INTRODUCTION:

As a part of our clinical posting. I was posted in Gynae ward and I was assigned to write a
care plan. So I choose a patient by the name Monika Dewangan, age 35 years, she was
diagnosed with ovarian syndrome. At time of collecting history I introduced myself to the
patient and ask her to cooperate with me while collecting her history and other required
information.

IDENTIFICATION DATA:

PATIENT NAME: Monika Dewangan

NAME OF THE HUSBAND: Nilutpal Dewangan

AGE: 35 years

GENDER: female

ADDRESS: Kawardha, C.G.

MARITAL STATUS: Married

RELIGION: Hindu

WARD: Gynae ward

BED: 10

EDUCATION: HS passed

OCCUPATION: HOME MAKER

OBSTETRICAL SCORE: G2P2L0A0S0

DIAGNOSIS: Ovarian Cyst

DATE OF ADMISSION:

WEIGHT: 70 kg

HEIGHT: 5 fit.
CHIEF COMPLAINS:

 Pain in lower abdomen since 2 weeks

 Loss of appetite since 4 days.
 Sleeping disturbance since 2 weeks

HISTORY OF PRESENT ILLNESS:

Mrs. Monika Deka complaint of she’s having pain in lower abdomen from last 2weeks,
cessation of menstruation since 6 months, loss of appetite since 4 days, sleeping disturbance
since 2 weeks, so because of these condition she is admitted in the GMCH in Gynae ward.

HISTORY OF PAST ILLNESS:

 There is no past medical history of TB, HTN, DM.

 She has done caesarean section in her previous pregnancy.

FAMILY HISTORY:

She belongs to a nuclear family having five members. Her husband working as a Farmer. The
monthly income in her family Rs 14,000.

FAMILY HISTORY OF ILLNESS:

There is no history of any disease like TB, HTN, DM & hereditary disease, twin pregnancy in
her family.

Sl.No Name of Age Relationshi educatio Occupatio Marital Health

. the and p n n status status
family sex
members
1 Monika 35 Patient Class HS Home Married Not
Dewanga years, passed maker healthy
n Femal
e
2 Nilutpal 38 Husband B.A Farmer Married Health
Dewanga years, passed y
n Male
3 Anupama 68 Mother in Class V Home Married Health
Dewanga years, law passed maker y
n Femal
e
4 Minashre 7 Daughter Class II student Unmarrie Health
e years, d y
 Dewanga Femal
n e
5 Nidhanjit 5 son Class I Student Unmarrie Health
Dewanga years, d y
n Male

GENOGRAM:

Key:

- Male

- Female

- Patient.
HEALTH FACILITY NEAR HOME:

There is a District Hospital in her village at a distance of about 2 km. transportation facility
available like bicycle, motorcycle.

HOUSING:

 She lives in a pucca house.

 Having 3 rooms with adequate ventilation.
 Present sanitary latrine for toileting.
 Electricity supply is available.
 They use municipality water supply taps for drinking,

Personal history:

Personal hygiene: She is maintaining her oral hygiene by brushing daily and taking bath
once daily with soap and normal water.

Diet: she takes vegetarian and non-vegetarian diet and she takes meals 4 times a day. She
don’t have any addiction of alcohol and tobacco. She drinks about 2-3 lts. of water per day.
She takes rest of about 2 hrs at day time and 8 hours during night time. She takes no drugs for
sleep.

Elimination: She has a regular bowel and bladder habits.

Mobility and Exercise:she has regular walking habits of evening every day.

Menstrual history:

She got menarche at 13 years old age with regular cycles of 28-30 days interval & 3-4 days
duration with average amount of bleeding.

Sexual and marital history:

she is married since 10 years and has satisfactory relationship with her spouse. General health

of her spouse is good.

Obstetrical history:

Past obstetrical history:

She has done caesarean section in her past pregnancy without any complication.

Observation and assessment:

 Her general appearance is good.

 Patient is conscious and anxious.
 She has no foul body odour & foul breath.

PHYSICAL EXAMINATION:

GENERAL EXAMINATION:

 Weight: 70 kg.
 Height: 5 fit.
 Foul body odour: Absent.
 Foul breath: Absent.
 Sensorium: conscious.

 Orientation: oriented to time, place and person.

 Nourishment: nourished.

 Body built: moderate.

 Activity: moderate.

 Look: Anxious.

 Hygiene: not maintained.

VITAL SIGNS:
 Temperature: 98ºF.
 Pulse: 74bpm.
 Respiration: 18/minute
 Blood Pressure: 110/70 mmHg.
INTEGUMENTARY SYSTEM:
SKIN:
 Colour: Fair in complexion
 Texture: normal
 Skin Turgor: normal
 Hydration: Hydrated
 Discoloration: absent.
 Lesions Muse present on skin: No any lesion and extra mass.

NAILS:
 On observation: Intact, clubbing of the nails not found.
 Nail beds: normal.
 Nail plate: white.
 Other signs/symptoms: None.

HAIR:
 Colour: Faire.
 Texture: Normal.
 Grooming: Well groomed.
 Distribution: Scanty.
 Other sign and symptoms: None.

HEAD:

 Shape: Normal.
 Scalp: Dry.
 Face: Normal.
 Subjective symptoms: Absent.

SENSORY SYSTEM:

EYES:

 Eyebrows: Equally distribution.

 Eyelashes: Equally distribution.
 Eyelids: Normally distributed.
  Pupillary Reflex: Reacting to light.
 Sclera: White in colour.
 Conjunctiva: Normal.
 Vision: Normal.
 Subjective Symptoms: No any complaints.
 Decreased tear production if any other: Not significant.

EARS:

 Pinna: Normally equal.

 Cerumen: Present.
 Ottorhoea: Absent.
 Hearing: patient respond to sound.
 Subjective Symptoms: No any complaints.

MOUTH & PHARYNX:

 Lips: Dry.
 Colour: Pale.
 Gums: No inflammation.
 Tongue: Dry.
 Taste: Normal.
 Teeth: Dental carries absent.
 Mucous membrane: Lesion present.
 Breadth Odour: Absent.
 Pharynx: Normal.
 Gag Reflex: Present.
 Tonsils: Not enlarge.
 Voice: Clear.
 Subjective Symptoms: No any complaints.

NECK:

 Range of motion: Possible.

 Lymph Nodes: Not enlarge.
 Thyroid Gland: Midline.
 Jugular Veins: Not distended.
  Subjective Symptoms: No any complaints

CARDIO & RESPIRATORY SYSTEM:

 Thorax: Symmetrical.
 Thorax Expansion: Normal and equal.
 Heart sound: S1 S2 can heard.
 Breath sound: Normal.
 Apical pulse: 80b/m.
 Cough: Absent.
 Sputum: Absent.
 Odour: Absent.
CHEST:
Inspection:
 Shape - normal
 Symmetry of expansion- equal
 Respiratory rate - 20 beats/min
 No cracked nipple, Montgomery tubercle present
 Primary and secondary areola present
Palpation
 Palpation done by circular method
 No lymph node enlargement
 Nipple –Normal, no sign for infection
 No pain, redness, tenderness
Percussion
 No abnormal sounds of fluid collection heard
Auscultation
 Normal heart sounds heard
 S1 and S2 heard
 No abnormal breath sounds heard
ABDOMEN
Inspection-
 Shape- Round
 Umbilicus - flattened
 Condition of bladder- emptied
 Palpation:
Patient feels pain in lower abdomen after palpation
BACK
 Lesion/ scar/infection/scoliosis/kyphosis/lordosis – not present

MUSCULOSKELETAL SYSTEM:

 Postural Curves: Normal.

 Muscle tone: Normal.
 Muscle strength: Weaker than normal.
 Symmetry: Symmetrical.
 Fingernails: Normal.
 Range of motion: Normal.
 Oedema swelling: Absent.
 Cyanosis: Absent.
 Subjective Symptoms: No any complaints.

GENITO URINARY SYSTEM:

 Lesions/scar: Absent.
 Vulva: Normal. No edematous.
 Discharge: Absent

RECTUM & ANUS:

 Bowel Elimination Pattern: 1-2/day.

 Haemorrhoid: Absent.

Medication:

Sl Name of Dose Rout Frequenc Action Side effects Nursing

. the drugs e y responsibilities
n
o
1. Injection 1 gm IV BD Its exerts Headache  Assess the
Ceftriaxon bactericidal Diarrhea vital signs of
e activity by Change in patient.
inhibiting test.  Provide
septum hydration
formation therapy to
and cell patient.
wall  Maintain I/O
synthesis of chart of
susceptible patient
bacteria.  About over
dose of drug.
 Educate about
side effects.
 Continuous
2. 40mg IV OD
monitoring of
InjPantop Vomiting,
Suppress client.
constipation
the final  Provide fiber
, Rash,
step in rich diet to the
headaches,
gastric acid client.
stomach
production,
pain, Gas,
by
Joint pain,
covalently
Dzziness.
binding to
the ATP
phase
enzyme
system at
the
secretory
surface of
the gastric
500m
3. g Oral BD parietal cell. Headache.
Tab Iron Nausea,
Folic Acid Vomiting.

Provides
eleminated
iron, an
essential
component
in the
formation
of
haemaglobi
n

INVESTIGATION:

Investigation Findings Normal Remark

WBC 14.58 4.00-11.00 High
RBC 4.48 4.50-5.50 Low
HGB(female) 11.7 13.00-15.00 Low
HCT(female) 37.3 36.00-47.00 Normal
MCV 83.3 76.00-98.00 Normal
MCH 26.1 27.00-32.00 Low
MCHC 31.4 32.00-36.00 Low
PLT 157 150-400 Normal
GLUCOSE DIPSI 104mg/dl <120mg/dl Normal
GLUCOSE 55mg/dl 80-120 Low
CREATININE 0.40mg/dl 0.66-1.25 Low
CRP 10.50mg/dl 0-10 High
TSH 2.37mlu/L 0.465-4.680 Normal
BILIRUBIN TOTAL 0.30mg/dl 0.20-1.30 Normal
 BILIRUBIN 0.30mg/dl 0.0-1.1 Normal
UNCONJUGATED
BILIRUBIN 0.00mg/dl 0.0-0.30 Normal
CONJUGATED
AST 33U/L 17-19 High
ALT 20U/L 4-50 Normal
TOTAL PROTEIN 6.30gm/dl 6.30-8.20 Normal
ALBUMIN 2.90gm/dl 3.50-5.00 Low
GLOBULIN 3.40gm/dl 2.80-3.20 High

 USG findings:

Left adnexal anechoic lesion with partial septate likely ovarian cyst measuring 6.8
x 5.0 x 7.1cm with no vascularity.

HEALTH EDUCATION:
Hospital Discharge

 Advised patient to maintain proper  Advised patient to maintain proper

sleep and rest. sleep and rest atleast 2 hours day
 Advised patient to take medication time and 8 hours night time.
regularly and on time.  Advised patient to take medication
 Advised patient to maintain personal regularly and on time.
hygiene.  Advised patient to maintain personal
 Advised patient to take adequate hygiene like brushing teeth, using
fluid and juices. clean cloths.
 Advised patient to take high fibre  Advised patient to take adequate
rich food, iron supplement. fluid and juices.
 Advised patient to take high fibre
rich food, iron supplement.
 Advised the patient to do for routine
screening as ordered by physician.
SUMMARY:

Monika Dewangan, 35 years of age, she is diagnose with ovarian cyst. This case is taken to
improve nursing care. The care giver established a good IPR with the client and her trust and
confidence was gained. The client reveled all her problems, thus the care giver was able
provide care to meet the need up to an optimum. During this period she gains knowledge on
different aspects like care of herself, which makes her more confident and due to this she is
now able to cope to any stressful situation. She was also given health education on nutrition,
personal hygiene, and regular follow up.