CASE STUDY

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General Objectives
The purpose of the presentation is to know related information and knowledge about the patient’s case/ condition and disease. This presentation will serve as guidelines for us student nurses in assessing and providing proper nursing care to our patient with the same problem or disease.

Specific Objectives
• To understand condition of disease and associate it with the patient through the introduction of the case • To know the nursing history, personal data, health history and physical assessment of the patient • To illustrate the anatomy and physiology and pathophysiolgy of the affected organ. • •


To discuss and determine manifestation and complications To develop an effective skill on how to manage care in patient with the disease To formulate a drug study with regards to the patients condition and correlate lab results to its normal values. To provide the client a nursing care plan and discharge plan to assure for clients total wellness during her hospitalization up to the time of her hospital discharge .



Overview of the disease
Ovarian cysts are small fluid-filled sacs that develop in a woman's ovaries. Most cysts are harmless, but some may cause problems such as rupturing, bleeding, or pain; and surgery may be required to remove the cyst(s). It is important to understand how these cysts may form.

Women normally have two ovaries that store and release eggs. Each ovary is about the size of a walnut, and one ovary is located on each side of the uterus. One ovary produces one egg each month, and this process starts a woman's monthly menstrual cycle. The egg is enclosed in a sac called a follicle. An egg grows inside the ovary until estrogen (a hormone), signals the uterus to prepare itself for the egg. In turn, the uterus begins to thicken itself and prepare for pregnancy. This cycle occurs each month and usually ends when the egg is not fertilized. All contents of the uterus are then expelled if the egg is not fertilized. This is called a menstrual period. In an ultrasound image, ovarian cysts resemble bubbles. The cyst contains only fluid and is surrounded by a very thin wall. This kind of cyst is also called a functional cyst, or simple cyst. If a follicle fails to rupture and release the egg, the fluid remains and can form a cyst in the ovary. This usually affects one of the ovaries. Small cysts (smaller than one-half inch) may be present in a normal ovary while follicles are being formed. Ovarian cysts affect women of all ages. The vast majority of ovarian cysts are considered functional (or physiologic). In other words, they have nothing to do with disease. Most ovarian cysts are benign, meaning they are not cancerous, and many disappear on their own in a matter of weeks without treatment. Cysts occur most often during a woman's childbearing years. Ovarian cysts can be categorized as noncancerous or cancerous growths. While cysts may be found in ovarian cancer, ovarian cysts typically represent a normal process or harmless (benign) condition.

Signs and Symptoms
Ovarian Cysts Causes
Oral contraceptive/birth control pill use decreases the risk of developing ovarian cysts because they prevent the ovaries from producing eggs during ovulation. The following are possible risk factors for developing ovarian cysts: • History of previous ovarian cysts

• • • • • •

Irregular menstrual cycles Increased upper body fat distribution Early menstruation (11 years or younger) Infertility Hypothyroidism or hormonal imbalance Tamoxifen therapy for breast cancer

Ovarian Cysts Symptoms
Usually ovarian cysts do not produce symptoms and are found during a routine physical exam or are seen by chance on an ultrasound performed for other reasons.

However, the following symptoms may be present:
• • • • • • • • • Lower abdominal or pelvic pain, which may start and stop and may be severe, sudden, and sharp. Irregular menstrual periods Feeling of lower abdominal or pelvic back Pelvic pain after strenuous exercise or Pain or pressure with urination or Nausea and vomiting Vaginal pain or spots of blood from vagina Infertility sexual intercourse bowel movements pressure or fullness Long-term pelvic pain during menstrual period that may also be felt in the lower

Anatomy and Physiology

Functional anatomy of the ovary

Female Reproductive System The female reproductive anatomy includes internal and external structures. The female reproductive system contains two main parts: the vagina and uterus, which act as the receptacle for the male's sperm, and the ovaries, which produce the female's ova. All of these parts are always internal; the vagina meets the outside at the vulva, which also includes the labia, clitoris and urethra. The vagina is attached to the uterus through the cervix, while the uterus is attached to the ovaries via the Fallopian tubes. At certain intervals, the ovaries release an ovum, which passes through the fallopian tube into the uterus. If, in this transit, it meets with sperm, the sperm penetrate and merge with the egg, fertilizing it. The fertilization usually occurs in the oviducts, but can happen in the uterus

itself. The zygote then implants itself in the wall of the uterus, where it begins the processes of embryogenesis and morphogenesis. When developed enough to survive outside the womb, the cervix dilates and contractions of the uterus propel the fetus through the birth canal, which is the vagina. The ova are larger than sperm and are generally all created by birth. Approximately every month, a process of oogenesis matures one ovum to be sent down the Fallopian tube attached to its ovary in anticipation of fertilization. If not fertilized, this egg is flushed out of the system through menstruation. The function of the external female reproductive structures (the genital) is twofold: To enable sperm to enter the body and to protect the internal genital organs from infectious organisms. The main external structures of the female reproductive system include:

Labia majora: The labia majora enclose and protect the other external reproductive organs. Literally translated as "large lips," the labia majora are relatively large and fleshy, and are comparable to the scrotum in males. The labia majora contain sweat and oil-secreting glands. After puberty, the labia majora are covered with hair. Labia minora: Literally translated as "small lips," the labia minora can be very small or up to 2 inches wide. They lie just inside the labia majora, and surround the openings to the vagina (the canal that joins the lower part of the uterus to the outside of the body) and urethra (the tube that carries urine from the bladder to the outside of the body). Bartholin's glands: These glands are located next to the vaginal opening and produce a fluid (mucus) secretion.

Clitoris: The two labia minora meet at the clitoris, a small, sensitive protrusion that is comparable to the penis in males. The clitoris is covered by a fold of skin, called the prepuce, which is similar to the foreskin at the end of the penis. Like the penis, the clitoris is very sensitive to stimulation and can become erect.

Vagina: The vagina is a canal that joins the cervix (the lower part of uterus) to the outside of the body. It also is known as the birth canal. The vagina is the tubular tract leading from the uterus to the exterior of the body in female mammals, or to the cloaca in female birds and some reptiles. Female insects and other invertebrates also have a vagina, which is the terminal part of the oviduct. The vagina is the place where semen from the male is deposited into the female's body at the climax of sexual intercourse, commonly known as ejaculation.

Uterus (womb): The uterus is a hollow, pear-shaped organ that is the home to a developing fetus. The uterus is divided into two parts: the cervix, which is the lower part that opens into the vagina, and the main body of the uterus, called the corpus. The corpus can easily expand to hold a developing baby. A channel through the cervix allows sperm to enter and menstrual blood to exit. The uterus or womb is the major female reproductive organ of humans. One end, the cervix, opens into the vagina; the other is connected on both sides to the fallopian tubes. The uterus mostly consists of muscle, known as myometrium. Its major function is to accept a fertilized ovum which becomes implanted into the endometrium, and derives

nourishment from blood vessels which develop exclusively for this purpose. The fertilized ovum becomes an embryo, develops into a fetus and gestates until childbirth. If the egg does not embed in the wall of the uterus a woman gets her period and the egg is flushed away.

Ovaries: The ovaries are small, oval-shaped glands that are located on either side of the uterus. The ovaries produce eggs and hormones. The ovaries are the place inside the female body where ova or eggs are produced. The process by which the ovum is released is called ovulation. The speed of ovulation is periodic and impacts directly to the length of a menstrual cycle. After ovulation, the ovum is captured by the oviduct, where it travelled down the oviduct to the uterus, occasionally being fertilized on its way by an incoming sperm, leading to pregnancy and the eventual birth of a new human being. The Fallopian tubes are often called the oviducts and they have small hairs (cilia) to help the egg cell travel.

Fallopian tubes: These are narrow tubes that are attached to the upper part of the uterus and serve as tunnels for the ova (egg cells) to travel from the ovaries to the uterus. Conception, the fertilization of an egg by a sperm, normally occurs in the fallopian tubes. The fertilized egg then moves to the uterus, where it implants to the uterine wall. Cervix: The cervix is the lower, narrow portion of the uterus where it joins with the top end of the vagina. It is cylindrical or conical in shape and protrudes through the upper anterior vaginal wall. Approximately half its length is visible; the remainder lies above the vagina beyond view.

Oviducts: The Fallopian tubes or oviducts are two very fine tubes leading from the ovaries of female mammals into the uterus. On maturity of an ovum, the follicle and the ovary's wall rupture, allowing the ovum to escape and enter the Fallopian tube. There it travels toward the uterus, pushed along by movements of cilia on the inner lining of the tubes. This trip takes hours or days. If the ovum is fertilized while in the Fallopian tube, then it normally implants in the endometrium when it reaches the uterus, which signals the beginning of pregnancy

Total With and Salpingo-oophorectomy

Abdominal Without

Hysterectomy Bilateral

Total abdominal hysterectomy is utilized for benign and malignant disease where removal of the internal genitalia is indicated. The operation can be performed with the preservation or removal of the ovaries on one or both sides. In benign disease, the

possibility of bilateral and unilateral oophorectomy should be thoroughly discussed with the patient. Frequently, in malignant disease, no choice exists but to remove the tubes and ovaries, since they are frequent sites of micrometastases. The purpose of the operation is to remove the uterus through the abdomen, with or without removing the tube and ovaries.

Physiologic Changes. The predominant physiologic change from removal of
the uterus is the elimination of the uterine disease and the menstrual flow. If the ovaries are removed with the specimen, the predominant physiologic change noted is loss of the ovarian steroid sex hormone production. Abdominal hysterectomies take from one to three hours. The hospital stay is three to five days, and it takes four to eight weeks to return to normal activities. The advantages of an abdominal hysterectomy are that the uterus can be removed even if a woman has internal scarring (adhesions) from previous surgery or her fibroids are large. The surgeon has a good view of the abdominal cavity and more room to work. Also, surgeons have the most experience with this type of hysterectomy. The abdominal incision is more painful than with vaginal hysterectomy and the recovery period is longer.

Purpose
The most frequent reason for hysterectomy in American women is to remove fibroid tumors, accounting for 30% of these surgeries. Fibroid tumors are non-cancerous (benign) growths in the uterus that can cause pelvic, low back pain, and heavy or lengthy menstrual periods. They occur in 30–40% of women over age 40. Fibroids do not need to be removed unless they are causing symptoms that interfere with a woman's normal activities. In addition to a total hysterectomy, a procedure called a bilateral salphingooophorectomy is sometimes performed. This surgery removes the ovaries and the

fallopian tubes. Removal of the ovaries eliminates the main source of the hormone estrogen, so menopause occurs immediately. Removal of the ovaries and fallopian tubes is performed in about one-third of hysterectomy operations, often to reduce the risk of ovarian cancer.

Laboratory/Diagnostic Examination
Complete Blood Count Results Hemoglobin Hematocrit WBC count 13.7 41 16,000 Normal Values 14-18gm/gl 40-50vol 5,000-10,000 cumm

Differential Count Neutrophils Lymphocyte Eosinophils 78 32 3 40-60 35-40 2-4

Drug Study
Name of Action the Drug Indication Dosage Adverse &Preparation Reaction Nursing Responsibility

Mefenamic Acid

Produces anti-Mild to500mg q6 inflammatory, moderate pain, analgesic &dysmenorrhea antipyretic effects possibly through inhibition of prostaglandin synthesis.

CNS: >Observe 10 rights in drowsiness, giving medication dizziness, > Administered with nervousness food to minimize GI CV: edema adverse reactions. GI: nausea,>Contraindicated in vomiting, GI ulceration r diarrhea, pepticinflammation. ulceration, >Teach patient sign hemorrhage and symptoms of GI GU:dysuria, bleeding, and tell hematuria, patient to report these nephrotoxicity to the doctor Hepatic: immediately. hepatotoxicity >Severe hemolytic Skin:rash, anemia may occur urticaria with prolonged use. Monitor CBC periodically. >Stop drug if rash, visual disturbances, diarrhea develops.

Name of Action the Drug

Indication Dosage Adverse and Reaction Preparati on

Nursing Responsibi lity

Metronidazole (Flagyl) ANTIINEFECTIVES (amebicides& antiprotozoals)

>Direct –actingThe indication1g / rectum 1hrCNS: headache,>Always observe trichomonacide are based on theprior to OR seizures, fever, vertigo,the 10 Rights and amebicideanti-parasitic and ataxia, dizziness,when giving that works insideantibacterial confussion,depression, medication. and outside inactivity. irritability >Give oral form the intestines.>Amebic liver Vision disorder:with meals to It’s thought toabscess, transient visionminimize GI upset enter the cells ofIntestinal disorders such as>Tell pt. he may microorganisms amebiasis, diplopia, myopia experience a that containTrichomoniasis GI: epigastric pain,metallic taste and nitroreductase, >Bacterial pain, nausea, vomiting,have dark or redforming unstableinfections caused diarrhea, metallic taste,brown urine. compounds thatby aerobic dry mouth >Instruct pt in binds DNA andmicroorganisms Hypersensitivity proper hygiene inhibits >To prevent Reactions: rash,>Tell pt to avoid synthesis, postoperative pruritus, flushing,alcohol during causing cellinfection in urticaria, anaphylacticmetronidazole death. contaminated shocks therapy and for colorectal GU: darkened urine,atleast one day surgery polyuria, dryness ofafterwards beause >Bacterial vagina,dysuria of possibility of Vaginosis dislfiram-like (Antabuse effect) >Clostridium difficlereaction. associated >May cause diarrhea and transient visual colitis disorder, dizziness& >Pelvic Inflammatory confusion avoid activities disease requiring alertness like driving a vehicle.

Name of Action the Drug

Indication

Dosage Adverse Reaction &Preparation

Nursing Responsibility

Bisacodyl Stimulant Chronic 2 tablets (hoursCNS: dizziness, faintness,>Give drugs at laxative thatconstipation; of sleep) muscle weakness withtimes that don’t increases preparation excessive use interfere with peristalsis, for child birth, GI: abdominal cramps,scheduled probably bysurgery, or burning sensation inactivities or direct effectrectal or rectum with suppositories,sleep. on smoothbowel nausea and vomiting >Before giving muscle of theexamination. METABOLIC: for constipation, intestine, by alkalosis, fluid anddetermine irritating the electrolyte imbalance,whether patient muscle or has adequate hypokalemia. stimulating the intake MUSCULOSKELETAL: fluid colonic exercise and diet. tetany intramural >Tablets and plexus. suppositories are Drug also use together to promotes fluid clean the colon accumulation before and after in colon and surgery and small before barium intestine. enema. >Insert suppository as high as possible in to the rectum, and try to position suppository against the rectal wall. Avoid embedding within fecal material because doing so may delay onset of action. >Bisco-Lax may

contain tartazine.

Name of Action the Drug

Indication

Dosage Adverse &Preparation Reaction

Nursing Responsibility

Morphine Binds with>Severe pain 3mg throughCNS: dizziness,>Reassess patient’s Sulfate opiate light-level of pain at least >Moderate toEpidural cathetereuphoria, receptor insevere painq12 x 3 headedness, 15 to 30 minutes. the CNS,requiring nightmares, >Keep opioid altering continuous, sedation, anatagonist perception around somnolence, the (naloxone) and of andclock opioid seizures, resuscitation emotional >Single dose, depression, equipment available. response toepidural hallucinations, >Monitor pain. nervousness, extended pain circulatory, physical relief after respiratory, bladder dependence. major surgery. and bowel function CV: carefully. bradycardia, >Oral solutions of cardiac arrest,various shock, concentrations and hypertension, an intensified oral tachycardia solution are GI: constipation,available. nausea and>Oral capsules may vomiting, be carefully opened anorexia, biliaryand the entire tract spasm, drycontents poured into mouth, ileus cool soft foods such GU: urineas water, orange retention, juice, apple sauce or HEMATOLOGIC: pudding. thrombocytopenia >Morphine is drug RESPIRATORY: of choice in apnea, respiratoryrelieving MI pain; arrest, respiratorymay cause transient depression decrease in blood SKIN: pressure. diaphoresis,

edema, pruritus and skin flushing OTHER: decreased libido

Name of Action the Drug

Indication Dosage Adverse &Preparati Reaction on

Nursing Responsibility

Cefuroxime Second >Serious 1.5 qm IVPCV: phlebitis,> Before giving drug generation lower after negativethrombophlebiti ask patient if she is cephalosp respiratory skin testing s allergic to penicillin orin thattract GI: diarrhea,or cephalosporin. inhibits infection, pseudo>Obtain specimen for cell wallUTI, skin or membranous culture and sensitivity synthesis skin colitis, nausea,test before giving first promoting structure anorexia anddose. osmotic infections, vomiting >Absorption of oral instability; bone or joint GU: urinedrug is enhanced usually infections, retention, >Tablets may be bactericida septicemia, HEMATOLOGI crushed, if absolutely l meningitis C: necessary for patient and thrombocytopen who can’t swallow gonorrhea ia, hemolytictablets. >Preanemia, operative transient prevention neutropenia, >Bactericida eosiniphilia. l exarbations RESPIRATORY of chronic : apnea, bronchitis or respiratory secondary arrest, bacterial respiratory infection of depression acute SKIN: bronchitis maculopapular >Acute and bacterial erythematous maxillary rashes, urticaria, sinusitis pain, induration, >Pharyngitis sterile and abscesses, tonsillitis temperature

>Otitis media

elevation, tissue sloughing at IM injection site OTHER: anaphylaxis, hypersensitivity reactions, serum sickness

Discharge Plan
Medication
Oral contraceptives: Birth control pills may be helpful to regulate the menstrual cycle, prevent the formation of follicles that can turn into cysts, and possibly reduce the size of an existing cyst. Pain relievers: Anti-inflammatories such as ibuprofen (for example, Advil) may help reduce pelvic pain. Narcotic pain medications by prescription may relieve severe pain caused by ovarian cysts.

Exercise
• • • • Relaxation exercise turning to sides every 2 hours if lying in bed for long hours do light activities such as walking, or sitting down Exercise social interaction with the family

Treatment
Surgical treatments for Ovarian Cysts Functional ovarian cysts are the most common type of ovarian cyst. They usually disappear by themselves and seldom require treatment. Growths that become abnormally large or last longer than a few months should be removed or examined to determine if they are in fact something more harmful.

Self-Care at Home
Pain caused by ovarian cysts may be treated at home with pain relievers, including nonsteroidal anti-inflammatory drugs such as ibuprofen (Motrin), acetaminophen (Tylenol), or narcotic pain medicine (by prescription). Limiting strenuous activity may reduce the risk of cyst rupture or torsion.

Medical Treatment
Ultrasonic observation or endovaginal ultrasound are used repeatedly and frequently to monitor the growth of the cyst.

Health Teachings:
 Proper hygiene.  Proper diet such as eating nutritional foods that are rich in protein and Vit. C to promote well-being.  Increase physical activities.  Avoid eating sweet foods.  Adequate rest and sleep.

OPD (follow up)
7 days after the patient was discharge, patient should have his follow up check up on the nearest health center or hospital Diet Increase oral fluid intake Prevent eating of sweet foods Have a high fiber diet

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