I.

Introduction
A case study of a particular disease is made to enhance the understanding ability

of the student nurse in dealing with their patient. This case on Adenomyosis in which

Total Abdominal Hysterectomy and Bilateral Salpingo-Oophorectomy was performed

and studied because the student nurse wants and is eager to learn more about the

condition. This case study was made and supervised under a clinical instructor in order to

learn about the particular condition and to learn skills in actual clinical setting.
After making this case study, the student nurse will be able to have a good

understanding in rendering care to the client before, during and after hospitalization of

the patient who underwent Total Abdominal Hysterectomy Bilateral Salpingo-

Oophorectomy due to Adenomyoma. Lastly, the student nurse will understand properly

her role in cases like this and in how to perform holistic care in this case in this situation.
Adenomyosis is a condition in which the inner lining of the uterus (the

endometrium) breaks through the muscle wall of the uterus (the myometrium).

Adenomyosis can cause menstrual cramps, lower abdominal pressure, and bloating

before menstrual periods and can result in heavy periods. The condition can be located

throughout the entire uterus or localized in one spot.

Total abdominal hysterectomy bilateral salpingo oophorectomy (TAHBSO) is the

removal of entire uterus, the ovaries, fallopian tubes and the cervix. TAHBSO is often

performed on cancer patients or to relieve severe pelvic pain from things like,

endometriosis or adenomyosis. It is also used as a last resort for postpartum obstetrical

haemorrhage or uterine fibroids that cause heavy or unusual bleeding and discomfort in

some women.

II. Objectives:
1. Student-Nurse Centered Objective
1.1. General Objectives:

1
 At the end of 3 days of nursing care, the student nurse will be able to gain more

knowledge and enhances skills in managing a patient with adenomyosis who underwent

Total Abdominal Hysterectomy Bilateral Salpingo-Oophorectomy.

1.2. Specific Objectives:

After 8 hours of student nurse-patient interaction, the student nurse will be able to:

1. gain information in connection to reason why the patient is admitted

2. make a thorough assessment about the patients personal history, family

background and lifestyle

3. define Adenomyosis
4. state the causes of Adenomyosis
5. enumerate clinical manifestation of adenomyosis, manifested by the patient
6. recall the anatomy and physiology of the organ affected by ovarian cyst
7. trace the pathophysiology of adenomyosis
8. differentiate the classical and clinical manifestation of adenomyosis
9. develop a plan of care necessary in managing adenomyosis
10. evaluate a feedback or patients reaction, state or condition after implementation

of the case
11. differentiate the different indication, contraindication and complication of Total

Abdominal Hysterectomy Bilateral Salpingo-Oophorectomy

12. prevent infection from occurring in the post-operative wound

2
2. Patient Centered
2.1. General Objectives:

At the end of the 3 days holistic nursing care, the patient and significant

others will be able to gain information for the management and prevention of

adenomyoma and management of post Total Abdominal Hysterectomy Bilateral

Salpingo-Oophorectomy.

2.2. Specific Objectives:

After 8 hours of student nurse-patient interaction, the patient will be able to:

3
 1. exhibit positive attitude and response towards the student nurse
2. understand the definition of Adenomyosis
3. identify the causes of disease condition
4. verbalize what she feels and her opinion of the condition
5. cooperate in activities of daily living
6. gather information about the disease process of adenomyosis
7. enhance a sense of independency in caring for herself
8. determine behaviors that improves the health condition

III. Nursing Assessment

1. Personal History
1.1. Patients Profile

Name: Alima, Grace Canete

Age: 49 years old

Sex: Female

Civil Status: Single

Address: Brgy. Liloan Ormoc City

Birthdate: May 25 1962

Occupation: Housewife

Admission Date: January 5, 2017

Room No: 215

4
 Complaints: Vaginal Bleeding

Diagnosis: Adenomyosis

Physician: Dr. Gardenia Larrazabal

Dr. Lourdes De Veyra

Dr. Carmelito Paradela

Case No. 011795545

1.2. Family and Individual, Social and Health history:

Ms. Alima, 49 years old, lived in a simple lifestyle at Brgy. Liloan Ormoc

City, Leyte. A year prior to admission Ms. Alima underwent dilatation and curettage in

Ormoc District Hospital, because of a miscarriage. Ms. Alima verbalized that after the

dilatation and curettage she started to have heavier menstrual period, and often uses

diapers during her menstruation. Ms. Alima is currently living with her brother and two

children at Brgy. Liloan, Ormoc City, Leyte. Ms. Alima and her husband separated after

their fourth child was miscarriaged. Ms. Alima had four pregnancies but only two of her

children are alive, because his first son died at the age of ten and her 4 th pregnancy was

aborted at 3 weeks of gestation. Ms. Alima was born in Ormoc city and was baptized as

pure Catholic. She was born a Filipina by nature. Ms. Alima has 2 siblings and is in a

5
good relationship with them. A month prior to admission the patient verbalized that she

had two separate menstrual cycles in one month and that the second menstruation was

longer, heavier, and more painful leading to a decision that she would like to be

hospitalized. When patient was admitted she had a pelvic ultrasound and was pre-

operatively diagnosed with Adenomyoma, due to this diagnosis the physician

recommended that the patient undergo an operation so that the tissue can be biopsied. On

January 2017 the patient underwent Total Abdominal Hysterectomy Bilateral Salpingo-

Oophorectomy. Patient has no allergy to food and drug

1.3. Level of Growth and Development

1.3.1. Normal development of Middle Adulthood (40-65 years old)

Physical Development

A number of changes that start when young adults are in their mid- twenties

become noticeable as effectively as the fifth decade approaches. Both men and women

experience decreasing hormonal production during the middle years. The menopause

refers to the so-called change of life in women, when menstruation ceases. The

menopause usually occurs sometime between ages 40-55. At this time the ovarian activity

declines until ovulation ceases. The common symptoms related to the decline of estrogen

are hot flashes, chillness and a decrease in metabolic rate.

Psychological Development

6
 Erikson viewed the developmental choice of the middle-aged adult as generativity

versus stagnation. Generativity is defined as the concern for establishing and guiding the

next generation. Generative middle-aged persons are able to feel a sense of comfort in

their lifestyle and receive gratification from charitable endeavors. Erikson wrote that

people who are unable to expand their interests at this time and who does not assume the

responsibilities of middle age suffer a sense of boredom and impoverishment that is

stagnation.

Prior to this period, the marriage partner or lover and the other persons were

crucial to a definition of self. The middle age person does not make comparisons with

others, often no longer fears aging or death, and enjoys the independence and freedom of

middle age. Other peoples opinions become less important, and the earlier habit of trying

to please everyone is overcome. The focus shifts from inner self and being to others and

doing.

Cognitive Development

Reaction time during the middle years stays much the same. Memory and

problem solving are maintained through middle adulthood. Learning continues and can

be enhanced by increasing motivation at this time In life. The experiences of the

professional, social, and personal life of middle-aged persons will be reflected in their

cognitive performance.

Moral Development

7
 Kohlberg believed that extensive experience of personal moral choice and

responsibility is required before people can reach the post-conventional level. Kohlberg

found that few of his subjects achieved the highest level of moral reasoning.

Spiritual Development

At this stage, the individual can view truth from a number of viewpoints.

Fowlers fifth stage of moral development corresponds to Kohlbergs. Fowler believes

that only a few individuals after the age of thirty reach this stage. In middle age people

tend to be less dogmatic about religious beliefs, and religion often offers more comfort to

the middle aged person than it did previously.

1.3.2. The Ill Person at Particular Stage of Patient

Many people in early adulthood remain healthy, however, the risk of

developing a health problem is greater that of the young adult. Leading causes of

death in this age group include: motor vehicle and occupational injuries, chronic

disease such as cancer, cyst and cardiovascular disease. Lifestyle patterns in

combination with aging, family history and developmental stressors (e.g.

menopause) and situational stressors (e.g divorce) are often related to help

problems that do arise.

Illnesses and conditions experienced in early adulthood may affect their

roles and responsibility. Strained family relationships, modification in family

activities, increase health care task, increase financial stress; the need for housing

8
adaptation; social isolation, medical concerns, and grieving may all result from

illness. The ill behavior of depression, describe them as feeling sad and alone.

Alteration in sleep patterns such as difficulty in sleeping, anxiety, feeling of social

interest, headache, regardless of the amount of rest and feeling of fatigue, low

self-esteem and seek attention from the significant others.

Prior to admission, the patient experienced heavy menstrual flow for 3

weeks. On January 4, 2017, her brother rushed her to the Emergency Room and

she decided to have an operation. Post-operatively, the patient was happy and

relieved knowing that the operation was done and was successful, although pain

was being felt because of the midline incision on her abdomen but she was

satisfied with the result and was able to rest well in her stay in the hospital for

recovery. The patient was very cooperative to the nursing procedure that was

performed and listened to the nurse on her take home medication and to the

physicians instruction to be back for a follow-up check-up after one week at

OSPA-FMC by Dr. Gardenia Larrazabal

9
2. Diagnostic Results
Ultrasound report
Gynecology

Date Performed: January 5 2017

Uterus: 6.1 x 3.7cm x 7.8cm anteverted

There is an ill-defined mass at the posterior uterine wall with coarse

echopattern measuring 6.1 x 6.6cm

Endometrium: thick 1.4cm hyperechoic

Adnexa: right ovary 1.6 x1.4 x 2.7cm

There is a solid echogenic structure within the endometrial cavity measuring

2.1x 1.2cm suggestive of an endometrial pathology

Left Ovary: 1.6cm x 2.2cm x 1.7cm

10
 Abnormalities Noted: Lateral to Uterus

Cervix: 2.0 x 1.7 x 2.6cm

Diagnosis: enlarged anteverted uterus with an echogenic structure within. Consider an

endometrial pathology. Both ovaries are normal. Suggest tissue correlation Adenomyoma.

Hematology

Date Performed: January 9 2017

Diagnostic Test Normal value Result Significance

White blood cells 5.000-10.000 x 6.5 x 10^9/L Normal
10^9/L

4.2000-5.4000 x 3.85 x 10^12/L Decreased. May be

Red blood cells
10^12/L due to abnormal loss
of erythrocytes, or
lack of needed
elements or
hormones for
erythrocyte
production.

11.0000-15.0000
g/dl 9.9 g/dl
Hemoglobin Decreased. May be
caused by: blood
loss, hemolytic
anemia, and bone
37.0000-47.0000% marrow suppression
Hematocrit

11
 31.5% Decreased. May be
due to blood loss,
overhydration,
80.0000-96.0000fl
dietary deficiency or
MCV 27.0000-31.0000pg anemia

MCH 81.8% Normal.

32.0000- 36.0000 25.7pg Decreased. May be

g/dl due to iron
MCHC
deficiency anemia
150.0000-450.0000
x 10^9/L 31.4g/dl Decreased. May be
Platelet due to iron
deficiency anemia
50.0000- 70.0000%
159 X 10^9/L Normal.
Neutrophil

1.0000-6.0000%

Eosinophil 20.0000-40.0000% 80.7% Increased. May be

due to stress or an
Lymphocyte acute infection

1.6% Normal

0-7% 16.0% Decreased. May be

due to: adrenal
Monocyte 0-3% corticosteroids and
other
Basophil
immunosuppressive
drugs

0.9% Normal.

0.8% Normal.

12
3. Physical Assessment

Physiologic Inspection Palpation Percussion Auscultation

Body parts

Head - round and - no masses

symmetrical felt upon
palpation

Hair - blonde in color - smooth and

and evenly not oily; not
distributed, no brittle
lice

Scalp - no lice noted, -smooth upon

lighter in color papation
than the - no masses
complexion felt upon
palpation

Forehead - no scars, - no masses

13
 symmetrical, felt upon
brown in color palpation

Face - round in shape, - no lumps

no bruises and no
-with bilateral nodules; skin
nasolabial folds is oily

Eyes - symmetrical in -no

line with each discharges
other; none upon
protruding palpation

Brows - thin and evenly

distributed; -no lumps; no
symmetrically lesions
aligned

Lashes - curled upward

slightly -non-brittle

Lids - no
inflammation
Upper eyelid - no cuts and
inflammation

Lower eyelid - no cuts and

inflammation

Sclera - white in color,

without lesions

Conjunctiva - pale in color

and blood
vessels are
visible

Cornea - no discharges,
moist and shiny

Iris - black and

brown
coloration

14
Pupil
- pupils equally
round and
reactive to light
and
accommodation

Muscle
Function - able to see the
objects in
different
directions
Muscle
Balance - both eyes blink
symmetrically

Visual
Acquity - no snellen
chart

Peripheral
Vision
- peripheral
Nose vision is good - flat sound
- no pain felt heard
- absence of
pimples and
Frontal lesion - flat sound
Sinuses - no pain felt heard
-no evidence of
swelling around
the eyes
Maxillary
Sinuses -no presence
- no evidence of of lumps
swelling around
Lips the eyes
- no pain felt
- cracked lips, upon
dark pink in palpation
Gums color
-moist
- pale in color,
Teeth no swelling

15
Tongue - slightly yellow

- midline of the
mouth and able
to move her
Frenulum tongue

- attached to the
Sublingual tongue, moist
Area
- blood vessels
Hard Palate were visible

- concave, light
pink

Soft Palate

-concave, light
Uvula pink

- located at the
midline
Ears
-non-tender
- symmetrical
External
-non-tender
- symmetrical to
eyes
Internal

- not visible
Auditory
Acuity
- patient was
able to hear in
Neck one meter
distance -no palpable
masses
- fair
Lymph complexion,
Nodes able to move -not palpable

Trachea - not visible

-not enlarged,

16
 no masses
Thyroid - located at the
glands center -no palpable
masses
-moves up while
swallowing
Thorax
Chest -resonance Bronchovesicula
anterior - symmetric over lung, dull r sound
excursion over scapula
-spine vertically and ribs
aligned and no
presence of - no murmurs
Lungs wounds sound

- regular
breathing -78beats per
Heart minute

- tympany - bowel sound

Abdomen - no presence sound heard heard for 23
of pain seconds
- fair during
complexion; palpation
dressing to
surgical site
noted; surgical
wound is -dull
Liver dressed with
betadine - no pain felt
solution -dull
Spleen

- no pain felt -dull

Kidney

Extremities

Upper
muscle tone -No pain felt
- skin is
- fair warm to
complexion touch
- PR=78
Upper beats/ min.

17
muscle
Strength - able to
resist the
- equal in force
strength - T=37.7
degrees
IVF Celsius

Lower - no pain felt

muscle tone - D5W upon
palpation

Lower
muscle - able to
strength perform the
- patient wasnt reflexes
able to perform
the test because
she cant stand
up on the second
day however the
Balance patient was able
to walk around
slowly
Patient can walk
slowly while
holding unto
someone

4. Functional health pattern

Health perception
The patient said that before she was diagnosed with a possible case of

adenomyoma, she was not that attentive to her hea;th needs. She does not have

vitamins, but is in a healthy diet eating lots of fruits and vegetables. She usually

copes with sickness through resting and she also admitted that she is a chain

smoker- smoking 3 packs a day. However last month she had noticed she had a

longer menstrual period and began to grow concerned about her health.
Nutritional metabolic pattern

18
 The patient is currently on soft diet and says that she is already very

hungry. Before she was admitted she used to eat vegetables and fruits and rarely

ate meat. She verbalized that she does not eat rice during breakfast but rather she

only drinks coffee or milk. Sometimes they also eat fish.

Elimination
Patients catheter has just been removed and she was already done

voiding. She has not yet defecated since she was admitted. Prior to admission the

patient verbalized that she used to urinate at least 7 times a day and that she has

plenty of urine, she also defecates at least once a day prior to admission.
Activity and exercise pattern
Prior to hospitalization the patient admitted that she had a sedentary

lifestyle and granted her house chores as exercise for the day. Prior to

hospitalization the patient was unable to ambulate before the operation because

she was in pain, a day after the operation she was capble of sitting down, at the

second day she was able to ambulate

Coping and Stress
Before the patient was hospitalized she used to watch tv and smoke when

she is stressed she also talks to her son and daughter whom she says are very

attentive to her. After the operation, the patient is still able to cope with things

because her family was there beside to take care for her and help her for fast

recovery. She was able to express what she feels about the operations she

underwent.

Cognitive/Perceptual

The patient doesnt have any problems in vision, hearing, taste, smelling

and sense of touch. She is able to read and write. She is oriented to time, place

and she is responsive to verbal and physical stimuli.

19
Sexuality and Reproduction

Patient was separated with her husband after their youngest child was

aborted. The patient had four previous pregnancies but the fourth pregnancy was

aborted when she was 3 weeks pregnant and she had a Dilatation and curettage at

Ormoc district Hospital.

Roles and Relationship

The patient is close with her family and has no problem in relating with

them. She lives with her brother and two children. She is separated with her

husband because or personal reasons. Prior to hospitalization her younger child

was left with her brother, while her older child and her brother was the one

attending to her needs in the hospital.

Values and Belief

The patient and her entire family are Roman Catholic. She does believe in

the so called binisaya. As part of spiritual growth they all go to church every

Sunday and spend time together during this day.

20
5. Pathophysiology and Rationale
5.1. Normal Anatomy and Physiology of Organ/System Affected

Reproductive System of the Female

Ovaries

21
 The ovary is an ovum-producing reproductive organ, often found in pairs as part

of the vertebrate female reproductive system. Ovaries in females are homologous to

testes in males, in that they are both gonads and endocrine glands.

Ovaries are oval shaped and, in the human, measure approximately 3 cm x 1.5 cm

x 1.5 cm (about the size of a Greek olive). The ovary (for a given side) is located in the

lateral wall of the pelvis in a region called the ovarian fossa. The fossa usually lies

beneath the external iliac artery and in front of the ureter and the internal iliac artery.

Ovaries secrete both estrogen and progesterone. Estrogen is responsible for the

appearance of secondary sex characteristics of females at puberty and for the maturation

and maintenance of the reproductive organs in their mature functional state. Progesterone

functions with estrogen by promoting cyclic changes in the endometrium (it prepares the

endometrium for pregnancy), as well as by helping maintain the endometrium in a

healthy state during pregnancy.

Uterine (Fallopian) Tubes

The Fallopian tubes, named after Gabriel Fallopius (Gabriele Falloppio), also

known as oviducts, uterine tubes, and salpinges (singularsalpinx) are two very fine tubes

lined with ciliatedepithelia, leading from the ovaries of female mammals into the uterus,

via the utero-tubal junction. In non-mammalian vertebrates, the equivalent structures are

the oviducts.

In a woman's body the tube allows passage of the egg from the ovary to the

uterus. Its different segments are (lateral to medial): the infundibulum with its associated

22
fimbriae near the ovary, the ampullary region that represents the major portion of the

lateral tube, the isthmus which is the narrower part of the tube that links to the uterus, and

the interstitial (also intramural) part that transverses the uterine musculature. The tubal

ostium is the point where the tubal canal meets the peritoneal cavity, while the uterine

opening of the Fallopian tube is the entrance into the uterine cavity, the utero-tubal

junction. Ovaries are also connected to the urinary bladder.

There are four parts of the fallopian tube from the ovary to the uterus

The fimbria

Infundibular

Ampulla - where the ovum is fertilized

Isthmus

Layers

The fallopian tube is made of three layers

Mucosa - these are folded walls with ciliated cells along them.

Muscularis externa

23
 Serosa

Uterus

The uterus (from Latin "uterus" (womb, belly), plural uteruses or uteri) or womb

is a major female hormone-responsive reproductive sex organ of most mammals

including humans. One end, the cervix, opens into the vagina, while the other is

connected to one or both fallopian tubes, depending on the species. It is within the uterus

that the fetus develops during gestation, usually developing completely in placental

mammals such as humans and partially in marsupials such as kangaroos and opossums.

Two uteruses usually form initially in a female fetus, and in placental mammals they may

partially or completely fuse into a single uterus depending on the species. In many

species with two uteruses, only one is functional. Humans and other higher primates such

as chimpanzees, along with horses, usually have a single completely fused uterus,

although in some individuals the uteruses may not have completely fused. The term

uterus is used consistently within the medical and related professions, while the

Germanic derived term womb is also common in everyday usage in the English language.

Vagina

The vagina (from Latinvagna, literally "sheath" or "scabbard") is a

fibromusculartubular tract leading from the uterus to the exterior of the body in female

placental mammals and marsupials, or to the cloaca in female birds, monotremes, and

some reptiles. Female insects and other invertebrates also have a vagina, which is the

terminal part of the oviduct. The Latinate plural "vaginae" is rarely used in English.

24
The human vagina is an elastic muscular canal that extends from the cervix

to the vulva.[1] Although there is wide anatomical variation, the length of the

unaroused vagina is approximately 6 to 7.5 cm (2.5 to 3 in) across the

anterior wall (front), and 9 cm (3.5 in) long across the posterior wall (rear).

During sexual arousal the vagina expands in both length and width. Its

elasticity allows it to stretch during sexual intercourse and during birth to

offspring. The vagina connects the superficial vulva to the cervix of the deep

uterus.

(Source: Elaine Marieb, Human Anatomy and Physiology 7th Edition, Chapter 23, pg.

512)

5.2. Make a Schematic Drawing to Show Pathophysiology of Disease its

effect on tissue or organ

Predisposing Factors Precipitating Factors

- Age (Older age) -cesarean section (C-section)

- Parity -surgical pregnancy termination
- Previous uterine abrasion -pregnancy
- local hyperestrogenism Pelvic Inflammatory Disease
-

Lesions of the ovary

25
 Severing of ties in the endometrial cells

Abnormal growth of endometrial tissue

growth into the myometrium (muscle layer of the uterus)

Adenomyosis

Endometrial tissue
Broken
myometrium
Focused in one Thickening of the
area endometrial wall

Stimulation of
Inflammation
Adenomyoma estrogen and
progesterone are not
balanced
Removal of the
Pain response Follicle growth
myometrium

Endometrial
bleeding
Hysterectomy
Low hemoglobin:
anemia

26
5.3. Pathophysiology and rationale of adenomyosis

In adenomyosis the tissue that lines the endometrium invades the uterine

wall. The term adenomyosis is derived from the terms adeno (gland) myo (muscle) and

osis (conditioon). This incidence is highest in women 40 to 50 years of age. Symptoms

include hypermenorrhea, acquired dysmenorrhea, polymenorrhea, and premenstrual

staining. Physical examination findings on palpation include an enlarged, firm, and tender

uterus. The uterus may appear lumpy during a laparoscopy and feel thick to touch, and

there may be a measurably increased flow of blood to the uterus, but the actual implants

are not visible. For this reason a woman with adenomyosis may be mistakingly diagnosed

as having fibroids. Even in the ultrasound image, if the adenomyosis have clumped

together into groups (known as adenomyomas), they can resemble fibroids. Treatment

depends on the severity of bleeding and pain. Hysterectomy may offer greater relief than

more conservative therapies. A biopsy of uterine muscle can provide a definitive

diagnosis( Brunner & Suddarth's Textbook of Medical-surgical Nursing, Volume 1 edited

by Suzanne C. O'Connell Smeltzer, Brenda G. Bare, Janice L. Hinkle, Kerry H. Cheever

pp1457)

27
5.4. Comparison of clinical and classical symptoms

Classical Symptoms Clinical Symptoms Rationale

Manifested; This condition occurs when
Heavy or prolonged Cues: glands from the
menstrual bleeding verbalization of patient endometrium become
that she has had embedded in the uterine
menstruation for more muscle, often causing heavy
than 2 weeks with bleeding and painful
heavy flow menses( Brunner &
Suddarth's Textbook of
Medical-surgical Nursing,
Volume 1 edited by
Suzanne C. O'Connell
Smeltzer, Brenda G. Bare,
Janice L. Hinkle, Kerry H.
Cheever pp1456)

Severe cramping or Manifested. This condition occurs when

sharp, knifelike pelvic Cues: glands from the
pain during Patient verbalized that endometrium become
menstruation during this embedded in the uterine
(dysmenorrhea) menstruation period muscle, often causing heavy
she had a more painful bleeding and painful
dysmenorrhea menses( Brunner &
Suddarth's Textbook of
Medical-surgical Nursing,
Volume 1 edited by
Suzanne C. O'Connell
Smeltzer, Brenda G. Bare,
Janice L. Hinkle, Kerry H.
Cheever pp1456)

28
 Menstrual cramps Manifested. This condition occurs when
that last throughout your Cues: The patient glands from the
period and worsen as verbalized that she had endometrium become
you get older dysmenorrhea during her embedded in the uterine
periods muscle, often causing heavy
bleeding and painful
menses( Brunner &
Suddarth's Textbook of
Medical-surgical Nursing,
Volume 1 edited by
Suzanne C. O'Connell
Smeltzer, Brenda G. Bare,
Janice L. Hinkle, Kerry H.
Cheever pp1456)

Not manifested.
Pain during
intercourse

Manifested. In adenomyosis the

Cues: endometrial tissue, which
Blood clots that pass Patient verbalized that normally lines the uterus,
during your period she often has blood exists within and grows into
clots during urination the muscular wall of the
and also in her napkins. uterus. The displaced
endometrial tissue
continues to act as it
normally would thickening,
breaking down and bleeding
( Brunner & Suddarth's
Textbook of Medical-
surgical Nursing, Volume 1
edited by Suzanne C.
O'Connell Smeltzer, Brenda
G. Bare, Janice L. Hinkle,
Kerry H. Cheever pp1456)

Manifested The muscular overgrowth

Cues: patient verbalized causes the endometrial

29
 Abdominal pressure and that she felt like her lower glands to get trapped in the
bloating abdomen seems bigger myometrium, resulting in
problems in the digestive
tract( Brunner & Suddarth's
Textbook of Medical-
surgical Nursing, Volume 1
edited by Suzanne C.
O'Connell Smeltzer, Brenda
G. Bare, Janice L. Hinkle,
Kerry H. Cheever pp1456)

IV. Nursing Interventions

1. Care Guide for Patient with Adenomyosis
Provide isolation and monitor visitors as indicated. Body substance isolation

should be used for all infectious patients. Reverse isolation/restriction on of

visitors may be needed to protect the immunosuppressed patient ( Brunner &

Suddarth's Textbook of Medical-surgical Nursing, Volume 1 edited by Suzanne C.

O'Connell Smeltzer, Brenda G. Bare, Janice L. Hinkle, Kerry H. Cheever pp1458)

Wash hands before or after each care activity, even gloves are used. Reduces risk

of cross contamination because gloves may have noticeable defects, get torn or

damaged during use. ( Brunner & Suddarth's Textbook of Medical-surgical

Nursing, Volume 1 edited by Suzanne C. O'Connell Smeltzer, Brenda G. Bare,

Janice L. Hinkle, Kerry H. Cheever pp1458)

Maintain patency of indwelling catheter; keep drainage tubing free of kinks.

Promotes free drainage of urine, reducing risk of urinary stasis and retention and

30
 infection. ( Brunner & Suddarth's Textbook of Medical-surgical Nursing, Volume

1 edited by Suzanne C. O'Connell Smeltzer, Brenda G. Bare, Janice L. Hinkle,

Kerry H. Cheever pp1458)

Provide routine voiding measures: privacy, normal position, running water in

sink, pouring warm water over perineum. Promotes relaxation of perineal muscles

and may facilitate voiding efforts. ( Brunner & Suddarth's Textbook of Medical-

surgical Nursing, Volume 1 edited by Suzanne C. O'Connell Smeltzer, Brenda G.

Bare, Janice L. Hinkle, Kerry H. Cheever pp1458)

Inspect dressings and perineal pads, noting color, amount, and odor of drainage.

Weigh pads and compare with dry weight if patient is bleeding heavily. Proximity

of large blood vessels to operative site and/or potential for alteration of clotting

mechanism increases risk of postoperative hemorrhage. ( Brunner & Suddarth's

Textbook of Medical-surgical Nursing, Volume 1 edited by Suzanne C. O'Connell

Smeltzer, Brenda G. Bare, Janice L. Hinkle, Kerry H. Cheever pp1458)

Auscultate bowel sounds. Note abdominal distension, presence of nausea and

vomiting. Indicators of presence or resolution of ileus, affecting choice of

interventions. ( Brunner & Suddarth's Textbook of Medical-surgical Nursing,

Volume 1 edited by Suzanne C. O'Connell Smeltzer, Brenda G. Bare, Janice L.

Hinkle, Kerry H. Cheever pp1458)

Assist patient with sitting on edge of bed and walking. Early ambulation helps

stimulate intestinal function and return of peristalsis. ( Brunner & Suddarth's

Textbook of Medical-surgical Nursing, Volume 1 edited by Suzanne C. O'Connell

Smeltzer, Brenda G. Bare, Janice L. Hinkle, Kerry H. Cheever pp1458)

Encourage adequate fluid intake, including fruit juices, when oral intake is

resumed. Promotes softer stool; may aid in stimulating peristalsis. ( Brunner &

31
 Suddarth's Textbook of Medical-surgical Nursing, Volume 1 edited by Suzanne C.

O'Connell Smeltzer, Brenda G. Bare, Janice L. Hinkle, Kerry H. Cheever pp1458)

Review effects of surgical procedure and future expectations. The patient needs to

know that she will no longer menstruate or bear children, and the possible need

for hormonal replacement. Provides knowledge base from which patient can

make informed choices. ( Brunner & Suddarth's Textbook of Medical-surgical

Nursing, Volume 1 edited by Suzanne C. O'Connell Smeltzer, Brenda G. Bare,

Janice L. Hinkle, Kerry H. Cheever pp1458)

Identify dietary needs. Give foods high in protein and iron. Facilitates healing and

tissue regeneration and helps correct anemia when present. ( Brunner &

Suddarth's Textbook of Medical-surgical Nursing, Volume 1 edited by Suzanne C.

O'Connell Smeltzer, Brenda G. Bare, Janice L. Hinkle, Kerry H. Cheever pp1458)

2. Nursing care plans

Cues Nursing Scientific basis Plan of care Interventions Rationale

diagnosis
Subjective Alteration in After 8hrs 1.Accept .Pain was a
cues: comfort: of holistic clients subjective

32
sakit kayo Acute Pain nursing description experience and
ako tiyan as related to intervention of pain. cannot be felt
verbalized by postsurgical the client Acknowledg by others.
patient incision as will be able e the pain Source:
evidenced by to: experience Nursing Care
Objective pain-scale of a) reduce and convey Plans &
cues: 6/10,10as the pain from a acceptance Documentation
Character- grade of
highest, of clients : Nursing
stinging pain 6/10 to
facial response to Diagnoses and
Onset- 2
grimace and 3/10, 10as pain. Collaborative
hours after
muscle the highest. Problems pp
giving pain b) verbalize
guarding 474
reliever nonpharmac
Location- 2.Observe
ologicmetho 2.Observations
incision site non-verbal
ds toprovide may not be
Duration- cues/pain
relief congruent with
lasts until behaviors verbal reports.
next pain and other Source:
reliever objectives Nursing Care
medication defining
S- pain scale Plans &
characteristic Documentation
of 6/10
s, as noted, : Nursing
Pattern- pain
especially in Diagnoses and
is relieved
persons, who Collaborative
after pain
cantcommu Problems pp
medication is
nicate. 474
given and
patient has 3.Provide 3.To promote
rested comfort
Association- non-
measures: pharmacologic
associated
touch, pain
with pain in
repositioning management.
lower
, nurse Source:
abdomen
presence. Nursing Care
Plans &
Documentation
: Nursing
Diagnoses and
Collaborative
Problems pp
474

33
 4.Encourage
diversional 4.To distract
activities: attention.
TV/radio, Source:
socialization Nursing Care
of others. Plans &
Documentation
: Nursing
Diagnoses and
Collaborative
Problems pp
5.Encourage 474
use of
Relaxation 5.To reduce
techniques: tension.
focused Source:
breathing, Nursing Care
imaging, Plans &
Documentation
: Nursing
Diagnoses and
Collaborative
Problems pp
6. Collabora
474
te with
the client Collaboration
to can help
determin minimize
e feeling of pain
effective Source:
pain Nursing Care
relief Plans &
interventi Documentation
on : Nursing
Diagnoses and
Collaborative
Problems pp
.7.Cooperate 474
with the
family of the 7.To be able to
client to follow up the

34
 document the situation of the
health of the patient Source:
patient Nursing Care
Plans &
Documentation
: Nursing
Diagnoses and
Collaborative
Problems pp
474

35
cues Nursing Scientific Plan of care Interventions rationale
diagnosis basis
Subjectiv Impaired skin Surgical After 8 hours Independent:
e Cues: integrity Interventio of holistic 1. Keep the 1.Moistures harbors
Naa koy related to n nursing care , area clean bacteria and
samad sa surgical (TAHBSO) the patient will and dry pathogen Nursing
ubos na incision in the involves an be able to:
Care Plans &
parte sa midline lower Incision on Demonstrate
ako tiyan epigastric the lower Proper way of Documentation:
gikan sa region midline wound care Nursing Diagnoses
operasyo epigastric and proper and Collaborative
n as region. dressing Problems pp 467
verbalize Surgery Understand the 2. Provide a
d by the involves importance of splinting 2.Splinting
patient cutting caring the pillow provides support to
/penetratio incision site the area ,
Objective n of skin minimizing
cues: surface and discomfort and
Prese skin layers encouraging the
nce which patient to move and
of causes cough Nursing Care
woun injury or Plans &
d on the skin/ Documentation:
plater tissue. Nursing Diagnoses
at Because of and Collaborative
abdo the injury Problems pp 467
minal there in 3. Inspect the
area vasodilatati incision 3.Frequent
Slight on to every shift assessment can
blood hurriedly using detect early signs
y send the REEDA and symptoms of
disch nutrients in (redness, infection Source:
arge the body edema, Nursing Care Plans
at via ecchymosis, & Documentation:
woun bloodstrea discharge, Nursing Diagnoses
d m. and and Collaborative
dressi Because of approximati Problems pp 467
ng vasodilatati on)
Redn on there is
ess redness on 4. Carefully
the dress 4.To prevent

36
on surroundin wounds infection source:
the g tissue on Nursing Care Plans
skin the injury & Documentation:
surro site
Nursing Diagnoses
undin
g the Reference: 5. Inform and Collaborative
incisi Principles patient of Problems pp 467
o of Med- the purpose 5. To increase
Surg Vol. of self-care compliance Source:
1 4th practices Nursing Care Plans
edition by & Documentation:
Lemone Nursing Diagnoses
and Burke
and Collaborative
6. Use
appropriate Problems pp 467
barrier
dressings, 6.To protect wound
wound and or the
coverings, surrounding area.
drainage Source: Nursing
appliance Care Plans &
and skin
Documentation:
protective
agents for Nursing Diagnoses
open and Collaborative
wounds. Problems pp 467

7. Provide
optimum
nutrition
including
vitamins 7.To provide a
such as Vit. positive nitrogen
C and E. balance to aid in
skin/tissue healing
and maintain
general good
health. Source:
Nursing Care Plans
& Documentation:
8. Encourage
Nursing Diagnoses
early
ambulation and Collaborative
or Problems pp 467
mobilization

37
 8.To promote
circulation and
reduces risks
associate with
immobility.
9. Limit or Nursing Care Plans
avoid use of & Documentation:
plastic Nursing Diagnoses
material. and Collaborative
Problems pp 467

9.Moisture
potentiates skin
10. Increase breakdown. Source
protein Nursing Care Plans
intake & Documentation:
Nursing Diagnoses
and Collaborative
Problems pp 467

10.To promote
wound healing.
Source: Nursing
Care Plans &
Documentation:
Nursing Diagnoses
and Collaborative
Problems pp 467

38
Cues Nursing Scientifi Pla Interventions Rationale Evaluatio

diagnosis c basis n of n

care
Physiologic Altered Measures to

deficit: physical promote

Difficulty mobility: mobility:

turning difficulty

turning 1.Enumerat Help to

39
Objective from side e safety understand

Cues: to side measures to more about

-difficulty related to patient such safety to his

turning pain felt as avoid condition

from side to on affected doing things (Source:

side site upon alone Nurses

-presence of exertion Pocket

abdominal secondary Guide; 12th

surgical to post edition;

incision pelvic Doenges

-pain felt on laparotom et.al; page

affected site y 529)

upon

exertion 2.Encourag 2.To

-limited e adequate promote

range of intake of well-being

motion fluids and and

-slowed nutritious maximizes

movement foods energy

-weakness consumptio

T-36.6C (Source:

P- 79bpm Nurses

40
R- 20cpm Pocket

BP- Guide; 12th

110/80mmH edition;

g Doenges

et.al; page

Subjective 3.Instruct 530)

Cues: patient to

use side 3.For

Maglisod rails patient

kog lihok safety and

tungod sa changing

tahi sa position

akuang (Source:

tiyan, as Nurses

verbalized Pocket

by the Guide; 12th

patient edition;

Doenges

4.Assist et.al; page

patient 531)

reposition

herself on a 4,To

regular prevent

41
 schedule decubitus

ulcer and

promote

proper

blood

circulation

(Source:

Nurses

Pocket

Guide; 12th

5. Identify edition;

energy Doenges

conserving et.al; page

techniques 529)

for activities

of daily 5.Limits

living fatigue,

maximizing

production

(Source:

Nurses

Pocket

Guide; 12th

42
 6.Involve edition;

patient in Doenges

care, et.al; page

assisting 530)

them to

learn ways 6.To help

of managing patient to

problems of know how

altered to manage

mobility her

condition

(Source:

Nurses

Pocket

7.Consult Guide; 12th

with edition;

physical Doenges

therapist as et.al; page

indicated 531)

7.To

develop

individual

43
 exercise and

mobility

program

(Source:

Nurses

Pocket

Guide; 12th

edition;

Doenges

et.al; page

530)

44
 Drug Therapeutic Record (Post-Op)

Drug/ Dose/ Classification/ Indication/ Principle of Treatment

Frequency Mechanism Contraindication Care
Route and Side Effect

Omeprazole Antiulcer Drug Indication:

40g - reduces gastric - active
IVTT OD acid secretion duodenal ulcer
8am-6pm and increases - GERD
gastric mucus Contraindication
and bicarbonate :
production -
creating a hypersensitivity
protective coating to drug or its
on gastric components
mucusa - alcohol

45
 intolerance
Side Effects:
- headache,
anxiety, nausea,
vomiting, pain,
rash

Ferrous Sulfate Hematinic Iron deficiency Use Monitor

PO, OD Provides Pregnant cautiously hemoglobin
Timing: 8:00 elemental iron, an women in peptic and
am essential Postpartum ulcer, reticulocyte
component in the women ulcerative counts
formation of Contraindicated colitis, and during
hemoglobin in regional therapy
hemosiderosis , Give tablets
enteritis
hemochromatos Tell patient with orange
is and hemolytic to continue juice to
anemia a regular promote iron
Nausea, dosing if absorption.
she misses Check for
vomiting,
a dose. constipation;
constipation,
Patient record color
black stools
shouldnt and amount

double the of stool.

Teach
dose.
dietary
measures to
prevent
constipation.

46
Cefuroxime Anti-infective
750 mg q8h
- interferes with
IVTT
8am-4pm- bacterial cell wall
12am synthesis and
division by
binding to cell
wall, causing cell
to die
Indication:
- moderate to
severe
infections
- gonorrhea
- otitis media
Contraindication
:
-hypersensitivity
to
cephalosporins
or penicillins
-carnitine
deficiency

Side Effects:
Non-Steroidal - headache,
Celecoxib Abti-Infammatory nausea,
200mg Drugs vomiting,

47
1 cap BID -it exhibits anti- dyspnea,
8am-6pm infammatory hematuria,
activities thus allergic reaction
eliminates patient
problem.
- Indication:
-treatment of
dysmenorrheal
-patient with
lower back pain

Side effect:
-abdominal pain
-flatulence
-tooth disorder
-decreased
female fertility

48
Narrative charting
Received patient per stretcher conscious with ongoing ivf #7 D5LR KVO rate

infusing well at patients right arm

Signed consent and WHO checklist checked
Ushered to OR#2 and placed comfortably at OR table
Attached to cardiac monitor and pulse oximeter
Anesthesia inducted by Dr. Paradela
Urinary cathether inserted and attached to urobag
Placed in supine position
Skin preparation and draping done aseptically
Initial counting of instruments, sponges, and needles done
Operation started
Midline incision was made
Skin opened layer by layer
Peritoneal cavity entered
Bleeders clamped and cauterized
Above ivf changed to PNSS
Blood transfusion started with fresh whole blood type AB started
Peritoneal cavity was entered
Ligaments of the uterus are ligated, divided and sutured
Simultaneous washing and suctioning done
Second counting of instruments sponges and needles done, complete
Suturing layer by layer done
Final counting of instruments sponges amd needles done complete
Skin was closed layer by layer
Operation ended
Patient was brought to recovery room for monitoring

49
Health Teaching Plan (Post-Op)

Objectives Content Methodolog Evaluation

y

50
General:

At the end of 8
hours of student
nurse,
client/patient and
significant others
interaction, the
client/patient and
significant others
will be able to gain
knowledge, skills,
and attitude in
caring for patient
post pelvic
laparotomy.

Specific: Specific:

After 45 minutes of After 45 minutes of

student nurse- student nurse-patient
patient and and significant others
significant others interaction, the patient
interaction, the and significant others
patient and was able to:
significant others
will be able to:

1.define TAHBSO 1. is the removal of Discussion 1. defined Total

entire uterus, the and Use of abdominal bilateral
ovaries, fallopian Visual Aids salpingo oophorectomy

51
 tubes and the cervix.

2. enumerate the Purpose: -Discussion 2. enumerated the

purpose of Hysterectomy is often -pictures purpose of pelvic
TAHBSO performed on cancer -question laparotomy
paitients or to relieve
and answer
severe pelvic pain
from things like,
endometriosis or
adenomyosis..

Hysterectomy is also
used as a last resort
for postpartum
obstetrical
haemorrhageor
uterine fibroids that
cause heavy or
unusual bleeding and
discomfort in
somewomen.

3. identify the risks -Discussion 3. identified the risks of

of TAHBSO -pictures pelvic laparotmy
Risks:
-flashcards
3.1 vaginal bleeding
-question
3.2menstrual flow that
and answer
is unusually heavy or
filled with clots
3.3abdominal pain
that increases in
intensity
3.4chills and/or a
fever
3.5 redness, swelling,
bleeding, or

52
 drainage at your
incision sites
4. demonstrate Client 4. demonstrated
beginning skills in To do this: Demonstrati beginning skills in wound
wound care Clean the wound with on and care
(Source: running water (see Return
Fundamentals of illustration). Wash the Demo
Nursing; Udan; 3rd skin around the injury
edition; page 559) with soap. Don't worry
if soap gets into the
wound, though it is
likely to sting and
irritate the raw tissue.
Rinse the wound
thoroughly to rid it of
any dirt and soap.
Tweezers can be
used to remove
particles. Use of
hydrogen peroxide is
neither necessary nor
encouraged (see tips
below). Only cover the
wound if it is likely to
come in contact with
clothing or dirt. Cuts
less than 2
centimeters long can
be held closed with
butterfly bandages. If
the edges of a

53
 laceration are not
easily pulled together,
then the wound may
need stitches.
Adhesive bandages
are the easiest way to
cover most minor
lacerations and
abrasions.
5. show positive 5. showed positive
attitude in attitude in management
management of a of a wound
wound

Evaluation and Recommendation

Evaluation and Implication of this case study to:

Nursing Practice

54
 This study will serve as a guide for the future nurses in the formulation and

implement action of care plan of patient who undergone Pelvic Laparotomy with

Salpingectomy including thorough assessment of events condition as well as

prevention of further complications.

Nursing Education

This study endeavors to increase the knowledge of the students about the

underlying health condition of the patient as well as their knowledge about

medical-surgical nursing. This serves as a guide and provides information to

people having this disease as well as health care providers.

Nursing Research

The primary aim of the researcher is to contribute the ongoing articulation,

development and advancement of medical nursing practice in order to strengthen

the contribution in enhancing the well being of the patients. Ongoing research is

needed to ensure the effectiveness of nursing care and different treatment of

disease. This case study will support, guide and help develop nursing practice in

the clinical setting especially in the care of patient who undergone Pelvic

Laparotomy with Salpingectomy.

Referral and Follow-up:

55
 The nurse is responsible for the coordination to the community health

center for a continuous monitoring and care of the client while she is into home

care setting. It includes the special care endorsements for the patient to the

community health officers and to the family. It is also essential for the nurse to

inform the patient for follow-up care to prevent possible complications and

awareness on current health condition. Consultation to the doctor should be

emphasized by the nurse to the patient and family.The nurse should remember

that right after surgery,he/she need to keep a close eye on their vitals, ins/outs,

and mental status to catch problems early. The nurseshould check out the

dressing over the surgical site to make sure it's not pouring out blood or some

other fluid. Early ambulation and pulmonary toilet is very important in order to

avoid complications such as pneumonia and deep vein thrombosis.

56