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Hydatiform mole
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Case Study - H-mole

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  2. 2. • After the case presentation, we the nursing students will be able to acquire new knowledge, enhance learned skills and develop desirable attitudes towards the care of a patient who is diagnosed with Hydatidiform mole (H-mole) utilizing the nursing process.
  3. 3. Knowledge: • define and describe Hydatidiform mole (H- mole); • discuss the incidence and prevalence rate, etiology, risk factors, signs and symptoms, complications, diagnostic tests and treatment of the said problem;
  4. 4. • discuss the anatomy and physiology of female reproductive system related to the patient’s condition; • explain the pathophysiology of Hydatidiform mole(H-mole) in relation to patient’s condition;
  5. 5. Specifically, we will be able to:
  6. 6. • compare the laboratory results with the standard normal values, diagnostic test results and identify its clinical significance; and • enumerate the medications that have been administered and know its dosage, actions, adverse or side effects, contraindications and nursing responsibilities involved.
  7. 7. Skills: • assess the patient using the cephalo-caudal format and identify problems related to the patient’s condition. • formulate nursing diagnosis in relation to the patient’s condition using concept map. • formulate and implement nursing care plan that address patients’ identified problem.
  8. 8. • evaluate the patient’s response to medical and nursing interventions rendered. • apply effective therapeutic communication with the patient and to her significant others.
  9. 9. Attitude: • acknowledge the patient and family’s expression and feelings about her condition. • develop understanding about patients’ behavior in relation to the experienced illness and provide ways on how to cope with it; and • display positive attitude when interacting with the patient who has Hydatidiform mole.
  10. 10. is a decrease in the hemoglobin in the blood levels usually below the normal range of 12- 16g/dl for women.
  11. 11. a part of the cell that carries the genetic material of a person.
  12. 12. a procedure in which the cervix is mechanically dilated and the contents of the uterus scraped or suctioned out. It is performed after an incomplete miscarriage.
  13. 13. a hormone produced during pregnancy. Excreted in urine, hCG is used in testing to detect pregnancy. This can also be detected in serum specimen.
  14. 14. An abnormal pregnancy in which there is no fetus, only an abnormal mass growth.
  15. 15. a fluid filled vesicles that rapidly grow causing the uterus to be larger than expected to the duration of pregnancy.
  16. 16. an exaggerated form of morning sickness characterized by extreme, frequent, and severe nausea and vomiting during pregnancy, and sometimes leading to dehydration and hospitalization.
  17. 17. too much thyroid hormone production.
  18. 18. It involves removal of the uterus which ensures removal of all tumor cells.
  19. 19. it is the first day of last menstrual period, the date that is used to calculate the 40 weeks of pregnancy and a woman's due date.
  20. 20. is a black line that runs down the center of the abdomen to the top of the pubic bone. This darkening is caused by pregnancy hormones. The linea nigra may be more noticeable in dark-skinned women than those who are fair-skinned.
  21. 21. a layer of cells that surrounds an embryo finger-like projection called Villi.
  22. 22. • refers to blood often found on underwear, the toilet paper, in the toilet bowl or after sexual intercourse. The blood loss may or may not be accompanied by other symptoms such as pain.
  23. 23. neoplastic disorder that originates in the placenta
  24. 24. Hydatidiform mole (H-mole)also as known Gestational Trophoblastic Disease (GTD) is a rare mass or growth which arises from fetal tissue that may form inside the uterus at the beginning of a pregnancy. Frequently there is no fetus at all. In the complete or classic mole, there is marked edema and enlargement of the villi with disappearance of the villous blood vessels.
  25. 25.  There is proliferation of the trophoblastic lining of the villi. Hydatidiform mole (H-mole) also is a group of rare tumors that involve abnormal growth of cells inside a woman's uterus. It also does not develop from cells of the uterus like cervical cancer or endometrial (uterine lining) cancer do. Instead, these tumors start in the cells that would normally develop into the placenta during pregnancy.
  26. 26. Hydatidiform mole (H-mole) or GTD also begins in the layer of cells called the trophoblast that normally surrounds an embryo. (Tropho- means nutrition, and -blast means bud or early developmental cell.)  Early in normal development, the cells of the trophoblast form tiny, finger-like projections known as villi. The villi grow into the lining of the uterus.
  27. 27. In time, the trophoblast layer develops into the placenta, the organ that protects and nourishes the growing fetus. Most Hydatidiform mole (H-mole) also are benign (not cancer) and they don't invade deeply into body tissues or spread to other parts of the body. But some are malignant (cancerous).
  28. 28. Because not all of these tumors are cancerous, this group of tumors may be referred to as gestational trophoblastic disease, gestational trophoblastic tumors, or gestational trophoblastic neoplasia. (The word neoplasia simply means new growth.) All forms of Hydatidiform mole (H-mole) also can be treated. And in most cases the treatment produces a complete cure.
  29. 29. Types of Hydatidiform mole (H-mole)
  30. 30. All trophoblastic villi swell and become cystic. If an embryo forms, it dies early at only 1 to2 mm in size, with no fetal blood present in the villi.
  31. 31. On chromosomal analysis, although the karyotype is anormal 46XX or 46XY, this chromosome component was contributed only by a father or an “empty ovum “was fertilized and the chromosome material was duplicated.
  32. 32.  With a partial mole, some of the villi form normally. The syncytiotrophoblastic layer of thevilli, however, is swollen and misshapen. A macerated embryo of approximately 9 weeks; gestation maybe present in the villi
  33. 33.  A partial mole has 69 chromosomes (a triploid formation in which there is three chromosomes instead of two for every pair, one set supplied by an ovum that apparently was fertilized by two sperm or an ovum fertilized by one sperm in which meiosis or reduction division did not occur).
  34. 34.  This could also occur if one set of 23 chromosomes was supplied by one sperm and an ovum did not undergo reduction division supplied 46. In contrast to complete moles, partial moles rarely lead to choriocarcinoma.
  35. 35. Incidence (World Wide and in the Philippines)
  36. 36. • Although Hydatidiform mole (H-mole) is rare approximately only 1 in every 1,500 occurs inpregnancies in North America, Australia, New Zealand and Europe. • In 2011 up to 2.0 per 1,000 pregnancies in Southeast Asia & Japan. • Up to 20% of these will require treatment for malignant sequelae (2011).
  37. 37. • The incidence of Hydatidiform mole is approximately 1 in every 1200 pregnancies occur in the Philippines. (P. Sanchez, 2010). • The condition tends to occur most often in women who have a low protein intake, in women older than age 35 years, in women of Asian heritage, and in blood group A women who marry blood group O men (Aghajanian, 2007).
  38. 38. Risk Factors
  39. 39. American Indians, Eskimos, Hispanics, African Americans, & Asians extremes of maternal age: •>35 or <21 risk is 1.9 times higher •>40 risk is 7.5 times higher
  40. 40. prior molar pregnancy – 10-20 times greater than general population: familial cluster are associated with novel missense NLRP7 gene mutation on chromosome19q.
  41. 41. Signs and Symptoms
  42. 42. anemia from blood loss excessive nausea and vomiting abdominal cramps (caused by uterine distention pallor- indicating anemia may be present Amenorrhea
  43. 43. vaginal bleeding as the main complaint; due to the separation of vesicles from the uterine wall and there may be blood- stained, watery discharge (the watery part is from the ruptured vesicles) prune juice-like discharge may occur brownish because it is retained for sometime inside the uterine cavity.
  44. 44. blood may be concealed in the uterus, thereby causing enlargement. abdominal pain: may be dull-aching due to rapid distension of uterine by mole or by concealed hemorrhage; colicky due to start of expulsion. ovarian pain due to stretching of ovarian capsule or complication in the cystic ovary as torsion.
  45. 45. Diagnostic tests
  46. 46. a test that measures levels of pregnancy hormones in additional blood tests - tests, like those for anemia, may provide evidence of H-mole.
  47. 47. performed after the third month revealing grapelike clusters rather than a fetus, no fetal skeleton detected by ultrasound, and evidence of a snowflakelike pattern
  48. 48. an imaging technique that uses sound waves to produce an image on a monitor of the abdominal organs.
  49. 49. a noninvasive procedure that takes cross- sectional images of the brain or other internal organs; to detect any abnormalities that may not show up on an ordinary x-ray. The CT scan may indicate enlarged lymph nodes - a possible sign of a spreading cancer or of an infection.
  50. 50. a diagnostic procedure that uses a combination of large magnets, radiofrequencies, and a computer to produce detailed images of organs and structures within the body.
  51. 51. a type of scan that monitors the biochemical functioning of cells by detecting how they process certain compounds, such as glucose (sugar). Cancer cells metabolize glucose at a much higher level than normal tissues.
  52. 52. this is a hybrid technology combines the strengths of two well-established imaging techniques, allowing physicians to precisely overlay the metabolic data of the PET scan and the detailed anatomic data of the CT scan to pinpoint the location and stage of tumors.
  53. 53. Medical Management
  54. 54. A urinary pregnancy test should be performed 3 weeks after medical management of failed pregnancy if products of conception are not sent for histological examination.
  55. 55. Anti-D prophylaxis is required following evacuation of a molar pregnancy. Preparation of the cervix immediately prior to evacuation is safe.
  56. 56. The use of oxytocic infusion prior to completion of the evacuation is not recommended.
  57. 57. If the woman is experiencing significant haemorrhage prior to evacuation, surgical evacuation should be expedited and the need for oxytocin infusion weighed up against the risk of tumour embolisation. Blood transfusion to treat severe anemia due to vaginal bleeding.
  58. 58. Prophylactic course of Methotrexate, the drug of choice for choriocarcinoma. Pelvic examinations and chest X- rays at regular intervals. Histophatology of evacuated specimen from curettage.
  59. 59. Surgical Management
  60. 60.  is a surgical procedure used to remove non cancerous hydatidiform moles. The opening in the cervix is dilated and the inside uterus lining is scraped (curetted) clean using suction and curette (spoon-shaped instrument).
  61. 61.  D & C is commonly used to obtain tissue for microscopic evaluation to rule out cancer. D & C may also be used to diagnose and treat heavy menstrual bleeding, and to diagnose endometrial polyp’s and uterine fibroids.
  62. 62. D & C can also be used as an early abortion technique up to 16 weeks.
  63. 63. is the method of choice of evacuation for complete molar pregnancies. It is also the method of choice of evacuation for partial molar pregnancies except when the size of the fetal parts deters the use of suction curettage and then medical evacuation can be used.
  64. 64.  is procedure in which the cervix is dilated and tissue is removed from the uterus. D&E is used to describe two different procedures.
  65. 65. D&E can also be used to describe a surgical removal of a fetus and placenta between 14- 20 weeks of gestation, called also late abortion or second trimester abortion. To accomplish dilatation/dilation and evacuation, negative pressure/vacuum is used to aspirate tissue from the inside of the uterus. The procedures thought to be less traumatic to the surface of the uterine cavity than a sharp curettage.
  66. 66. • it is the removal of the uterus. This is used rarely to treat hydatidiform moles but may be chosen, particularly if the woman does not want to become pregnant again. It may be done through the abdomen or the vagina.
  67. 67. •Others are: oTumors in the uterus like uterine fibroids or endometrial cancer oCancer of the cervix or severe cervical dysplasia (a precancerous condition of the cervix)
  68. 68. oCancer of the ovary oEndometriosis, in those cases in which the pain is severe and not responsive to nonsurgical treatments
  69. 69. oSevere, long-term (chronic) vaginal bleeding that cannot be controlled by medications oProlapsed of the uterus oComplications during childbirth (like uncontrollable bleeding)
  71. 71. Sagittal Section of the Female Pelvis
  72. 72. Normal human embryonic development.
  73. 73. Predisposing Factor Resident of Asian country (Rate 15x higher than U.S.) Precipitating Factors •Defects in ova Abnormalities in uterus Nutritional deficiency Diet low in protein and folic acid Chromosomal abnormalities Hormonal imbalances Coitus (Sex)
  74. 74. Haploid Ova (Triploid formation) •69XXX chromosomes or 69XXY chromosomes Haploid Sperm (Empty ovum) Duplicated sperm 90% 46XX chromosomes 10% 46XY chromosomes Abnormal Fertilization
  75. 75. Hyperplasia Swelling of Chorionic Villi Excessive Uterine Enlargement Tumorous Growth in Placenta Rapid increase in fundic height Rapid increase in weight Vaginal Bleeding Thromboplastic Tissue Formation Formation of Moles Passage of Grape-like clusters High levels of hCG Excessive nausea and vomiting Highly positive urine test for pregnancy COMPLETE MOLE
  76. 76. Hydatidiform mole formation video
  77. 77. Name: Ms. R. P. M. Age: 23 years old Sex: Female Civil Status: Single Religion: Roman Catholic Birth Date: Jan. 27, 1992 Birth Place: Aranas Balete, Aklan Current Address: Arcangel Sur Balete, Aklan Educational Attainment: High School Graduate Occupation: none
  78. 78. Chief Complaint: Vaginal bleeding Date of Admission to ER: Feb. 18, 2015 Mode of Transportation upon Admission: Transported via L300 van Accompanied by: Husband Emotional/ Mental Status upon Admission: Alert, oriented and cooperative
  79. 79. Temperature- 36.7 Pulse Rate- 85 bpm Respiratory Rate- 21 cpm Blood Pressure- 120/70 mmHg
  80. 80. Attending Physicians: (HOUSE CASE) Admitting Physician: Dr. H.C.E.Q. Surgeon: Dr. G.M.V. Anesthesiologist: Dr. C.B.V.S.
  81. 81. Other APs: •Dr. M.A.D.V •Dr. F.I.G. •Dr. J.S.R.B. •Dr. D.A.M. •Dr. K. G. S. M. Co-management of Dept. of Internal Medicine: Dr. M.V.G.B.
  82. 82. Admission/ Principal Diagnosis: G2P1 (1000) Hyadatiform Mole 14 weeks; Severe Anemia Surgery/ Procedures performed: Suction Dilatation and Curettage / Blood Transfusion Source of Information: Primary: Patient Secondary: Patient’s chart, Attending Physician
  83. 83. On the 11th day of February 2015, around 6:00 in the morning at Archangel Sur, Balete, Aklan, Ms. R.P.M. woke up because of a wet feeling coming from her vagina, so she rose from her bed to check it in the bathroom, she then found out that it was blood approximately 1 pad.
  84. 84. She thought it was just menstruation because she thought she was just delayed for two months on her monthly menstruation that’s why she did nothing with it, just wear napkin and did her daily morning routine- take her breakfast and do exercise.
  85. 85. But around 11:00 A.M. in the morning, the bleeding progressed allowing her to consume 3 pads of soaked napkins in the morning and another 5 pads of napkins in the afternoon until in the evening. Next day, February 12, the bleeding stopped and came back on February 18 around 6:00 A.M.
  86. 86. And she started vomiting excessively about 3 to 4 times approximately 100ml of clear whitish liquid. She was then brought to the RHU in Balete by her mother around 8:00 A.M. . In the RHU, Dr. J.D. examined her and requested her to do an abdominal ultrasound.
  87. 87. She was referred by Dr. J.D. to be admitted that day in DRSTMH but she was required to have blood transfusion and they had no blood available yet that’s why they decided to went home around 10:30 A.M. of the same day. They continuously looked for blood on February 19, 2015.
  88. 88. On, February 20, 2015, there was blood available and around 3:30 P.M. Ms. R.P.M., accompanied by her mother went to Kalibo via by a L3 van for admission in DRSTMH. 4:15 P.M., Ms. R.P.M. And her mother arrived to DRSTMH.
  89. 89. She was then brought to the E.R. and was examined by Dr. H.C.E.Q. and was diagnosed 14 weeks Molar Pregnancy. During Admission the patient is experiencing persistent cough. Fluimucil 600mg 1 tab in one half glass and salbutamol 1neb every 6hours had been prescribed by the Dr. J.S.R.B.
  90. 90. According to Ms. R.P.M., during her childhood, she had received complete doses of the required vaccines. She verbalized that she never acquired chronic illness. As far as Ms. R.P.M. could remember, only had history of common colds, cough and flu. she also said that she was once admitted in the DRSTMH on September 08, 2014 because of fetal death in utero during the 36th week of her pregnancy.
  91. 91. Obstetrical History
  92. 92. According to Ms. R.P.M., her last menstrual period was on November 11, 2014. She had been pregnant twice. During her first pregnancy, she was able to conceive the fetus until 36th week but wasn’t able to deliver it because her fetus died while it is still in her uterus. Her second pregnancy, was 14 weeks molar pregnancy.
  93. 93. According to Ms. R.P.M., her first menstruation was when she was 15 years old. According to her, her menstruation is regular that lasts for 3 days and usually consumed 2-3 pads of napkins per day.
  94. 94. She also verbalized, during her menstruation, she never suffered dysmenorrhea but suffered headache and dizziness and when she had, she said she would just take a rest and take over -the-counter medicine for her headache. According to her, she never consumed alcohol and drugs during her pregnancies. Her family also doesn’t have any history of genetic or chromosomal abnormalities.
  96. 96. Father: 47 y/o (+) H.P.N Alive Mother: 45 y/o (+) H.P.N Alive R.M (Female) 25y/o (+) H.P.N Alive R.M (Female) 20y/o Alive and well R.M (Female) 18y/o (+) Anemia R.M (Female) 23y/o (patient) diagnose d with H-Mole
  98. 98. Biopsychosocial Pattern
  99. 99. She usually consumes 1 cup of rice and vegetables and fish every meal. They usually have meat once a week whenever his husband has extra money from his salary.
  100. 100. She usually sleeps before 7 in the evening and wakes up at 5 in the morning. She rarely complains of sleeping problems.
  101. 101. She defecates 1 to 2 times a day to a brownish, well formed stool and voids 3-4 times a day to a yellowish colored urine. She has no any complaints in defecation and urination.
  102. 102. Mrs. R.P.M. claims that before she seeks medical attention, she goes to “albularyo” to lessen their financial burden. She doesn’t believe in herbal drugs. Whenever she experienced minor illnesses such as cough, colds or fever, she drinks plenty of fluids and takes OTC drugs such as Paracetamol or Neozep.
  103. 103. Mrs. R.P.M. has routines of daily living. According to her, she exercises every morning such as walking for 15-30 minutes. She is also the one doing household chores. Watching TV is one of her relaxation at home.
  104. 104. In terms of decision making, it is mainly her husband who does it and sometimes whenever they are unable to decide or unable to solve the problem for themselves they ask for their parent’s advice.
  105. 105. She is a Roman Catholic. She often goes to church every Sunday.
  106. 106. She has a good relationship with her husband, parents, siblings, relatives and friends.
  108. 108. • Receive patient lying on bed. on supine position wearing pink t-shirt and blue short. She is approximately 5’1 in height. She has proportionate body built with symmetrical facial contour. The client has an IVF of PLR 1L + 10 “U” oxytocin at the level of approximately 900 ml. Patent and infusing well at left cephalic vein. She is conscious, awake, alert and coherent. • Vital signs upon assessment: T: 37.2°C/ax. PR: 89bpm RR: 19 bpm BP: 110/70mmhg
  110. 110. Skin • Skin is dry, warm to touch and brown in color. • Skin turgor is at 4 seconds and the client temperature is uniform. • Moles noted on the left shoulder (0.1 inches in diameter) • Presence of striae on her lower abdomen.
  111. 111. Hair • Hair is evenly distributed and no scalp dryness and scaling observed. • No brittleness observed. • Hair is long, thick in distribution and black in color. • Uses shampoo daily. Nails • Color and shape of the nail is pink and no clubbing. • It is dirty and untrimmed. Hard, 160° and firmly attached to nail bed. • Capillary refill of less than 2 seconds and trims her nails twice a week.
  112. 112. Head • Head is rounded and symmetrical, hard skull contour. • No nodule and masses observed. Eyes • Her eyes are symmetrical, black in color, almond shape. • Pupils are equal in size specifically 5mm in diameter; constricts when diverted to light and dilates when she gazes afar, conjunctivas are pink. • Eyelashes are equally distributed and skin around the eyes is intact. • Eyes involuntarily blink.
  113. 113. Ears • Ears are equally aligned in proportion to eyes. • Auricles are smooth, light brown in color and have no lesions. • No cerumen noted upon inspection. Nose and sinuses • Nose in midline no discharge or flaring and uniform in color. • Air moves freely as the client breaths through nares. • No tenderness in sinuses upon inspection.
  114. 114. Mouth and Pharynx • Dry mucous membrane. • Lips are moist and pink in color. • No dentures noted. • Pink gums and no lesions or bleeding noted. Neck • Neck is short, proportional to neck and shoulder. • Lymph nodes are non-palpable. No lumps and swelling noted. • Trachea is in the midline. • Neck has strength that allows movement back and forth, left and right. • Patient is able to freely move her neck.
  115. 115. Breast and Axillae • It is symmetrical, brown in color. • Nipple and areola is circular in shape, symmetry and no discharges on nipple and areola. • No nodes palpated on axilla and clavicle. No scars noted.
  116. 116. • No reports of pain during the inhalation and exhalation. • Respiratory rate is 18 breaths/min; rhythm is normal and eupnea upon assessment. • Skin is intact (-) accessory muscle use, (-) nasal flaring and barrel chest. • Breathing pattern is quiet, rhythmic and effortless respiration.
  117. 117. • She has history of allergy in dust. • Bilateral crackles upon auscultation. • With Productive cough of whitish in color.
  118. 118. • There is no distention of jugular vein during inspection. • Neck vessels rhythm is regular it is symmetry and no thrills as palpated. • Upon percussion and auscultation no abnormalities found. • No history of heart problems. • Blood Pressure of 110/70mmhg ; Pulse Rate of 89 beats per minute.
  119. 119. • Abdomen is rounded. There is presence of stretch marks on lower abdomen. • Abdominal movement present during respiration respiration. • No rashes, no mark pulsation, no visible peristalsis and no discoloration noted.
  120. 120. • Patient refused for physical examination of the genitals. • But she verbalized that there was minimal bleeding of color bright red approximately 1 pad per day. • Urine output: Approximately voids 4x day to 250cc of yellowish urine.
  121. 121. • Symmetrical muscles on both sides of the body. • There are no contractures or shortening of the muscle and tendons. • Muscle strength is equal on each sides of the body graded as 5/5. • There are no deformities on the bones. • Both extremities, joint moves smoothly and effortless.
  122. 122. • There is no problem mentioned in the impressions. • Patient is oriented to time and place. • She is responsive to the questions we asked. • She’s able to sense touch and temperature on various areas of the body. • The client can identify familiar object by touch able to determine draw numbers in palm of hand. • She was able to recall immediate recent and remote memory.
  123. 123. • Test for Cranial Nerves: CN I- Olfactory Nerve. • No anosmia. Patient smelled and identified the substance. CN II- Optic Nerve. • Patient is sensitive to light. CN III, IV, VI- Oculomotor, Trochlear, Abducens. • Intact and able to move eye in six cardinal field. Pupils equally round, reactive to light and accommodation. CN V- Trigeminal Nerve. • Intact, No difficulty mastication noted. Able to sense object put on.
  124. 124. CV VI- Facial Nerve. • Patient is able to do different facial expressions. • Able to sense different textures on the face. CN VII- Acoustic Nerve • Patient is able to hear the tiktok sound from a wristwatch approximately 1 inch away from the ear. CN IX, X- Glossopharyngeal and Vagus Nerves. • Patient is able to swallow and able to say “AH”. Positive gag reflex using tongue depressor.
  125. 125. CN XII- Hypoglossal Nerve. • Patient sticks out tongue and moves it from side to side. CN XI- Spinoaccessory Nerve. • Patient shrugs or turns head against resistance.
  126. 126. Check Glasgow Coma Scale (GSC): I. Motor Response (6) - Obeys commands fully. II. Verbal Response (5) - Alert and Oriented. III. Eye Opening (4) - Spontaneous eye opening Score: GCS =15
  127. 127. REPORT: The uterus is anteverted with globular contour and homogenous echopattern measuring 18.2 x 13.7 x 10.3 cm. (cervix measures 2.9 x 2.6 2.8 cm). The endometrial cavity is filled with a complex heterogeneous mass measuring 12.6 x 10.9 X 8.1 cm with numerous anechoic cystic spaces of varying size and shapes (volume 582.0 cc). The subendometrial halo is intact. The thinnest portion of the myometrium measures 0.3 cm at the antero-fundal area. The right ovary is converted to a septated anechoic mass measuring 4.3 x 3.7 x 3.9 cm. The left ovary is also converted to a similar mass measuring 5.1 x 3.0 x 3.7 cm. There is no free fluid n the cul de sac.
  128. 128. • Endometrial mass consider Gestational Trophoblastic Disease probably Hydatidiform Mole. • Theca lutein cysts, bilateral
  130. 130. Rationale: To determine significant deviation of blood components from normal values.
  131. 131. Date Normal Values Results Significance February 20,2015 1:36 PM February 22, 2015 6:40 AM Hemoglobin 120-160 g/L Hematocrit 0.36-0.41v vol Fr RBC count 4.20-5.40x1012/L WBC count 4.50-11.00 g/L Platelet Count 150-460 g/L Neutrophil 0.36-0.66 g/L Hemoglobin 120-160 g/L Hematocrit 0.36-0.41v vol Fr 78 0.22 2.71 4.9 400 0.58 111 0.31 Decrease. This signifies anemia related to inadequate iron intake. Due to blood loss from vaginal bleeding. Decrease. This signifies leucopenia or infection. Normal Normal Decrease. This signifies to anemia inadequate iron intake and blood loss.
  132. 132. Date Normal Values Results Significance February 22, 2015/ 10:54 PM February 25, 2015/ 6:06 AM RBC count 4.20-5.40x1012/L WBC count 4.50-11.00 g/L Neutrophil 0.36-0.66 g/L Hemoglobin 120-160 g/L Hematocrit 0.36-0.41v vol Fr Hemoglobin 120-160 g/L Hematocrit 0.36-0.41v vol Fr RBC count 4.20-5.40x1012/L WBC count 4.50-11.00 g/L Neutrophil 0.36-0.66 g/L 3.69 8.5 0.72 111 0.30 95 0.26 3.10 6.6 0.33 Decrease. This signifies anemia. Normal Increased. This signifies infection Increase from previous reading due to BT. This signifies anemia related to blood loss. Decreased. This Signifies Anemia related to blood loss Normal Increase. This signifies infection. Normal
  133. 133. Rationale: To determine significant deviation of urine components from normal values. Date: February 23, 2015/3:50 PM
  134. 134. Test Results Normal Values Significance Color Dark yellow Straw, Amber Normal Transparency Slightly hazy Clear/ Slightly hazy Normal Specific Gravity 1.025 0.010-1.025 Normal Protein Negative Negative Normal Sugar Negative Negative Normal
  135. 135. Red Blood Cell 0-1 hPF 0-2 hPF Normal Pus Cells 0-3 hPF 0-3 hPF Normal Mucous Threads Moderate Few Inflammation/ infection Epithelial Cells Moderate Few Inflammation/ infection Urates Few Few Normal
  137. 137. Subjective/Objective Cues: (Hypothetical: Depending on the presenting s/sx of patient) Nursing Diagnosis: Deficient Knowledge
  138. 138. Nursing Diagnosis: Deficient Knowledge May be related to: • Lack of exposure/recall, information misinterpretation • Unfamiliarity with information resources Possibly evidenced by: • Statement of the problem/concerns, misconceptions • Request for information • Inappropriate, exaggerated behaviors (e.g., agitated, apathetic, hostile) • Inaccurate follow-through of instructions/development of preventable complications
  139. 139. Objectives General: • Verbalize understanding of disease process/perioperative process and postoperative expectations. • Correctly perform necessary procedures and explain reasons for the actions. • Initiate necessary lifestyle changes and participate in treatment regimen.
  140. 140. Nursing Interventions: Independent • Assess patient’s level of understanding. Rationale: Facilitates planning of preoperative teaching program, identifies content needs. • Review specific pathology and anticipated surgical procedure. Verify that appropriate consent has been signed. Rationale: Provides knowledge base from which patient can make informed therapy choices and consent for procedure, and presents opportunity to clarify misconceptions. • Use resource teaching materials, audiovisuals as available. Rationale: Specifically designed materials can facilitate the patient’s learning.
  141. 141. • Preoperative or postoperative procedures and expectations, urinary and bowel changes, dietary considerations, activity levels/ transfers, respiratory/ cardiovascular exercises; anticipated IV lines and tubes NGT, drains, and catheters). Rationale:Enhances patient’s understanding or control and can relieve stress related to the unknown or unexpected. • Preoperative instructions: NPO time, shower or skin preparation, which routine medications to take and hold, prophylactic antibiotics, or anticoagulants, anesthesia premedication. Rationale:Helps reduce the possibility of postoperative complications and promotes a rapid return to normal body function.
  142. 142. • Intraoperative patient safety: not crossing legs during procedures performed under local or light anesthesia. Rationale: Reduced risk of complications or untoward outcomes, such as injury to the peroneal and tibial nerves with postoperative pain in the calves and feet. • Expected or transient reactions (low backache, localized numbness and reddening or skin indentations). Rationale: Minor effects of immobilization and positioning should resolve in 24 hr. If they persist, medical evaluation is required.
  143. 143. • Discuss individual postoperative pain management plan. Identify misconceptions patient may have and provide appropriate information. Rationale: Increases likelihood of successful pain management. • Provide opportunity to practice coughing, deep- breathing, and muscular exercises. Rationale:Enhances learning and continuation of activity postoperatively
  144. 144. Subjective/Objective Cues: (Hypothetical: Depending on the presenting s/sx of patient) Nursing Diagnosis: Anxiety
  145. 145. Nursing Diagnosis: Anxiety • May be related to: • Situational crisis; unfamiliarity with environment • Change in health status; threat of death • Separation from usual support systems
  146. 146. Nursing Diagnosis: Anxiety Possibly evidenced by: • Increased tension, apprehension, decreased self-assurance • Expressed concern regarding changes, fear of consequences • Facial tension, restlessness, focus on self • Sympathetic stimulation
  147. 147. Objectives General: • Acknowledge feelings and identify healthy ways to deal with them. • Appear relaxed, able to rest/sleep appropriately. • Report decreased fear and anxiety reduced to a manageable level.
  148. 148. Nursing Interventions: Independent • Provide preoperative education, including visit with OR personnel before surgery when possible. Discuss anticipated things that may concern patient: masks, lights, IVs, BP cuff, electrodes, bovie pad, feel of oxygen cannula or mask on nose or face, autoclave and suction noises, child crying. Rationale: Can provide reassurance and alleviate patient’s anxiety, as well as provide information for formulating intraoperative care. • Inform patient of nurse’s intraoperative advocate role. Rationale: Develops trust and rapport, decreasing fear of loss of control in a foreign environment.
  149. 149. • Identify fear levels that may necessitate postponement of surgical procedure. Rationale: Overwhelming or persistent fears result in excessive stress reaction, potentiating risk of adverse reaction to procedure and/or anesthetic agents. • Validate source of fear. Provide accurate factual information. Rationale: Identification of specific fear helps patient deal realistically with it. • Note expressions of distress and feelings of helplessness, preoccupation with anticipated change or loss, choked feelings. Rationale: Patient may already be grieving for the loss represented by the anticipated surgical procedure, diagnosis or prognosis of illness.
  150. 150. • Tell patient anticipating local or spinal anesthesia that drowsiness and sleep occurs, that more sedation may be requested and will be given if needed, and that surgical drapes will block view of the operative field. Rationale: Reduces concerns that patient may “see” the procedure. • Introduce staff at time of transfer to operating suite. Rationale: Establishes rapport and psychological comfort. • Compare surgery schedule, patient identification band, chart, and signed operative consent for surgical procedure. Rationale: Provides for positive identification, reducing fear that wrong procedure may be done.
  151. 151. • Prevent unnecessary body exposure during transfer and in OR suite. Rationale: Patients are concerned about loss of dignity and inability to exercise control. • Give simple, concise directions and explanations to sedated patient. Review environmental concerns as needed. Rationale: Impairment of thought processes makes it difficult for patient to understand lengthy instructions. • Control external stimuli. Rationale: Extraneous noises and commotion may accelerate anxiety
  152. 152. • Refer to pastoral spiritual care, psychiatric nurse, clinical specialist, psychiatric counseling if indicated. Rationale: May be desired or required for patient to deal with fear, especially concerning life-threatening conditions, serious and/or high-risk procedures. • Discuss postponement or cancellation of surgery with physician, anesthesiologist, patient, and family as appropriate. Rationale: May be necessary if overwhelming fears are not reduced or resolved.
  153. 153. Collaborative: • Administer sedatives, hypnotics as prescribed. Rationale: Used to promote sleep the evening before surgery; may enhance coping abilities. • Administer anti-anxiety agents as prescribed. Rationale: May be provided in the outpatient admitting or preoperative holding area to reduce nervousness and provide comfort.
  154. 154. Subjective/Objective Cues: (Hypothetical: Depending on the presenting s/sx of patient) Nursing Diagnosis: Perioperative Positioning, risk for injury
  155. 155. Nursing Diagnosis: Perioperative Positioning, risk for injury Risk factors may include • Disorientation; sensory/perceptual disturbances due to anesthesia • Immobilization; musculoskeletal impairments • Obesity/emaciation; edema
  156. 156. Nursing Diagnosis: Perioperative Positioning, risk for injury Possibly evidenced by • Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.
  157. 157. Objectives General: • Be free of injury related to perioperative disorientation. • Be free of untoward skin/tissue injury or changes lasting beyond 24–48 hr following procedure. • Report resolution of localized numbness, tingling, or changes in sensation related to positioning within 24–48 hr as appropriate.
  158. 158. Nursing Interventions: Independent • Note anticipated length of procedure and customary position. Be aware of potential complications. Rationale: Supine position may cause low back pain and skin pressure at heels, elbows, or sacrum; lateral chest position can cause shoulder and neck pain, plus eye and ear injury on the patient’s downside. • Review patient’s history, noting age, weight, height, nutritional status, physical limitation and preexisting conditions that may affect choice of position and skin or tissue integrity during surgery. Rationale: Elderly persons, lack of subcutaneous padding, arthritis, diabetes, obesity, abdominal stoma, hydration status and temperature are some factors.
  159. 159. • Stabilize both patient cart and OR table when transferring patient to and from OR table, using an adequate number of personnel for transfer and support of extremities. Rationale: Unstabilized cart or table can separate, causing patient to fall. • Anticipate movement of extraneous lines and tubes during the transfer and secure or guide them into position. Rationale: Prevents undue tension and dislocation of IV lines, NG tubes, catheters, and chest tubes; maintains gravity drainage when appropriate.
  160. 160. • Secure patient on OR table with safety belt as appropriate, explaining necessity for restraint. Rationale: OR tables and arm boards are narrow, placing patient at risk for injury, especially during fasciculation. • Protect body from contact with metal parts of the operating table. Rationale: Reduces risk of electrical injury. • Prepare equipment and padding for required position, according to operative procedure and patient’s specific needs. Pay special attention to pressure points of bony prominences (arms, ankles) and neurovascular pressure points (breasts, knees). Rationale: Depending on individual patient’s size, weight, and preexisting conditions, extra padding materials may be required to protect bony prominences, prevent circulatory compromise and nerve pressure, or allow for optimum chest expansion for ventilation.
  161. 161. • Position extremities so they may be periodically checked for safety, circulation, nerve pressure, and alignment. Monitor peripheral pulses, skin color and temperature. Rationale: Prevents accidental trauma, hands, fingers, and toes could inadvertently be scraped, pinched, or amputated by moving table attachments; positional pressure of brachial plexus, peroneal, and ulnar nerves can cause serious problems with extremities; prolonged plantar flexion may result in foot drop. • Place legs in stirrups simultaneously (when lithotomy position used), adjusting stirrup height to patient’s legs, maintaining symmetrical position. Pad popliteal space and heels and/or feet as indicated. Rationale: Prevents muscle strain; reduces risk of hip dislocation in elderly patients. Padding helps prevent peroneal and tibial nerve damage.
  162. 162. • Provide footboard and/or elevate drapes off toes. Avoid and monitor placement of equipment, instrumentation on trunk and extremities during procedure. Rationale: Continuous pressure may cause neural, circulatory, and skin integrity disruption. • Reposition slowly at transfer from table and in bed. Rationale: Myocardial depressant effect of various agents increases risk of hypotension and/or bradycardia.
  163. 163. • Determine specific postoperative positioning guidelines, elevation of head of bed following spinal anesthesia, turn to unoperated side following pneumonectomy. Rationale: Reduces risk of postoperative complications. • Recommend position changes to anesthesiologist and/or surgeon as appropriate. Rationale: Close attention to proper positioning can prevent muscle strain, nerve damage, circulatory compromise, and undue pressure on skin and/or bony prominences.
  164. 164. Subjective/Objective Cues: (Hypothetical: Depending on the presenting s/sx of patient) Nursing diagnosis: Risk for Infection
  165. 165. Nursing diagnosis: Risk for Infection Risk factors may include: • Broken skin, traumatized tissues, stasis of body fluids • Presence of pathogens/contaminants, environmental exposure, invasive procedures
  166. 166. Nursing diagnosis: Risk for Infection Possibly evidenced by: • Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.
  167. 167. Objectives General: • Identify individual risk factors and interventions to reduce potential for infection. • Maintain safe aseptic environment.
  168. 168. Nursing Interventions Independent: • Adhere to facility infection control, sterilization, and aseptic policies and procedures. Rationale: Established mechanisms designed to prevent infection. • Verify sterility of all manufacturers’ items. Rationale: Prepackaged items may appear to be sterile; however, each item must be scrutinized for manufacturer’s statement of sterility, breaks in packaging, environmental effect on package, and delivery techniques.
  169. 169. • Review laboratory studies for possibility of systemic infections. Rationale: Increased WBC count may indicate ongoing infection, which the operative procedure will alleviate; or presence of systemic or organ infection, which may contraindicate or impact surgical procedure and/or anesthesia. • Verify that preoperative skin, vaginal, and bowel cleansing procedures have been done as needed depending on specific surgical procedure. Rationale: Cleansing reduces bacterial counts on the skin, vaginal mucosa, and alimentary tract. • Prepare operative site according to specific procedures. Rationale: Minimizes bacterial counts at operative site.
  170. 170. Examine skin for breaks or irritation, signs of infection. • Rationale: Disruptions of skin integrity at or near the operative site are sources of contamination to the wound. Maintain dependent gravity drainage of indwelling catheters, tubes, and/or positive pressure of parenteral or irrigation lines. • Rationale: Prevents stasis and reflux of body fluids. Identify breaks in aseptic technique and resolve immediately on occurrence. • Rationale: Contamination by environmental or personnel contact renders the sterile field unsterile, thereby increasing the risk of infection.
  171. 171. • Contain contaminated fluids and materials in specific site in operating room suite, and dispose of according to hospital protocol. Rationale: Containment of blood and body fluids, tissue, and materials in contact with an infected wound. Patient will prevent spread of infection to environment and/or other patients or personnel. • Apply sterile dressing. Rationale: Prevents environmental contamination of fresh wound. • Provide copious wound irrigation, e.g., saline, water, antibiotic, or antiseptic. Rationale: May be used intraoperatively to reduce bacterial counts at the site and cleanse the wound of debris, e.g., bone, ischemic tissue, bowel contaminants, toxins.
  172. 172. • Obtain specimens for cultures or Gram stain. Rationale: Immediate identification of type of infective organism by Gram stain allows prompt treatment, while more specific identification by cultures can be obtained in hours or days. Dependent • Administer antibiotics as indicated. Rationale: May be given prophylactically for suspected infection or contamination.
  173. 173. Subjective/Objective Cues: (Hypothetical: Depending on the presenting s/sx of patient) Nursing Diagnosis: Risk for Altered Body Temperature
  174. 174. Nursing Diagnosis: Risk for Altered Body Temperature Risk factors may include: • Exposure to cool environment • Use of medications, anesthetic agents • Extremes of age, weight; dehydration
  175. 175. Nursing Diagnosis: Risk for Altered Body Temperature Possibly evidenced by • Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention. Desired Outcomes • Maintain body temperature within normal range.
  176. 176. Nursing Interventions: Independent • Note preoperative temperature. Rationale: Used as baseline for monitoring intraoperative temperature. Preoperative temperature elevations are indicative of disease process: appendicitis, abscess, or systemic disease requiring treatment preoperatively, perioperatively, and possibly postoperatively. • Assess environmental temperature and modify as needed: providing warming and cooling blankets, increasing room temperature. Rationale: May assist in maintaining or stabilizing patient’s temperature.
  177. 177. • Cover skin areas outside of operative field. Rationale: Heat losses will occur as skin (legs, arms, head) is exposed to cool environment. • Provide cooling measures for patient with preoperative temperature elevations. Rationale: Cool irrigations and exposure of skin surfaces to air may be required to decrease temperature. • Note rapid temperature elevation or persistent high fever and treat promptly per protocol. Rationale: Malignant hyperthermia must be recognized and treated promptly to avoid serious complications and/or death.
  178. 178. • Increase ambient room temperature (e.g., to 78°F or 80°F) at conclusion of procedure. Rationale: Helps limit patient heat loss when drapes are removed and patient is prepared for transfer. • Apply warming blankets at emergence from anesthesia. Rationale: Inhalation anesthetics depress the hypothalamus, resulting in poor body temperature regulation. • Monitor temperature throughout intraoperative phase. Rationale: Continuous warm or cool humidified inhalation anesthetics are used to maintain humidity and temperature balance within the tracheobronchial tree. Temperature elevation and fever may indicate adverse response to anesthesia. Note: Use of atropine or scopolamine may further increase temperature.
  179. 179. Dependent: • Provide iced saline as indicated. Rationale: Lavage of body cavity with iced saline may help reduce hyperthermic responses. • Obtain dantrolene (Dantrium) for IV administration. Rationale: Immediate action to control temperature is necessary to prevent death from malignant hyperthermia.
  180. 180. Subjective/Objective cues: (Hypothetical: Depending on the presenting s/sx of patient) Nursing Diagnosis: Ineffective Breathing Pattern
  181. 181. Nursing Diagnosis: Ineffective Breathing Pattern May be related to: • Decreased lung expansion, energy • Tracheobronchial obstruction
  182. 182. Nursing Diagnosis: Ineffective Breathing Pattern Possibly evidenced by: • Changes in respiratory rate and depth • Reduced vital capacity, apnea, cyanosis, noisy respirations Desired Outcomes: • Establish a normal/effective respiratory pattern free of cyanosis or other signs of hypoxia.
  183. 183. Nursing Interventions: • Maintain patient airway by head tilt, jaw hyperextension, oral pharyngeal airway. Rationale: Prevents airway obstruction. • Auscultate breath sounds. Listen for gurgling, wheezing, crowing, and/or silence after extubation. Rationale: Lack of breath sounds is indicative of obstruction by mucus or tongue and may be corrected by positioning and/or suctioning. Diminished breath sounds suggest atelectasis. Wheezing indicates bronchospasm, whereas crowing or silence reflects partial- to-total laryngospasm.
  184. 184. • Observe respiratory rate and depth, chest expansion, use of accessory muscles, retraction or flaring of nostrils, skin color; note airflow. Rationale: Ascertains effectiveness of respirations immediately so corrective measures can be initiated. • Monitor vital signs continuously. Rationale: Increased respirations, tachycardia, and/or bradycardia suggests hypoxia. • Position patient appropriately, depending on respiratory effort and type of surgery. Rationale: Head elevation and left lateral Sims’ position prevents aspiration of secretions or vomitus; enhances ventilation to lower lobes and relieves pressure on diaphragm
  185. 185. • Initiate “stir-up” (turn, cough, deep breathe) regimen as soon as patient is reactive and continue in the postoperative period. Rationale: Active deep ventilation inflates alveoli, breaks up secretions, increases O2 transfer, and removes anesthetic gases; coughing enhances removal of secretions from the pulmonary system. • Elevate head of bed as appropriate. Get out of bed as soon as possible. Rationale: Promotes maximal expansion of lungs, decreasing risk of pulmonary complications.
  186. 186. Dependent: • Suction as necessary. Rationale: Airway obstruction can occur because of blood or mucus in throat or trachea. • Administer supplemental O2 as indicated. Rationale: Maximizes oxygen for uptake to bind with Hb in place of anesthetic gases to enhance removal of inhalation agents. • Provide and maintain ventilator assistance Rationale: Depending on cause of respiratory depression or type of surgery (pulmonary, extensive abdominal, cardiac), endotracheal tube (ET) may be left in place and mechanical ventilation maintained for a time. • Assist with use of respiratory aids: incentive spirometer. Rationale: Maximal respiratory efforts reduce potential for atelectasis and infection.
  187. 187. Subjective/Objective cues: (Hypothetical: Depending on the presenting s/sx of patient) Nursing Diagnosis: Acute Pain
  188. 188. Nursing Diagnosis: Acute Pain May be related to: • Disruption of skin, tissue, and muscle integrity; musculoskeletal/bone trauma • Presence of tubes and drains.
  189. 189. Nursing Diagnosis: Acute Pain May be related to: • Disruption of skin, tissue, and muscle integrity; musculoskeletal/bone trauma • Presence of tubes and drains. Possibly evidenced by • Reports of pain • Alteration in muscle tone; facial mask of pain • Distraction/guarding/protective behaviors • Self-focusing; narrowed focus • Autonomic responses. Desired Outcomes • Report pain relieved/controlled. • Appear relaxed, able to rest/sleep and participate in activities appropriately.
  190. 190. Nursing Interventions: Independent: • Note patient’s age, weight, coexisting medical or psychological conditions, idiosyncratic sensitivity to analgesics, and intraoperative course. • Rationale: Approach to postoperative pain management is based on multiple variable factors. • Evaluate pain regularly (every 2 hrs noting characteristics, location, and intensity (0–10 scale). Emphasize patient’s responsibility for reporting pain/ relief of pain completely. Rationale: Provides information about need for or effectiveness of interventions.
  191. 191. • Note presence of anxiety or fear, and relate with nature of and preparation for procedure. Rationale: Concern about the unknown (e.g., outcome of a biopsy) and/or inadequate preparation (e.g., emergency appendectomy) can heighten patient’s perception of pain. • Assess vital signs, noting tachycardia, hypertension, and increased respiration, even if patient denies pain. Rationale: Changes in these vital signs often indicate acute pain and discomfort.
  192. 192. • Assess causes of possible discomfort other than operative procedure. Rationale: Discomfort can be caused or aggravated by presence of non-patent indwelling catheters, NG tube, parenteral lines (bladder pain, gastric fluid and gas accumulation, and infiltration of IV fluids or medications). • Reposition as indicated: semi-Fowler’s; lateral Sims’. Rationale: May relieve pain and enhance circulation. Semi- Fowler’s position relieves abdominal muscle tension and arthritic back muscle tension, whereas lateral Sims’ will relieve dorsal pressures.
  193. 193. • Provide additional comfort measures: backrub, heat or cold applications. Rationale: Improves circulation, reduces muscle tension and anxiety associated with pain. Enhances sense of well-being. • Improves circulation, reduces muscle tension and anxiety associated with pain. Enhances sense of well-being. Rationale: Relieves muscle and emotional tension; enhances sense of control and may improve coping abilities.
  194. 194. • Document effectiveness and side and/or adverse effects of analgesia. Rationale: Respirations may decrease on administration of narcotic, and synergistic effects with anesthetic agents may occur.
  195. 195. Dependent • Give analgesic as indicated. Rationale: Analgesics given IV reach the pain centers immediately, providing more effective relief with small doses of medication. • Local anesthetics: epidural block or infusion Rationale: Anesthetics may be injected into the operative site, or nerves to the site may be kept blocked in the immediate postoperative phase to prevent severe pain.
  196. 196. Subjective/Objective cues: (Hypothetical: Depending on the presenting s/sx of patient) Nursing Diagnosis: Impaired Skin/Tissue Integrity
  197. 197. Nursing Diagnosis: Impaired Skin/Tissue Integrity May be related to • Mechanical interruption of skin/tissues • Altered circulation, effects of medication; accumulation of drainage; altered metabolic state
  198. 198. Nursing Diagnosis: Impaired Skin/Tissue Integrity Possibly evidenced by • Disruption of skin surface/layers and tissues Desired Outcomes • Achieve timely wound healing. • Demonstrate behaviors/techniques to promote healing and to prevent complications.
  199. 199. Nursing Interventions Independent : • Reinforce initial dressing and change as indicated. Use strict aseptic techniques. Rationale: Protects wound from mechanical injury and contamination. Prevents accumulation of fluids that may cause excoriation. • Gently remove tape (in direction of hair growth) and dressings when changing. Rationale: Reduces risk of skin trauma and disruption of wound.
  200. 200. • Apply skin sealants or barriers before tape if needed. Use hypoallergenic tape or Montgomery straps or elastic netting for dressings requiring frequent changing. Rationale: Reduces potential for skin trauma and/or abrasions and provides additional protection for delicate skin or tissues • Check tension of dressings. Apply tape at center of incision to outer margin of dressing. Avoid wrapping tape around extremity. Rationale: Can impair or occlude circulation to wound and to distal portion of extremity.
  201. 201. • Inspect wound regularly, noting characteristics and integrity Rationale: Early recognition of delayed healing or developing complications may prevent a more serious situation. Wounds may heal more slowly in patients with comorbidity, or the elderly in whom reduced cardiac output decreases capillary blood flow. • Assess amounts and characteristics of drainage. Rationale: Decreasing drainage suggests evolution of healing process, whereas continued drainage or presence of bloody or odoriferous exudate suggests complications • Maintain patency of drainage tubes; apply collection bag over drains and incisions in presence of copious or caustic drainage. Rationale: Facilitates approximation of wound edges; reduces risk of infection and chemical injury to skin and tissues.
  202. 202. • Elevate operative area as appropriate. Rationale: Promotes venous return and limits edema formation. Note: Elevation in presence of venous insufficiency may be detrimental. • Caution patient not to touch wound. Rationale: Prevents contamination of wound. • Cleanse skin surface (if needed) with diluted hydrogen peroxide solution, or running water and mild soap after incision is sealed. Rationale: Reduces skin contaminants; aids in removal of drainage or exudate.
  203. 203. • Apply ice if appropriate. Rationale: Reduces edema formation that may cause undue pressure on incision during initial postoperative period. • Irrigate wound; assist with debridement as needed. Rationale: Removes infectious exudate or necrotic tissue to promote healing • Monitor or maintain dressings: hydrogel, vacuum dressing. Rationale: May be used to hasten healing in large, draining wound/ fistula, to increase patient comfort, and to reduce frequency of dressing changes. Also allows drainage to be measured more accurately and analyzed for pH and electrolyte content as appropriate.
  204. 204. Dependent: • Use abdominal binder if indicated. Rationale: Provides additional support for high-risk incisions (obese patient).
  205. 205. Nursing Diagnosis: Deficient Knowledge May be related to • Lack of exposure/lack of recall, information misinterpretation • Unfamiliarity with information resources • Cognitive limitation
  206. 206. Nursing Diagnosis: Deficient Knowledge Possibly evidenced by: • Questions/request for information; statement of misconception • Inaccurate follow-through of instructions/development of preventable complications
  207. 207. Desired Outcomes • Demonstrate adequate perfusion evidenced by stable vital signs, peripheral pulses present and strong; skin warm/dry; usual mentation and individually appropriate urinary output.
  208. 208. Nursing Interventions • Review specific surgery performed and procedure done and future expectations. • Rationale: Provides knowledge base from which patient can make informed choices. • Review and have patient or SO demonstrate dressing or wound when indicated. • Identify source for supplies. • Rationale: Promotes competent self-care and enhances independence.
  209. 209. • Review avoidance of environmental risk factors: exposure to crowds or persons with infections. Rationale: Reduces potential for acquired infections • Discuss drug therapy, including use of prescribed and OTC analgesics. Rationale: Enhances cooperation with regimen; reduces risk of adverse reactions and/or untoward effects. • Identify specific activity limitations. Rationale: Prevents undue strain on operative site
  210. 210. • Recommend planned or progressive exercise. Rationale: Promotes return of normal function and • Schedule adequate rest periods. Rationale: Prevents fatigue and conserves energy for healing, enhances feelings of general well-being. • Review importance of nutritious diet and adequate fluid intake. Rationale: Provides elements necessary for tissue regeneration or healing and support of tissue perfusion and organ function.
  211. 211. • Encourage cessation of smoking. Rationale: Smoking increases risk of pulmonary infections, causes vasoconstriction, and reduces oxygen-binding capacity of blood, affecting cellular perfusion and potentially impairing healing. • Identify sign and symptoms requiring medical evaluation, e.g., nausea and/or vomiting; difficulty voiding; fever, continued or odoriferous wound drainage; incisional swelling, erythema, or separation of edges; unresolved or changes in characteristics of pain. Rationale: Early recognition and treatment of developing complications (ileus, urinary retention, infection, delayed healing) may prevent progression to more serious or life-threatening situation
  212. 212. • Stress necessity of follow-up visits with providers, including therapists, laboratory Rationale: Monitors progress of healing and evaluates effectiveness of regimen. • Include SO in teaching program or discharge planning. Provide written instructions and/or teaching materials. Instruct in use of and arrange for special equipment. Rationale: Provides additional resources for reference after discharge. Promotes effective self-care. • Identify available resources: home care services, visiting nurse, outpatient therapy, contact phone number for questions. Rationale: Enhances support for patient during recovery period and provides additional evaluation of ongoing needs and new concerns
  213. 213. Nursing Diagnosis: Risk for Altered Tissue Perfusion May be related to: • Interruption of flow: arterial, venous • Hypovolemia
  214. 214. Nursing Diagnosis: Risk for Altered Tissue Perfusion Possibly evidenced by • Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention. Desired Outcomes • Demonstrate adequate perfusion evidenced by stable vital signs, peripheral pulses present and strong; skin warm/dry; usual mentation and individually appropriate urinary output.
  215. 215. Nursing Interventions: • Change position slowly initially. Rationale: Vasoconstrictor mechanisms are depressed and quick movement may lead to orthostatic hypotension, especially in the early postoperative period. • Assist with range-of-motion (ROM) exercises, including active ankle and leg exercises. Rationale: Stimulates peripheral circulation; aids in preventing venous stasis to reduce risk of thrombus formation. • Encourage and assist with early ambulation. Rationale: Enhances circulation and return of normal organ function.
  216. 216. • Avoid use of knee gatch and/or pillow under knees. Caution patient against crossing legs or sitting with legs dependent for prolonged period. • Rationale: Prevents stasis of venous circulation and reduces risk of thrombophlebitis. • Assess lower extremities for erythema, edema, calf tenderness (positive Homans’ sign). • Rationale: Circulation may be restricted by some positions used during surgery, while anesthetics and decreased activity alter vasomotor tone, potentiating vascular pooling and increasing risks of thrombus formation.
  217. 217. • Monitor vital signs: palpate peripheral pulses; note skin temperature/ color and capillary refill. Evaluate urinary output/time of voiding. Document dysrhythmias. Rationale: Indicators of adequacy of circulating volume and tissue perfusion or organ function. Effects of medications or electrolyte imbalances may create dysrhythmias, impairing cardiac output and tissue perfusion. • Investigate changes in mentation or failure to achieve usual mental state. Rationale: May reflect a number of problems such as inadequate clearance of anesthetic agent, oversedation (pain medication), hypoventilation, hypovolemia, or intraoperative complications
  218. 218. • Administer IV fluids or blood products as needed. Rationale: Maintains circulating volume; supports perfusion. • Apply antiembolitic hose as indicated. Rationale: Promotes venous return and prevents venous stasis of legs to reduce risk of thrombosis.
  219. 219. Status Post Suction Curettage for H-Mole NCP#1. Risk for Fluid volume deficit r/t maternal blood loss NCP#3. Ineffective airway clearance related to increased mucus production as evidenced by persistent cough NCP#2. Grieving related to unexpected fetal loss.incision.
  220. 220. • Straight Arrow: denotes direct relationship from medical diagnosis/ chief complaint • Broken Arrow: demotes Risk Nursing Diagnosis • Dotted Arrow: or denotes linking relationship between or among Nursing Diagnoses • Diamond Arrow: denotes readiness for enhanced Wellness of Health promotion Diagnosis after intervention.
  222. 222. ASSESSMENT: Subjective Data: “Ginadugo gyapon ako it Sangkiri” as verbalized by the patient Objective data: • minimal vaginal bleeding with two pads use not fully soaked. • weakness/fatigue • pale/appearance • dry mucous membrane at the mouth • dry skin • Skin turgor (4secs) Vital signs: • T: 36.7°c/ax RR: 19cpm PR: 89bpm BP: 110/70 mmHg
  223. 223. Nursing Diagnosis: Risk for Fluid volume deficit r/t maternal blood loss
  224. 224. Objectives/ Outcome Criteria General: To facilitate the maintenance of fluid balance in the body. Specific: At the end of the 8 hour shift the patient will be able to: • reduce vaginal bleeding from two soaked pads to 1 soaked pad • exhibit elastic skin turgor (2 sec.) • exhibit moist akin and mucous membrane • verbalized diminished of fatigue/ weakness • improve vital signs
  225. 225. Nursing Intervention Independent: • Assessed skin turgor and moisture of mucous membranes Rationale: Indicators of hydration status/ degree of deficit • Monitored Vital signs. Evaluate peripheral pulses, capillary refill. Rationale: to have a baseline data, reflects adequacy of circulating volume • Monitored I&O; include all output sources (e.g., emesis, diarrhea Rationale: Decreasing renal output and concentration of urine suggest developing dehydration and need for fluid replacement.
  226. 226. • Weighed daily. Rationale: Sensitive measurement of fluctuations in fluid balance • Observed for bleeding tendencies; Note the amount, lochia/color of the vaginal discharge Rationale: Early identification of problems (which may occur as a result of cancer), allows for prompt intervention. • Encouraged increase fluid intake as tolerated Rationale: To compensate with the fluid volume deficit problem • Encouraged rest. Rationale: Prevent unnecessary energy expenditure related to vomiting (as may trigger) and bleeding (loss of blood/RBC)
  227. 227. Dependent • Administered fresh whole blood as prescribed. Rationale: To replace blood loss. • Administered Tranexamic Acid 500 mg IVTT as ordered. Rationale: To prevent further fluid loss due to hemorrhage.
  228. 228. Evaluation: Goals Met. The patient is able to exhibit the elastic skin turgor, moist skin and mucous membrane and verbalized diminished for fatigue/weakness. Further evaluation can be achieved through repeat laboratory exams.
  229. 229. Assessment Subjective Data: “Gakasubo ako hay namatay akon unga” as verbalized by the patient Objective data: • Restless • Appears sad • Appears weak
  230. 230. Nursing Diagnosis: Grieving related to unexpected fetal loss.
  231. 231. Objectives: General: To identify positive and negative expressions, feelings and reactions related to fetal loss. Specific: After 8 hours of nursing intervention the patient will be able to: • Express feelings of guilt, fear and sadness. • Discuss personal response to grieving. • Develop new skills and behavior to integrate and manage life experiences. • Function at normal developmental level.
  232. 232. Nursing Intervention Independent • Allow the patient to express feelings about the unexpected fetal loss. Rationale: Support and normalize the grieving process. • Listen attentively to what the patient states about the unexpected loss. Rationale: To evaluate the patient’s response regarding the situation.
  233. 233. • Reinforce additional factual information as soon as it is available about the cause of the fetal demise. Rationale: Promotes understanding of the physiologic etiology of the loss and acceptance of the loss as real. • Provide emotional and moral support to the patient. Rationale: To help the patient cope with her grieving.
  234. 234. Dependent: • Refer for supportive counseling. Rationale: Supportive counseling may help the patient to gain strength and overcome situation.
  235. 235. Evaluation: Goal met. The patient expresses feelings about the situation.
  236. 236. Assessment Subjective: “Gina ubo gihapon ako” as verbalized by the patient. Objective: • With productive cough of whitish in color • Restlessness • Pale and weak in appearance
  237. 237. Nursing Diagnosis: Ineffective airway clearance related to increased mucus production as evidenced by persistent cough
  238. 238. Objectives General: The client will be able to maintain airway patency. Specific: After the end of the shift, the patient will be able to achieve patent airway as evidenced by: • return-demonstrate chest-physiotherapy to maintain patent airway • Respiratory rate will be in normal limits • Mucus secretion will decrease • Moderate persistent coughing with bilateral crackles upon auscultation will be minimize
  239. 239. Nursing Interventions Independent • Place patient into a high fowler position. Rationale: To maximize lung expansion and decrease respiratory effort • Demonstrated proper technique on chest-physiotherapy Rationale: To maintain patent airway and loosen the secretions.
  240. 240. • Advise patient to do back tapping with the help of her folks Rationale: To manually help loosen or dislodge secretions • Asses airway patency. Rationale: It helps check for any obstruction or accumulation of fluids and maintain adequate airway patenc. • Auscultate lung fields, noting areas of decrease or absence of airflow and adventitiousbreath sounds. Rationale: To identify areas of consolidation and determine possible bronchospasm or obstruction
  241. 241. • Advise to increase fluid intake. Rationale: Keeps mucus secretions moist and easier to expel • Maintain a relax, calm and non-stimulating environment. Rationale: Establish optimal rest/pattern
  242. 242. Dependent • Administer following medications as prescribed. Rationale: For compliance of therapeutic regimen.
  243. 243. Evaluation: Goal met. The patient maintained airway patency as evidenced by expectorating clear secretions after chest-physiotherapy & clear lung sounds.
  244. 244. DRUG STUDY
  245. 245. Prescribed Medication: Salbutamol 1 neb q6h Classification: Bronchodilators Action: Relaxes bronchial, uterine, and vascular smooth muscle by stimulating beta2 receptors. Indication: To prevent or treat bronchospasm in patients with reversible obstructive airway disease. To prevent exercise- induced bronchospasm
  246. 246. Adverse effects: CNS: tremor, nervousness, headache, hyperactivity, weakness, CNS stimulation, malaise CV: tachycardia, palpitations EENT: dry and irritated nose and throat with inhaled form, epistaxis,hoarseness GI: heartburn, altered taste, increased appetite METABOLIC: hypokalemia RESPI: Bronchospasm, dyspnea, bronchitis, increased sputum OTHER: hypersentivity reactions
  247. 247. Nursing Responsibilities • Monitor patient’s history. Rationale: To assess for any signs of allergy in medication. • Monitor vital signs especially BP. Rationale: Drug may cause hypertension. • Eat frequent small meals. Rationale: To prevent nausea and vomiting.
  248. 248. Prescribed Medication: Cefuroxime 750mg IVTT (ANST) prior to evacuation curettage. Classification: Second-generation cephalosporin/ antibiotic Action: Second-generation cephalosporin that inhibits cell- wall synthesis, promoting osmotic instability; usually bactericidal. Indication: Perioperative prevention. Other Indications: UTI’s, infections of the urinary and lower respiratory tracts, skin and skin-structure infections, bone and joint infections, septicemia, meningitis, and gonorrhea.
  249. 249. • Adverse effects: • CNS: headache, dizziness, lethargy, paresthesia • GI: nausea, vomiting, anorexia, abdominalpain, flatulents, pseudomembranous colitis, hepatoxicity. • GU: nephrotoxicity • HEMA: bone marrow depression (low WBC, low platelet, low hematocrit) • LOCAL: pain, abscess at the injection site, phlebitis, inflammation at IV site. • OTHER: superinfection
  250. 250. Nursing Responsibilities • Culture infection site and arrange for sensitivity test before and after or during therapy. Rationale: To check the effectiveness of drug. • Give oral drug with foods. Rationale: To decrease GI upset. • Discontinue drug if hypersensitivity occur. Rationale: To prevent further complications.
  251. 251. • Avoid vigorous activities. Rationale: Dizzines may occur. • Swallow drugs or tablets whole. Do not crush. Rationale: To avoid unusual taste.
  252. 252. Prescribed Medication: Diphenhydramine 50mg tab 30 mins PTBT Classification: antihistamine, anti-motion-sickness drug, antiparkinsonian, cough suppressant,
  253. 253. Action: Competitively blocks the effects of histamine at H1-receptor sites on effector cells. Indication: amelioration of allergic reactions to blood or plasma, active and prophylactic treatment of motion sickness, night time sleep aid, relief of symptoms associated with perennial and seasonal allergic rhinitis; vasomotor rhinitis; allergic conjunctivitis, sedation
  254. 254. Adverse effects • CNS: drowsiness, sedation, dizziness, disturbed coordination, fatigue, confusion, restlessness, excitation, nervousness, tremor, headache, blurred vision, diplopia • CV: hypotension, palpitations, bradycardia, tachycardia • GI: epigastric distress, anorexia, increased appetite and weight gain, nausea, vomiting, diarrhea or constipation • GU: urinary frequency, dysuria, urinary retention, decreased libido, impotence
  255. 255. • HEMA: hemolytic anemia, hypoplastic anemia, thrombocytopenia, leokupenia, agranulocytopenia, pancytopenia • RESPI: thickening of bronchial secretions, chest tightness, wheezing, nasal stuffiness, dry mouth, dry nose, dry throat, sore throat • OTHER: urticaria, rash, anaphylactic shock, photosensitivity, excessive perspiration
  256. 256. Nursing Responsibilities • Tell the patient to take Diphenhydramine with food or milk. Rationale: To reduce GI distress • Inform the patient about the use of sugarless gum, hard candy or ice chips. Rationale: It may reduce dry mouth Check lab results. Rationale: To determine the effectiveness of the drug
  257. 257. • Instruct patient to increase fluid intake if diarrhea may occur. Rationale: To prevent dehydration • Instruct patient to increase food that is high in fiber. Rationale: To relieve constipation • Instruct the patient to avoid alcohol Rationale: Serious sedation could occur
  258. 258. • Caution the patient when performing task that requires alertness. Rationale: Diphenhydramine may cause dizziness and drowsiness • Tell patient to notify the prescriber if tolerance develops. Rationale: The prescriber may increase the dosage of the drug
  259. 259. Prescribed Medication: Ranitidine Hydrochloride (Geoxer) 50mg IV PTOR Classification: Histaimine2 (H2) Antagonist; (Anti secretory)
  260. 260. Action: Competitively inhibits the action of histamine at H2receptors of the partial cells of the stomach, inhibiting basal gastric acid secretion and that is stimulated by food, insulin, histamine, cholinergic agonists gastrin and pentagastrin. Indication: Prior to OR indication. Other Indications: For prophylaxis of gastric ulcer
  261. 261. Adverse Effects: • CNS: Contusion agitation, or hallucinations, vertigo, dizziness, insomnia • CV: Tachycardia, bradycardia, PVC (Rapid IV admin) • GI: Abdominal pain, hepatitis, increase ALT Levels • Hem: Leukopenia granulocytopenia, Thrombocytopenia, Pancytopenia
  262. 262. •Local: Local burning an itching IV site • GU: Gynecomastia, Impotence, decrease libido •Dermatologic: Rash, alopecia • Others: Arthralgias
  263. 263. Nursing Responsibilities • Monitor patient’s vital signs especially the pulse rate before administering the drug Rationale: To determine any alteration based on the baseline data. • Check the patency at the IV line. Rationale: Obstructed tubing may alter the admin of the drug. • Administer the drug at least 2 minutes. Rationale: Rapid admin of the drug may cause hypotension and arrhythmias. • Asses for redness or inflammation on the IV site.
  264. 264. Prescribed Medication: Metoclopramide 10mg IV PTOR Classification: Antiemetic Indication: for prophylaxis of post op nausea and vomiting
  265. 265. Other Indications: Prevention of chemotherapy induced emesis. To stimulate gastric emptying. Action: Blocks dopamine receptors in chemoreceptor trigger zone of the CNS. Stimulates motility of the upper GI tract and accelerates gastric emptying.
  266. 266. Adverse Effects: • GI: Nausea &Vomiting, Diarrhea, Intestinal Spasm & Cramping. • CV: Declining of blood pressure and heart rate • CNS: Weakness and fatigue.
  267. 267. Nursing Intervention • Monitor blood pressure carefully if giving drug intravenously. Rationale: To detect and consult with the prescriber about treatment for sudden drops in blood pressure. • Provide importance info about drug such as including name of drug, dosage, problems and the importance of periodic monitoring and evaluation. Rationale: To enhance patient knowledge about drug therapy and promote compliance with drug regimen.
  268. 268. Prescribed Medication: Fluimucil 600mg 1 tab in ½ glass Classification: Mucolytic Action: Mucolytic activity: splits links in the mucoproteins contained in the respiratory mucos secretion, decreasing the viscosity of the mucus. Antidote to acetaminophen hepatoxicity; protects liver cells by maitaing cell fuction.
  269. 269. Indication: Mucolytic adjuvant therapy for abnormal viscid or inpissated mucus secretion in acute and chronic bronchopulmonary disease. Other Indication: pulmonary complications associated with surgery, anesthesia, post- traumatic chest condition, diagnostic bronchial studies.
  270. 270. Adverse effects: • GI: nausea, GI upset. • DERMA: Urticaria • Respi: brochospasm, increased productive cough • Other: rhinorrehea
  271. 271. Nursing Responsibilities • Assess patient’s history Rationale: To assess patient’s allergy to the drugs. • Eat frequent small meals. Rationale: To maintain nutrition.
  272. 272. Prescribed Medication: Cefuroxime 750mg IVTT q8h Classification: Second-generation cephalosporin/ antibiotic Action: Second-generation cephalosporin that inhibits cell-wall synthesis, promoting osmotic instability; usually bactericidal.
  273. 273. Indication: Prophylaxis for possible surgical site infection. Other Indications: Perioperative prevention, UTI’s, infections of the urinary and lower respiratory tracts, skin and skin-structure infections, bone and joint infections, septicemia, meningitis, and gonorrhea.
  274. 274. Adverse effects: • CNS: headache, dizziness, lethargy, paresthesia • GI: nausea, vomiting, anorexia, abdominalpain, flatulents, pseudomembranous colitis, hepatoxicity. • GU: nephrotoxicity
  275. 275. • HEMA: bone marrow depression (low WBC, low platelet, low hematocrit) • LOCAL: pain, abscess at the injection site, phlebitis, inflammation at IV site. • OTHER: superinfection
  276. 276. Nursing Responsibilities • Culture infection site and arrange for sensitivity test before and after or during therapy. Rationale: To check the effectiveness of drug. • Give oral drug with foods. Rationale: To decrease GI upset. • Discontinue drug if hypersensitivity occur. Rationale: To prevent further complications.
  277. 277. • Avoid vigorous activities. Rationale: Dizzines may occur. • Swallow drugs or tablets whole. Do not crush. Rationale: To avoid unusual taste. • Complete medication regimen as prescribed. Rationale: Compliance for therapeutic regimen.
  278. 278. Prescribed Medication: Methotrexate 0.5 ml IM, OD for 5 days Classification: Antineoplastic, Antimetabolites
  279. 279. Action: Inhibits folic acid reductase, leading to inhibition of DNA synthesis and inhibition of cellular replication; selectively affects the most rapidly dividing cells. Indication: Treatment of hyaditiform mole, gestational carcinoma, chorioadenoma destruens.
  280. 280. Adverse effects: • CNS: fatigue, malaise, dizziness • GI: ulcerative colitis, hepatic toxicity • GU: effects on fertility (menstrual dysfunction, infertility, defective oogenesis)
  281. 281. • Dermatologic: erythematous rashes • Hema: severe bone marrow depression, increase susceptibility to infection. • Respiratory: interstitial Pneumonitis • Hypersensitivity: anaphylaxis and sudden death.
  282. 282. Nursing Responsibilities • Monitor patient history. Rationale: To assess for any signs of allergy in medication. • Provide small, frequent meals; Frequent mouth care & dietary consultation. Rationale: To prevent nausea and vomiting & maintain nutrition when GI effects are severe. • Instruct patient to avoid driving or using dangerous equipment. Rationale: Possible drowsiness may occur.
  283. 283. • Encouraged patient to avoid crowd places, sick people, and working in soil. Rationale: To avoid infection. • Avoid alcohol while taking the drug. Rationale: Serious side effects may occur. • Arrange for Adequate Hydration during therapy. Rationale: To reduce the risk of hyperurecemia.
  284. 284. Prescribed Medication: Tranexamic Acid 1000mg IV q8h x 3days Classification: Antifibrinolytic
  285. 285. Action: Displace plasminogen from surface of fibrin by binding to high- affinity lysine site of plasminogen. The diminishes dissolution of hemostatic fibrin, which decreases bleeding. Indications: For Post-op preventive measure for hemorrhage. Other Indications: To treat cyclic heavy menstrual bleeding
  286. 286. Adverse effect: • CNS: cerebral thrombosis,dizziness, fatigue, headache, migraine • CV: deep vein thrombosis • EENT: central retinal artery, and vein obstruction, feeling of throat tightness, impaired color vision, ligneous conjunctivitis, sinusitis, visual abnormalities • GU: Acute renal cortical necrosis
  287. 287. • HEME: anemia • MS: Arthralgia, muscle cramps and spasms, myalgia, backpain • RESP: dyspnea, pulmonary embolism, respiratory congestion • SKIN: allergic skin reactions, facial flushing • OTHER: anaphylaxis, multiple allergies including seasonal
  288. 288. NURSING RESPONSIBILITIES • Monitor patient closely for allergic reactions to tranexamic acid such as dyspnea, a feeling of throat tightness, and facial flushing that may require emergency medical treatment, Rationale: to avoid further complications to patient and to stop taking drug. • Advise patient to report any changes in vision or ocular discomfort, Rationale: The prescribing physician may stop administering the drug.
  289. 289. Prescribed Medication: TRAMADOL (ULTRAM) 375mg; 1 cap PO TID x 2 days start Classification: Analgesic, centrally acting
  290. 290. Adverse effects: • CNS: Dizziness, headache, somnolence, vertigo, seizures, anxiety, CNS stimulation, confusion, coordination disturbance, euphoria, malaise, nervousness, sleep disorder. • CV: Vasodilation. • EENT: Visual disturbances.
  291. 291. Action: Unknown. A centrally acting synthetic analgesic compound not chemically related to opioids. Thought to bind to opioid receptors and inhibit reuptake of norepinephrine and serotonin. Indication: For post op pain management.
  292. 292. • GI: Constipation, nausea, vomiting, abdominal pain, anorexia, diarrhea, dry mouth, dyspepsia, flatulence. • GU: Menopausal symptoms, proteinuria, urinary frequency, urine retention. • RESPIRATORY: Respiratory depression. • SKIN: Diaphoresis, pruritus, rash.
  293. 293. Nursing Responsibilities • Control environment (temperature, lighting) if sweating or CNS effects occur. Rationale: to prevent adverse effects and provide immediate interventions if these occurs. • Avoid performing tasks that require alertness. Rationale: to prevent any injuries because the drug causes dizziness. • Report severe nausea, dizziness and severe constipation. Rationale: to provide immediate intervention.
  294. 294. • Assess type, location and intensity of pain before and after administration. Rationale: to ensure the effectiveness of the drugs. • Assess respiratory rate before and periodically during administration. Rationale: respiratory depression may occur • Assess bowel function routinely. Prevention of constipation should be instituted with increased intake of fluids and bulk. Rationale: to minimize constipating effects.
  296. 296. Discharge to a patient plan undergone Suction Dilatation and Curettage.
  297. 297. • Encourage the patient for compliance of medication. Rationale: To prevent drug resistance and to ensure effectiveness of the drug. • Educate the patient and the significant others about the adverse effect of the medication as manifested by untoward symptoms that may require immediate notifications of the physician. Rationale: To become aware of when to seek medical attention and address the problem immediately.
  298. 298. • Instruct the significant others to provide the client a calm and well ventilated environment. Rationale:To provide restful environment to the client. • Instruct the significant others to maintain environmental sanitation. Rationale: The patient is susceptible in contracting infections as she undergone surgery.
  299. 299. • Encourage the patient to seek for follow-up check up. Rationale: To determine client’s current medical condition.
  300. 300. • Educate the patient on how to perform proper perineal care such as washing the vagina from front to back. Rationale: Proper perineal care prevents infection. • Teach the client the necessary measures of maintaining good skin integrity. Rationale: Bathing and inspecting the skin will preserve skin integrity.
  301. 301. • Advice the client to use their Philhealth card if there is any to avail its benefits. Rationale: To reduce financial problem.
  302. 302. • Encourage the family to prepare nutritious foods such as vegetables, fruits and meat. Rationale: Provide more energy, Vitamins and minerals necessary in medical illness and repair of damage tissues. • Advice the family to give the patient’s foods rich in vitamins C such as oranges and calamansi juice. Rationale: Vitamin C helps boost patient’s immunity. • Recommend restrictions of caffeine. Rationale: Because this substance could affect the effectiveness of the drugs.
  303. 303. • Encourage family members to assist and support the client in meeting his needs and allow open communication. Rationale: To enhance coordination and continuity of care.
  304. 304. • Pelvic is recommended for 4-6 weeks after evacuation of the uterus, and the patient is instructed not to become pregnant for 12months. Adequate contraception is recommended. Rationale: To avoid any confusion about the development of malignant disease. If pregnancy occurs, the elevation in beta-HCG levels cannot be differentiated from the disease process.
  305. 305. REFERENCES:   nal-trophoblastic-disease-what-is-g-t-d    disease.html  
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Case Study - H-mole


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