patient X has reached the stage of formal operation, according to
Jean Piaget's theory. In addition, patient X verbalized that she had her first relationship when she
was twenty years old. When they broke up three years later, she concentrated on her work and
also helped her parents with their daily needs. The patient possess the stage of late adolescence,
according to Sullivan theory. Then, at the age of 30, she met his loved ones, and at the age of 33,
she got married to her husband. At the age of 35, she got pregnant and gave birth at 28–29 weeks
of gestation via cesarean section due to placenta previa. Last year, in 2022, she suffered severe
vaginal bleeding, and she felt a mass in her lower abdomen.
2. Nutrition “Tatlong beses akong “Ngayon hindi na ako She eats regularly
and kumakain sa isang araw masyadong nakakakain from before her
Metabolism dati at kung ano ano nawawalan ako ng gan hospital admission.
Pattern nalang ang mga dahil sumasakit ang tiyan She eats whatever
kinakain kong pagkain ko. Naka soft diet ako food she likes
dahil nga busy sa ngayon at iniiwasaan ko especially fatty foods.
pagtitinda hindi na ako na yung mga During
nakakapagluto sa bahay pinagbababawal na hospitalization, the
at mga matatabang pagkain saakin, sa patient has loss her
pagkain lagi ang ngayon ipinagbabawal appetite and hasn’t
kinakain ko” ang mga matatabang eaten a lot because her
pagkain, at mga pagkain abdomen is painful.
na may salitre” She stated also that
she is in a soft diet
and she avoiding
foods that is forbidden
to her like fatty and
food that has salitre.
3. Elimination “Wala akong problema “Okay parin naman kahit The patient stated her
Pattern sa pag ihi, pagdumi at papaano, wala parin urination and
wala rin akong namang pinagbago, defecates remains the
ginagamit na laxative ganon parin gaya ng same before and after
dahil nakakatae naman dati” hospitalization.
ako ng maayos, isang
beses sa isang araw”
4. Activity “Nagbebenta ako ng “Nahihirapan gumalaw According to the
and Exercise mga gulay, hindi naman kasi masakitt, limitado patient she sells
Pattern ako nahihirapang nalang yung mga galaw vegetables and usually
huminga wala naman ko ngayon” does the household
akong ubo. Okay na ako chores, that serve her
sa exercise habang daily exercise. During
nagbebenta at sa mga hospitalization, her
gawaing bahay movements have been
naigagalaw ko naman very limited due to
katawan ko” some pain she still
feels on her abdomen.
5. Cognition “Wala naman akong “Ngayon masakit lang The patient has no
and ibang problema bukod talaga itong na sa may sensory problems. She
Perception sa pagtitinda at sa anak part ng tiyan ko yun understands direction
Pattern ko. Hindi pa naman ako lang” very well and has a
gaano nawawalan ng good memory. She
memorya” has no complaints
aside from the pain in
her abdomen.
6. Sleep and “Nakakatulog naman “Simula nung na admit The sleeping pattern
Rest Pattern ako ng maayos at wala ako dito hindi na ako of the patient has
naman akong gamot na nakakatulog ng maayos completely changed
ginagamit para kasi sumasakit yung sa from before and
makatulog” may part ng tiyan ko” during hospitalization.
Before she used to
sleep well and didn’t
used sedatives drugs.
And suddenly it
changed in the
hospital, upon
admission the patient
cannot sleep well
because of her
abdomen is painful.
7. Self-
“Hindi naman sa “Nanghhinayang kasi The perspective of the
Perception andmasasabi kong perpekto sayang ang mga araw patient is always
Self-Concept ako sa buhay pero nan andito ako sa positive, she knows
Pattern masaya ako sa naging Hospital. Ang pananaw that God is the only
takbo ng buhay ko, mga ko ngayon ay maiksi lang reason she made it this
desisyon at pananaw ko ang buhay kaya dapat far. She doesn’t
wala naman akong enjoyin lang, mahalin complicate things and
pinagsisisihan dahil ang sarili at alagaan” stated that life is too
alam kong kagustuhan short, so just enjoy it.
lahat ito ng Diyos”
8. Roles and “Kasama ko ang “Nung na admit ako The patient lived with
Relationships pamilya ko sa iisang syempre umaasa nalang her family. She and
Pattern bahay at dalawa kami ng ako sa asawa ko dahil her husband work
asawa ko ang siya nalang mag isa ang together for their
nagtratrabaho para sa nagtratarabaho para family but due to
pamilya. Madalas yung saamin” hospitalization, she’ s
asawa ko ang nasusunod now depends on her
sa mga desisyon para husband because he is
saamin” the one who still
working.
9. Sexuality “Pag niyaya ako umo oo “Syempre hindi na The patient is sexually
and ako, asawa ko naman active tulad ng dati dahil active from which she
Reproduction yun at wala namang nandito nga kami sa consider love making
Pattern problema sa ganitong hospital” as an expression of
bagay, minsan sa pagod love, but due to her
pero hindi naman confinement the
hadlang kung talagang patient is sexually
kailangan. Atleast 2-3 inactive.
times a week siguro
basta hindi pagod”
10. Coping and “Pag nagkakaroon ako “Ngayong nasa ganitong The patient treats her
Stress ng problema dinadaan sitwasyon ako, positive problems by doing
Tolerance ko nalang sa paggawa lang ako sa buhay laging household chores.
Pattern ng mga gawaing bahay nasa isip ko na lahat ng During her
at nakakatulong siya ito ay pagsubok lang, hospitalization, she
para makalimutan ko kaya lumalaban lang ako remains positive even
yung mga problema ko” lagi dahil alam kong after being in this
hindi naman ako situation because she
papabayaan ng Diyos “ knows that God will
not forsake her.
11. Values “Roman Catholic ako ”Ngayon mas lalo akong The patient is Roman
and Belief ngunit dahil sa trabaho naniwala sa kanya dahil and
Pattern hindi na ako sa kabila ng mga she has a very strong
nakakapunta sa nangyari saakin, nandito belief in the Higher
simbahan para parin ako nabubuhay at Power. She believes
makapagdasal ng alam ko na hindi niya that God is her source
taimtim pero ganon pa ako papabayaan. Sa of strength and feels
man naniniwala ako na kanya talaga ako that she can go
may Diyos at lagi parin humuhugot ng lakas through everything if
naman akong ngayon” she stays believing in
nagpapasalamat sa God.
kanya “
PATIENT APPRAISAL
01/05/23 7 am – 7 pm
Admitted a 45 y/o female c cc of abd’l mass under the service of Dr. Segundo
S/E by ROD
Secured consent signed by S.O.
Hooked to IVF
Initial VS taken and recorded
Labs and dx facilitated
Meds given as ordered
AP (?)
Endorsed
01/05/23 7 pm – 7 am
Acute pain
Received pt on bed, conscious and coherent c ongoing IVF patent and infusing well, (-) DOB, (-) chest pain, (-) desat, not in distress, (+) pain
on lower abdomen.
Assessed pt., v/s taken and recorded, all due meds given, ensured safety and comfort, encouraged verbalization of feelings and concerns,
WOF any untoward S/Sx, seen c intervals, provided quiet rest & sleep.
Endorsed
01/06/23 7 am – 7 pm
Acute pain
Received pt. on bed awake, conscious, coherent c ongoing IVF patent and infusing well, c tolerable abdominal pain, (-) DOB, (-) chest pain,
afebrile, not in CP distress
Assessed status, monitored v/s and recorded, due meds given, monitored for untoward S/Sx, ensured safety, kept comfortable, kept watched,
encouraged (?), attended to needs
01/06/23 7 pm – 7 am
Acute pain
Received pt. on bed, conscious and coherent, c ongoing IVF patent and infusing well, (-) DOB, (-) Desat, (+) abdominal pain.
Assessed pt., v/s taken and recorded, all due meds given, ensured safety and comfort, encouraged verbalization feelings and concerns,
provided adequate rest and sleep, WOF any untoward S/Sx, seen c intervals, all meds attended, kept watched.
Endorsed
01/07/22 7 am – 7 pm
F – Acute pain
D – Received on bed awaked and responsive c ongoing IVF patent and infusing well, afebrile, not in distress, (-) desat, (-) DOB still c
abdominal pain @ PS /10
A – Assessed, v/s taken and recorded, all due meds given as ordered, WOF any undue S/Sx, all needs attended, seen c intervals
9 am – Hooked 2nd unit of PRBC ↔ Blood transfusion reaction.
4 pm – Hooked 3rd unit of PRBC.; Referred to Dr. Mercell
R – Still c ongoing BT of 3rd (?). Endorsed
01/07/23 7 pm – 7 am
F – Acute pain
D – Received pt. on bed, conscious and coherent, c ongoing IVF patent and infusing well, afebrile, not in distress, (-) DOB, (-) Desat, still c
abdominal pain @ pain scale 5/10
A – Assessed pt., v/s taken and recorded, all due meds given as ordered, WOF any untoward S/Sx, ensured safety and comfort, encouraged
verbalization of feelings and concerns, all needs attended, seen c intervals, kept watched
R – still c abdominal pain but tolerable
Endorsing for continuity of care
01/08/23 7 am – 7 pm
Acute pain
Received pt. on bed conscious and coherent, c ongoing IVF patent and infusing well, afebrile still with episode of abdominal pain, not in
distress
Assessed pt., v/s taken and recorded, due meds given, all needs attended, seen at intervals, ensured safety and comfort, watched out for an
untoward S/Sx, kept watched
Endorsing for continuity of care
01/08/23 7 pm – 7 am
F – Acute pain
D – Received on bed awake and responsive c ongoing IVF patent and infusing well, afebrile not in distress, (-) desat, (-) DOB still c
abdominal @ pain scale 5/10
A – Assessed pt., v/c taken and recorded, all due meds given, ensured safety and comfort, encouraged verbalization of feelings and concerns,
provide adequate rest and sleep, WOF any untoward S/Sx, seen c intervals, all needs attended, kept watched
Endorsing for continuity of care
01/09/23 7 am – 7 pm
F – Readiness for enhance healthcare management
D – Received on bed, conscious and coherent, c IVF of D5NSS 1L @ 100 cc x 12°, patent and infusing well, (+) minimal abdominal pain as
verbalized by pt., (+) neck mass, (-) desat, (-) DOB not in distress
A – Assessed pt., v/s taken and recorded, all due meds given, encouraged to verbalize feelings and concerns, watched out for any untoward
S/Sx, seen at intervals, needs attended
R – Still c minimal abdominal pain, endorsed for continuity of care
01/09/23 7 pm – 7 am
F – Knowledge deficit r/t present condition
D – Received on bed c IVF patent (?), (?) pain, not in CP distress
A – (?)
R – Endorsed
01/10/23 7 am – 7 pm
F – Readiness for enhance healthcare management
D – Received pt. on bed conscious and coherent c ongoing IVF patent and infusing well, (+) minimal abdominal pain as verbalized, (+) neck
mass, (-) desat, (-) DOB, not in distress
A – Assessed v/s taken and recorded, all due meds given, encouraged to verbalized feelings and concerns regarding her health condition,
watched out for any untoward S/Sx, seen c interval, kept safety and comfort, all needs attended
PHYSICAL ASSESSMENT
Patient: X
Age: 45 years old / Female
Date of assessment: January 09, 2023 @10: 00 am
Diagnosis: Abnormal Uterine Bleeding , Pelvic Mass T/C Malignancy with compression symptoms, secondary to anemia
General Survey:
Patient X is seen in lying position on her bed with her relative beside.
Glasgowcoma scale is 15/15, E4V5M6. Patient has good posture and in positive mood as always, greeted us (student nurses) as we approach her.
Body structure is hair, Face, finger, eyelids, teeth and lower quadrant. Weight loss is not evaluated due to patient is not weighed recently. Initial
vital signs are: BP: 120/80 mmHg, T: 37.1 ºC, PR: 70 bpm, RR: 20 cpm, taken August 17, 2015 @ 3:20 pm prior to interview.
Findings Findings
Head Even distribution, Thick, black with Inspection Patient can’t fully
- Hair thick hair white hair due to aging wash her body
process.
Silky, resilient hair Evenly distributed because of her
No infection or but not well current status. So
Infestation combed hair. she was assisted by
Hair is dry and Her husband while
Coarse cleaning her body
No lesions, on bed. Hair
Infection, dandruff and becomes dry
infestation noted. because the scalp
doesn’t make
enough oil to
moisturize the hair.
Smooth, with
Smooth, uniform Uniform
consistency, consistency, no
absence of nodules presence of
or masses nodules or masses
- Internal Eye Sclera appears white White in color Inspection Essentially Normal
Structure Shiny, smooth, and Shiny and smooth but
pink or red in color pale upon observation No
palpebral conjunctiva edema noted Transparent,
Lacrimal sac and shiny
nasolacrimal duct- and smooth. Details of iris
are visible.
Absence of edema or
Blinks when touched
tearing
Constricts and dilates
Cornea- equally with the
Transparent, shiny, presence of light.
smooth; Constricts with light and
Details of iris are dilates without the
visible light
Blinks when touched Eyes can move co-
ordinately and
Pupils-
symmetrically with both
Black in color; equal eyes.
in size; normally 3-7 Patient no difficulty in
mm in diameter; reading. No reading
round smooth border; glasses needed.
iris flat and round
Six ocular
movements-
Both eyes coordinate,
move in unison, with
parallel alignment
Visual acuity-
Able to read
Newsprint 20/20
Ears- Auricles- Color same as Inspection Essentially Normal
Color same as facial skin
facial skin Symmetrical and
Symmetrical and aligned with outer canthus
aligned with outer in eye
canthus in eye No difficulty in
recoils after it is
folded
External ear canal-
Can hear ticking
off the clock when
placed on both
ears. Should be
symmetrical.
Nose and Sinuses External nose- Symmetric and Inspection Essentially Normal
straight
Symmetric and Palpation
No discharge or
straight
Absence of flaring
discharge or flaring
Uniform in color No
Uniform color tenderness,
Sinuses- masses palpated
Absence of
Tenderness
Teeth and Gums 28-32 whitish teeth Incomplete teeth. Inspection Poor dental
with smooth 2 tooth molar hygiene is
surfaces and edges. considered as the
No decayed areas, main cause of tooth
no missing teeth discoloration.
Tissue is smooth Yellowish teeth Inadequate
and moist without lesion noted. brushing and
Tissue, gums, and flossing to remove
Tongue should be tongue are pink and plaque and stain-
pink, moist, and no lesion noted producing
moderate size with Patient determined substances like
papillae present different tastes and coffee and tobacco
Tongue can no changes in taste noted. can cause tooth
determine between discoloration.
different tastes Foods like coffee,
Gums is tea can cause also
pink and no lesions discoloration.
Trachea in central
of neck
Fingernails -
Convex curvature, 180 degrees angle; Inspection, Essentially Normal
angle about 180 smooth in texture Palpation
degrees; smooth
texture
Highly vascular Nails appear to be pink Inspection Essentially Normal
and pink in color and highly vascular
Capillary refill – 1- 2 sec Cut fingernails in hands
but uncut fingernails in
toes
Capillary refill of 1
second.
(+) pale
Cranial Nerves
I. Olfactory – able to Can identify scent of bed Inspection Essentially normal
identify familiar side food.
scent
II. Optic- able to read No difficulty upon Making the patient read Essentially normal
newspaper with one reading. No the written word by
eye at a time reading glasses student nurses, also some
used. text messages from
cellular phone.
5/5: movement
possible against
gravity, but not
against resistance by the
examiner
5/5: movement
possible against
some resistance by
the examiner
5/5: normal
strength
ANATOMY AND PHYSIOLOGY
PATHOPHYSIOLOGY
The uterus is a hollow organ that sits behind the urinary bladder and in front of the rectum.
The top of the uterus above the openings of the fallopian tubes is called the fundus, and the region below the openings is called the uterine body.
The uterus tapers down into the uterine isthmus and finally the cervix, which protrudes into
the vagina.
Zooming into the cervix, there are two openings, a superior opening up top, and an inferior
opening down below, both of which have mucus plugs to keep the uterus closed off except
during menstruation and right before ovulation.
The uterus is anchored to the sacrum by utero-sacral ligaments, to the anterior body wall by round ligaments, and it’s supported laterally
by cardinal ligaments as well as the mesometrium,
which is part of the broad ligament.
The wall of the uterus has three layers: the perimetrium, which is a layer continuous with
the lining of the peritoneal cavity, the myometrium, which is made of smooth muscle that contracts
during childbirth to help push the baby out, and the endometrium, a mucosal layer, that
undergoes monthly cyclic changes.
The endometrium is itself made up of a single layer of simple columnar epithelium, which
has ciliated and secretory cells, that sit on top of connective tissue, or stroma.
There any many grooves in the stroma which is lined by the epithelium and these are the
uterine glands which secrete a glycogen rich fluid that’s essential for the developing
embryo during early pregnancy.
The menstrual cycle
1 month prior to admission, the patient started having abdominal pain with accompanying body weakness and worsening of condition
promoted consultation. History taken, patient is a 45 y/o G1P1 (0101) married vendor who was admitted due to abdominal pain. 2 months prior
to admission, the patient was noted to have an abdominal mass which gradually increased in size accompanied by abdominal pain. She also
noted to have heavy menstrual, 10 days prior to admission the patient consuming 5 diapers per day, consultation was done in an emergency
clinic in Manila and was advised to consult to a higher consultation.
Mrs. X has no history of childhood illness, even though she cannot recall if she was fully immunized. Her first menstruation started when
she was 12 years old and had a heavy bleeding for 4 to 5 days consuming 2 to 3 pads a day but didn't suffer dysmenorrhea and dyspareunia. She
suffered LBM and coughs sometimes but she took over the counter medications, like Loperamide tablets for LBM and Ascof for cough. She had
a cesarean section on her first born in 2013 because of severe vaginal bleeding and hypogastric pain, and was diagnosed at Isabela Provincial
Hospital with a case of Placenta Previa. She claimed that she has no allergies with foods and medications. She was immunized Covid vaccine
with Pfizer up to the second dose in 2022, no history of covid infection yet.
Furthermore, patients have fun eating meats and meat products like tocinos, sausages and barbecues in the streets. She added that eating in
fast food chains is their easy access to get their foods and some canned goods and thus, she believes that on these foods she get the disease. The
patient claimed that their life is full of stressful stimuli because of many transactions in their daily activities as a vendor.
FAMILY HISTORY
Mrs. X Grandfather and Grandmother have died but she didn't not know the cause of death. Her father has died because of kidney failures
and is diagnosed with chronic kidney failure but not medicated with no history of hypertension and diabetes. Her mother was still alive with
previous hospitalization due to vehicular accident with minor injuries. Her mother has no maintenance medications and no comorbidities.
NURSING CARE PLAN
COLABORATIVE:
Provide for Promotes active role
individualized and enhances senses
physical therapy or of control.
exercise program
that can be continued
by client after
discharge
DEPENDENT:
Administer IV fluids
as ordered. Maintain circulating
volume to maximize
tissue perfusion.
Blood
component therapy Blood transfusion
(Blood transfusion) increases the
as ordered. patient’s
blood volume
Objective data:
DRUG DRUG DOSAGE, MECHANISM INDICATION CONTRAINDICATION ADVERSE NURSING
CLASS ROUTE, AND OF ACTION EFFECT RESPONSIBILITIES
FREQUENCY
Generic Analgesic 50mg IV q8 Bind to opioid Moderate to Hypersensitivity, acute Nausea, vomiting, Before
Name: receptors and severe pain intoxication with any anorexia,
Tramadol inhibit reuptake CNS depressant, alcohol, constipation Assess the
of asthma, respiratory cramps, light- level of pain for
Brand norepinephrine headedness, location, type, and
depression
Name: and serotonin dizziness, character
ConZip sedation, and
respiratory Monitor input and
depression. output
During
Assess respiratory
status frequently
After
Evaluate therapeutic
response :decrease in
pain
After
Evaluate therapeutic
response: decrease in
pain
After
Evaluate therapeutic
response :decrease in
constipation
DRUG DRUG DOSAGE, MECHANISM INDICATIO CONTRAINDICAT ADVERSE NURSING
CLASS ROUTE, OF ACTION N ION EFFECT RESPONSIBILITIES
AND
FREQUEN
CY
Generic Laxative 30 cc PO at Acts Constipation Hypersensitivity to CNS: Before
Name: bed time directly on the laxative Muscle
Lactulose intestine by weakness Assess the patient for
increasing GI: Nausea, abdominal distention,
Brand motor vomiting, presence of bowel sound
Name: activity; anorexia, and usual pattern of bowel
Cephulac thought to diarrhea, rectal function.
irritate colonic burning (supp)
intramural META: During
plexus; Protein-
Mix with half a glass of
increases water losing
in the colon enteropathy, water , milk or fruit juice
alkalosis, to improve the taste
hypokalemia, After
tetany,
electrolyte and Inform patient to have
fluid adequate fluid intake
imbalances including at least 6–8
glasses/d.
Evaluate therapeutic
response :decrease in
constipation
DISCHARGE PLAN
Watch for any signs of bleeding
Encourage the patient to have an operation
Advice for diversional activities
Educate the patient home medicines
Educate the patient’s diet
Advice to have a daily exercise
Educate the patient to reduce the salt intake
Do a deep breathing technique for relaxation
Encourage to read a book
Educate the patient about self hygiene