IVORY ANN A. AFABLESUBMITTED BY:

MRS. NELIA AYSON R.NCLINICAL INSTRUCTOR

I. Biographic Data

Name: Polintan, Laonisa Espera

Address: #283 T.Santiago Street Viente Reales Valenzuela City

Age: 49 years old Gender: Female Religious Affiliation: Catholic

Marital Status: Married

Chief Complaint: Involuntary Urination

Provisional Diagnosis: Vesicovaginal fistula

II. Nursing History

A. Past Health History

1. Childhood Illness – Usually flu

2. Immunizations - Complete

3. Allergies - None

4. Accidents - None

5. Hospitalizations – Once (TAHBSO Surgical procedure last April

30,2008)

6. Medications used or currently taken - None

B. History of Present Illness

Eleven months prior to admission, patient had undergone TAHBSO (Total

Abdominal Hysterectomy with Bilateral Salphyngectomy and Oophorectomy) at

Quezon City General Hospital, 3 days after the Operation and removal of Internal

Foley Catheter; patient noted that she cannot control her urination. She consulted

the doctor who did the TAHBSO and was advised to have bladder draining, no

medication was prescribed.

Persistence of the involuntary urination prompted, consulted and was

subsequently admitted.

C. Family History

(-) Diabetes Mellitus

(-) HPN

(-) Asthma

(-) PTB

D. Obstetric History (for OB cases only)

- G4P3 (3013)

E. Developmental History (for Pediatrics cases only)

- N/A

III. Patterns of Functioning

A. Psychological Health

1. Coping patterns – Doing household chores and Praying

2. Interaction Patterns – (+) Accommodating

3. Cognitive Patterns – Easy to talk to

4. Self-concept – High self-esteem

5. Emotional Patterns – Happy

6. Sexuality – Feminine

7. Family Coping Patterns – Praying and Staying together

Interpretation: Normal Psychological Health

Analysis: Normal

B. Socio-Cultural Patterns

1. Cultural Patterns – Cooking Filipino dishes with family

2. Significant Relationships – with all the members of her family

3. Recreation Patterns – Staying at home cooking and cleaning

4. Environment – living with other relatives within a compound

5. Economic – Average status

Interpretation: Normal Socio-cultural pattern/ Interactive to others

Analysis: Normal

C. Spiritual Patterns

1. Religious Beliefs and Practices – Going to church every Sunday

2. Values and Valuing – Giving respect to elders as well as to others

Interpretation: Normal Spiritual Patterns, respectful

Analysis: Normal

IV. Activities of Daily Living

Activities of

Daily Living

Before

Hospitalization

During

Hospitalization

Interpretation and Analysis

1. Nutrition with appetite With appetite Normal, adaptive

2.

Elimination

Daily None normal because of diet

3. Exercise Daily None Normal because of indwelling

catheter and attached drainage

4. Hygiene Daily daily Normal adaptive

5. Sleep and

Rest

good poor normal

6.Sexual

Activity

None None Normal because she’s already a

widow

7. Substance

Use

None Prescribed by the

doctor

normal

V. Physical Assessment

General

Appearance

Norms Actual

Findings

Interpretation and

Analysis

1. Posture/Gait Steady Gait Good posture Normal

2. Skin color Varies from light to

deep brown

Fair skin Normal

3. Personal hygiene Good Good Normal

4. Nutritional

Status

Healthy Healthy Healthy

5.Age

Appropriateness

Normal appropriate

with age

Normal Normal appropriate to

her age

6. Verbal Behavior Normal Nice Normal

7.Non-verbal

behavior

Normal Normal Normal

Measurements

1. Temperature 36.5 36.5 Normal

2. Pulse Rate 60-100 82 Normal

3. Respiratory Rate 16-22 20 Normal

4. Blood Pressure 110/70 110/80 Normal

5. Weight 130 kgs Normal

6. Height 5’2” Normal

VI. Laboratory and Diagnostic Examinations Findings

Date Procedure Norms Result Interpretation and Analysis

3-11-

09

CBC Hgb- 120-

160

Hct- 37-47

WBC- 3.8-

10.8

RBC- 3.9-5.2

Segmenters

Lmphocytes

PT

121

40

9.6

3.72

.79

18%

Adequate

Normal

Normal

Normal

Below normal

Normal

ECG Normal Sinus

Rhythm

Normal

3-10-

09

Cystoscopy Vesicovaginal

fistula

Resulted from previous

surgical operation (TAHBSO)

Dye test Bladder leakage Resulted from previous

surgical operation (TAHBSO)

VII. Medications, IV, Infusions, Blood Transfusion, Treatment Given

Generic Classificati

on

Indication Contraindicati

on

Side Effects Nursing

Responsibilities

Erythromycin Anti-

infectives

To reduce the

development

of drug-

resistant

bacteria and

maintain the

Erythromycin is

contraindicated

in patients with

known

hypersensitivity

to this

The most frequent side effects of oral erythromycin preparations are gastrointestinal and are dose-related.

-Assess for infection.

-Observe for any S/S of anaphylaxis.

-Assess for

effectiveness

of E.E.S. and

other

antibacterial

drugs,

antibiotic.

Erythromycin is

contraindicated

in patients

taking

terfenadine,

astemizole,

pimozide, or

cisapride.

They include nausea, vomiting, abdominal pain, diarrhea and anorexia. Symptoms of hepatitis, hepatic dysfunction and/or abnormal liver function test results may occur.

renal

dysfunction.

Cefuroxime Anti-

infectives

Fights

bacteria in the

body.

- kidney disease

-liver disease

-colitis

-diabetes

-Malnourish

Vomiting, abdominal pain, colitis, vaginitis including vaginal candidiasis, toxic nephropathy, hepatic dysfunction including cholestasis, aplastic anemia, hemolytic anemia, and hemorrhage

-Assess for infection.-Observe for any S/S of anaphylaxis.-Assess for renal dysfunction

Metronidazole Anti-

infectives

Indicated in

the treatment

of serious

infections

caused by

susceptible

anaerobic

bacteria.

Patients with

severe hepatic

disease

metabolize

metronidazole

slowly, with

resultant

accumulation of

metronidazole

reports have been referable to the gastrointestinal tract, particularly nausea reported by about 12% of patients, sometimes accompanied by headache,

-Assess for infection.-Observe for any S/S of anaphylaxis.-Assess for renal dysfunction

and its

metabolites in

the plasma.

Accordingly,

for such

patients, doses

below those

usually

recommended

should be

administered

cautiously.

Diphenhydra

mine

temporarily relieves these symptoms due to hay fever or other upper respiratory allergies:

runny nose

sneezing

itchy, watery eyes

itching of the nose or throat

temporarily relieves these symptoms due to the common cold:

runny nose

sneezing

heart disease

glaucoma

thyroid disease

diabetes

trouble urinating due to an enlarged prostate gland

high blood pressure

a breathing problem such as emphysema or chronic bronchitis

cough accompanied by excessive phlegm (mucus)

persistent or

marked drowsiness may occur

alcohol, sedatives, and tranquilizers may increase drowsiness

excitability may occur, especially in children

be careful when driving a motor vehicle or operating machinery

-Assess level of consciousness

-Avoid alcoholic drinks

-Promote Safety

chronic cough such as occurs with smoking, asthma or emphysema

Morphine Analgesics Moderate to

severe pain.

-Hypersensitivity-Pregnancy-Patient who are

intoxicated with

alcohol

. The most frequent of these include constipation, nausea and somnolence.

-Encourage increase fluid intake- Promote safety

Buscopan Anti-

spasmodic

Controlled-

release tablet

indicated for

the treatment

of overactive

bladder with

symptoms of

urge urinary

incontinence,

urgency, and

frequency.

Contraindicated

in patients with

urinary

retention,

gastric retention

and other severe

decreased

gastrointestinal

motility

conditions,

uncontrolled

narrow-angle

glaucoma and

in patients who

are at risk for

these

conditions.

nasal dryness, cough, pharyngolaryngeal pain, dry throat;

gastroesophageal reflux disease, abdominal pain, loose stools, flatulence, vomiting;

-Encourage increase fluid intake- Promote safety

Vesicare Anti-

muscarinic

Indicated for

the treatment

of overactive

bladder with

symptoms of

Contraindicated

in patients with

urinary

retention,

gastric

Expected side effects of anti-muscarinic agents are dry mouth, constipation, blurred vision

-Encourage increase fluid intake- Promote safety

urge urinary

incontinence,

urgency, and

urinary

frequency.

retention,

uncontrolled

narrow-angle

glaucoma, and

in patients who

have

demonstrated

hypersensitivity

to the drug

substance or

other

components of

the product.

(accommodation abnormalities), urinary retention, and dry eyes.

Treatment/

Infusion

Classification Indication Contraindication Nursing

Responsibilities

D5LR Non-

pyrogenic

solution

For fluid and

electrolyte

replenishment

and caloric

supply.

Patients with

known allergy to

corn or corn

products.

-Assess for any Allergy.

-Monitor intake

and output.

VIII. Pathophysiology

IX. Prioritized List of Nursing Problems

Date Nursing Problems Identified Cues Justification

3-13-09 pain Facial grimace Post operative pain

anxiety restless fear of unknown

discomfort restless Involuntary urination

X. Nursing Care Plan

Assessment Nursing

Diagnosis

Plan of Care Nursing

Interventions

Evaluation

Subjective data:

“Ok na naman ako ngayon medyo masakit lang yung parting naoperahan pag nagagalaw.” as verbalized by the patient.

Objective data:

-with IVF of

D5LR 1L @

900cc level

regulated @

30gtts/min on

the left arm

-with Jackson

Pratt drain on

(-) pressure

with bloody

output

Acute pain related to post operative surgery

Patient will

verbalized

adequate relief

of pain and can

move with no

facial grimace

-Assess type and

location of pain

-Acknowledge

existence of

pain; anticipate

need for

analgesics.

(Early

intervention may

decrease the

total amount of

analgesic

required.)

-Consider

cultural

influences on

pain response

(Identifying

patient’s cultural

Goal met as evidence by:

-patient can

already move

with no facial

grimace, only

verbal saying

of mild pain.

-pain scale

from 6 to 2

-with

suprapubic

catheter

connected to

urine bag

draining to a

tea colored

output

-dressing dry

and intact

-Facial

grimace when

moving

-Pain scale of

6 out of 10

-Vital signs

taken:

BP: 110/80

Temp: 36.5

PR: 82

RR: 20

practices plays

important part in

dealing with

pain

management)

-Use pain modifying strategies.

A) Modify the environment.

B) Administer prescribed analgesics as needed.

C) Evaluate patient’s responses to medication

D) Consult the physician if relief of pain is not obtained.

DISCHARGE PLAN

M - Ensure that that client will follow doctor’s order regarding taking medications

at home.

E – Encourage client to exercise regularly.

T – Inform client to seek necessary treatment as doctors advised.

H – Encourage client to practice general hygiene to prevent infection

O - Inform client to make necessary follow up treatment as doctors advised.

D - Teach client to eat balance and healthy diet to promote healing and to gain

strength.

S – Have faith in God. Always pray.