Gyne G1

In partial fulfillment of the requirements in NCM 109 Care of Mother & Child at Risk w/
Problem (Acute & Chronic)
NURSING CASE ANALYSIS
PELVOABDOMINAL MASS PROBABLY MALIGNANT; ACUTE GASTRITIS;

HYPERTENSION; DYSLIPIDEMIA
(Diagnosis)
Presented by:
Aguda, Cherry Anne Fate S.
Alagao, Freznelle C.
Estabillo, Mernel Jane L.
Juan, Jean Laurice P.
Laylay, Deane Deryle B.
Pascua, Arnold Janssen M.
Pascual, Jashmir Geyonce Q.
Perdiguerra, Jasmin Grace A.
Ricardo, Allison April Q.
Ventura, Nathalin D.
Presented to:
Lorna A. Ulep, RN
Naida Benigna R. Ancheta, RN, MSN
Rainhard T. Galiza, RN
Teresita Ann O. Tinio, RN, MAN
MARCH 2024
1
CHAPTER I
INTRODUCTION
This chapter introduces the case study, its importance, and its impact on nursing practice.
Moreover, this section contains the goals and objectives of the case study specific to the disease
process of the client.
A pelvoabdominal mass, probably malignant, refers to an abnormal growth or swelling
located within the pelvic or abdominal region of the body, suspected to be cancerous. This mass
can arise from various tissues or organs such as the reproductive organs, gastrointestinal tract,
urinary system, or retroperitoneal structures, and it exhibits characteristics that raise suspicion
for malignancy (Wee, Sukumaran, & Leow, 2019). The term "probably malignant" indicates
that based on clinical evaluation, imaging studies, and possibly preliminary biopsy results,
indications are suggesting a high likelihood of malignancy, although a definitive diagnosis may
not yet be confirmed. While some pelvoabdominal masses may be benign, others raise
suspicion for malignancy, necessitating prompt and thorough evaluation.
Objectives
To further understand and gain extensive knowledge regarding Pelvoabdominal Mass
Probably Malignant. This case study will also explore other factors that can enhance our
knowledge in the field of our nursing practice and is accomplished for a comprehensive
analysis concerning the disease with the following objectives:
1. Describe the client's current health status and provide a detailed overview of their medical
history.
2. Assess the patient's developmental stage to recognize developmental milestones and age-
related considerations that may influence nursing care delivery and patient outcomes.
2
3. Explain the client’s diagnosis and discuss the disease process, including any underlying
factors or contributing factors.
4. Conduct a physical assessment to formulate a nursing care plan prior to the client's need.
5. Document any changes or trends in the patient's symptoms, physical findings, or laboratory
results within 24 hours.
6. Assess the patient's patterns of functioning to identify any disruptions or limitations in
functioning caused by the pelvoabdominal mass or its treatment.
7. Outline the recommended treatment plan for the client, including any medications, therapies,
or surgeries that may be necessary to discuss the role of nursing interventions in supporting the
client’s recovery and promoting their overall well-being.
8. Develop individualized nursing care plans based on the patient's assessed needs, preferences,
and treatment goals.
Importance and impact on the nursing practice
It helps nurses to better understand and manage complex conditions like
pelvoabdominal masses suspected to be malignant. By studying such cases, nurses can improve
their ability to assess and support patients effectively, ultimately leading to better patient
outcomes.
This study empowers professional nurses/ student nurses through education, providing
them with valuable insights and skills to handle similar cases. Additionally, it emphasizes
patient-centered care, to meet the individual needs and preferences of patients, and
collaboration ensuring comprehensive and coordinated care delivery.
3
Overall, conducting this case study enhances nursing practice by equipping nurses with
the knowledge, skills, and strategies needed to provide high-quality care for patients with
pelvoabdominal masses suspected to be malignant.
4
CHAPTER II
PERSONAL DATA
Name: Mrs. Orange
Age: 68 years old
Gender: Female
Date of Birth: February 19, 1955
Place of Birth: Dimaguiba
Address: Dimaguiba
Civil Status: Widow
Religion: Roman Catholic
Educational Attainment: 4th year high school graduate
Occupation: N/A
Date Admitted: February 13, 2024
Time Admitted: 4:35 pm
Admitting Diagnosis: G3P3(3002) Pelvoabdominal Mass Probably Malignant; Acute

Gastritis; Hypertension; Dyslipidemia
Attending Physician: Dr. Juan Dela Cruz MD. / Dr. Juanna Reyes MD.
5
CHAPTER III
FAMILY BACKGROUND
The family structure, characteristics, and relational dynamics significantly shape a
family's overall well-being. The structure, whether nuclear or extended, influences roles and
responsibilities. Unique characteristics, such as communication styles and values, define the
family's identity. Relational patterns determine how family members interact, bringing up
emotional bonds or potential conflicts. This chapter aims to discuss all of these aspects.
The Fruit Family is an extended family. The family consists of six (6) members. Mrs.
Orange stands as the head of the family since her partner already passed away. They have three
children but their first child already died. Apple, who is currently working abroad, is the second
child and Grapes is the youngest. Apple has three children namely Mango, Kiwi and
Strawberry. The family is currently residing at La Paz, Abra.
Mrs. Orange was born on February 19, 1955 and is now 68 years old. She is a housewife and
she is the one taking care of her grandchildren. Apple, the second child, was born on August
12, 1974 and is now 49 years old. She works as a domestic helper abroad and is the one sending
financial support to the family. Grapes, the youngest child, was born on December 22, 1981
and is now 42 years old. He is a farmer. Mango, Kiwi and Strawberry are the children of Apple
6
and they are currently studying. Since Apple is working abroad, Grapes and the three
grandchildren are the ones living with Mrs. Orange.
According to Mrs. Orange, the family lives in a bungalow house made of hollow blocks
and cement. The house has living spaces such as two bedrooms, living room, kitchen, dining
area, and bathroom and is determined to be adequate for the family. Mrs. Orange stated,
“Kaykayat dagitay apok iti maturog jay salas isu nga duwa kami lang ken tay anak ko ti
agkwarkwarto iti rabii.”
When it comes to decision-making, both Mrs. Orange, Apple and Grapes make
decisions together. In terms of health care, Mrs. Orange and Apple decide and in terms of
money and expenses, it is Mrs. Orange, Apple and Grapes who make the decision. When it
comes to their communication, she stated that they are open to each other and that whenever
there is a conflict inside the family, they always make a way to resolve it immediately. She
stated that one of their techniques in maintaining a good relationship is through understanding
every member’s feelings and situation. Mrs. Orange stated “Kanayon ko ibagbaga kadakwada
nga uray kaskasano ket agiinnawat kami tapno ti kasta napintas latta ti langen-langen mi.”
7
MONTHLY INCOME
Among the family members, Apple and Grapes are working. Apple is a domestic helper
abroad and she sends Php 4,000 every month. Grapes is a farmer and he earns approximately
Php 2,500 depending on their harvest. All in all, the family’s monthly income is Php 6,500.
BREAKDOWN OF EXPENSES
8
With the allotted budget for basic needs, the actual expenses in food is 3,000 pesos
(45%), 400 pesos (6%) for electricity, 2,500 pesos (37%) for education, 400 pesos (6%)for
Mrs. Orange maintenance medications and 400 pesos (6%) for other expenses such as tricycle
or jeep fare and cellular load.
ANALYSIS:
The total income of the family, which is 6,500 pesos, is inadequate to sustain the total
actual expenses of the family. However, Mrs. Orange stated, “Talaga nga narigat. Nu dadduma
nga agkurkurang iti kwarta mi innak nukwa agilako kadagiti mula mi a gulgulay naimbag la
a igatang sidaen. Pasaray bumulod/umutang nak met nukwa nu dadduma kadagiti kakabagyan
mi.”
If this concern is not being addressed, they might resort to borrowing money or
accumulating debt to meet their immediate needs. Over time, high levels of debt can become a
significant burden to them, leading to more financial difficulties. According to the American
Association for Marriage and Family Therapy, financial struggles can contribute to mental
health issues, such as depression and anxiety, for both adults and children within the family.
9
CHAPTER IV
HEALTH HISTORY
This chapter shows the illustration of the family’s genogram and the discussion of family
health history, as well as the past and present health history of the client
A. FAMILY HEALTH HISTORY
Figure 4.1 Genogram
Upon the interview, when we asked about the health disorders in the family, the client
responded that on her maternal side, her grandfather at the age of 67 years old had Kidney
failure due to smoking and alcoholism. The client stated that her grandmother died at 79 years
old however she doesn't remember the cause of her death as well as her aunt who died at 67
years old. However, she mentioned that her mother has hypertension and died due to cardiac
arrest. The client stated that she doesn’t remember her mother’s medication before as well as
10
the doctor who diagnosed her. The client stated that when the family members are experiencing
common illnesses such as cough, colds, and fever they use over the counter medicines such as
Paracatemol for every 4 hours and Symdex for 3 times a day. The client also mentioned she
uses Efficascent oil to massage if there are any muscle fatigue or pain she experienced.
For the paternal side, the client stated that her grandfather died at 75 years old and
grandmother at 70 years old. However, she stated that she cannot remember the cause of their
death due to her old age. She stated that her father died due to pneumonia, however she doesn't
remember the medications taken by his father as well as the doctor who diagnosed him. In
addition, the client stated that the brother of her father died at 46 years old due to motorcycle
accident. Also, the client stated that the oldest and second among the siblings of his father are
still alive and stated that she dont know their health history.
i. PAST HEALTH HISTORY
According to the client, she stated that she had chicken pox and hives when she was
Grade 2, and she did not experience mumps and measles before. The client said they solely
used home remedies and herbal medicines, which involve staying at home and using guava
leaves, by the process of boiling them or “aganger”. She believed that this process helps the
chickenpox to get easily dried by using it for rinsing during bath time. The client also
experiences common illnesses such as coughs, colds and fever. She uses over the counter
medicines such as Paracetamol for fever every 4 hours and Bioflu for every 6 hours for coughs
and colds. She solely used home remedies and never goes for a checkup. The client also
experienced sore eyes before and treated it by using Eye mo and applied it 1-2 drops each eye.
She believed that using eye mo is a quick relief of eye redness and minor discomforts caused
by irritants. The client further stated that she has an allergy with shrimps but she just knew it
when she was admitted and she stated that did not experience injury or accidents before. The
11
client only received first dose of Jansen as her vaccine on July 24 2021 and did not continue
her 2nd dose vaccine and booster because she believed that she is already weak for her age to
take the vaccination.
ii. PRESENT HEALTH HISTORY
Upon interview, the client chief complaint was feeling of dizziness, abdominal girth
and abdominal pain. She stated that she takes Amlodipine 5mg and Losartan 50mg after
breakfast for management to ease her headache as prescribed by the Doctor. The client also
stated that She suffered 3 days before consultation. She believed that eating squash,papaya
and fish sauce is the cause of her pain and she stated that she frequently lies in bed to
manage her dizziness and have adequate rest.
12
CHAPTER V
DEVELOPMENTAL DATA
This chapter tackles the client’s development as a person in the context of different
developmental theories such as Robert Havighurst’s Theory and Erick Erickson’s Theory.
1. Robert Havighurst’s
Our client is 68 y/o which means according to Havighurst, she belongs to old age. The
period of old age begins at the age of sixty and above. At this age, most individuals retire from
their jobs formally. In our society, the elderly are typically perceived as not so active,
deteriorating intellectually, becoming narrow minded and attaching new significance to
religion and so on. Many of the old people lose their spouses and because of which they may
suffer from emotional insecurity. Moreover, older adults may become caregivers to their
spouses (e.g., Schulz and Beach, 1999).
Mental or physical decline does not necessarily have to occur. Persons can remain
vigorous, active, and dignified until their eighties or even nineties. In fact, the older persons
have a vast reservoir of knowledge, experience, and wisdom on which the community can
draw. In view of the increase in life expectancy, an increasingly greater proportion of society
is joining the group of aged people. Hence, they need greater participation in national planning
and make them feel as an integral part of society. Old age has often been characterized as a
period of loss and decline. However, development in any period of life consists of both gains
and losses, although the gain-loss ratio (Heckhausen, Dixon, and Baltes, 1989; Baltes, 1987).
In Robert Havighurst’s developmental task it emphasized that learning is basic and that
it continues throughout life span. He developed 6 stages that include Infancy and Early
Childhood, Middle Childhood, Adolescence, Early Adulthood, Middle Age, and Later
Adulthood. Our client is 68 years old, thus she belongs to the 6th stage which is the old age. At
this stage of growth and development according to Havighurst, the individual is expected to:
13
1. Adjusting to decreasing physical strength and health.
2. Adjusting to retirement and reduced income.
3. Adjusting to the death of a spouse.
4. Establishing an explicit affiliation with one’s age group.
5. Meeting social and civil obligations.
6. Establishing satisfactory physical living arrangements.
OLD AGE (60 Years and Over)
Table 5.1 The Client’s Growth and Development According to Havighurst Theory
TASKS RESULT JUSTIFICATION
FULLY Our client verbalized “baket nakon

1. Adjusting to decreasing
ACHIEVED nakkong, agkapsot kapsot detoy
physical strength and health.
bagikon, nu dadduma
agpanpanunutak kadetoy kinabaket
ko ngem gapo ta ay ayaten dak dgty
annak kn appokok, umanay a ragsak
kon uray kastoy ti sakit ko isuda lng
mangpalpalag an riknakon”. Thus,
the result is fully achieved because
according to her, being positive is
what keeps her going.
14
PARTIALLY Our client verbalized “awan
2. Adjusting to retirement
ACHIEVED trabahok nakkong, hannak pulos
and reduced income.
nagtrabaho nakkong ngamin ta
hanko met nairadwar pinagbasak,
ngem nu pay kasta naragsak nak ta
adda trabaho dagitay annak ko isu
nga isudat mangtultulong kanyak
ita”. Thus, the result is partially
achieved since she hasn’t gone to
work.
PARTIALLY Our client verbalized “narigat

3. Adjusting to the death of
ACHIEVED nakkong, narigat ko inawan ti
a spouse.
ipapanaw ty nadungngo nga asawak
ta 2 tawen nga awan isuna idi
maawat kon, maikawa nak ununay
idi ta awan katinnulungakon,
narigat ngem kasta lang ti byag”.
Thus, the score is partially achieved
since she did not easily move on
from the death of her husband and it
took her some time. Widowhood is
15
among the most stressful of life
events (Holmes and Rahe 1967).
FULLY Our client verbalized “aktibo nak

4. Establishing an explicit
ACHIEVED sadjay lugar mi nakkong, kanayon
affiliation with one’s age
nak mapan maki miting aglalo nu ti
group.
miting iti senior citizen”. Thus the
score is fully met since she was
active back then before her illness.
FULLY
5. Meeting social and civil Our client verbalized “miyembro ak
ACHIEVED
obligations. ti Seniors Organization, botante ak
pay, sumal Sali nak ty community
service a kunada, sadjay lugar mi kn
kanayon nak makipartisipar ti anya
man a pasamak da”. Thus, the score
is fully achieved. Participation in
neighborhood groups, social service
16
groups, and groups related to health
is higher among adults aged 50 to 69
than other age groups, Guterbock
and Fries (1997).
FULLY Our patient verbalized “Kanayonak

6. Establishing satisfactory
ACHIEVED mapan agpagna pagna minalem dta
physical living
paraangan mi tapno maliwliwa ak
arrangements.
ken agbalinak nga nasalun at latta
iti agnanayon, haan man kasjay
dakkel detay balaymi naragsak kam
nga agyan ti uneg na isu launay
pagyamyamanak ta ammok nga
handakto baybay an ti pamilya”.
Thus, the score is fully achieved
since she feels safe and secure
around her family.
ANALYSIS:
Mrs. Orange completed all the tasks before she was diagnosed with the disease, she
cannot do her responsibilities anymore as a senior citizen but still, she was able to communicate
and take part in their community, as well as fulfill her responsibilities.
17
2. Erik Erikson’s
Our client is 68 y/o which means according to Havighurst, she belongs to the Ego
integrity vs. despair stage. This is a phase that occurs during late adulthood or old age and is
focused on reflecting back on life. Those who face conflicts at this stage will feel that their life
has been wasted and will experience many regrets. The individual will be left with feelings of
bitterness and despair. Those who feel proud of their accomplishments will feel a sense of
integrity. Successfully completing this phase means looking back with few regrets and a
general feeling of satisfaction. These individuals will attain wisdom, even when confronting
death.
This involves facing the ending of life, and accepting successes and failures, aging, and loss.
People develop ego integrity and accept their lives if they succeed, and develop a sense of
wisdom and those who do not, feel a sense of despair and anticipate their death. Those in late
adulthood need to achieve both the acceptance of their life and the certainty of their death
(Barker, 2016). Successful completion of this stage leads to wisdom in late life ( Erik Erikson,
1982).
18
EGO INTEGRITY VS. DESPAIR STAGE (65 Years and Over)
Table 5.2 The Client’s Growth and Development According to Erik Erickson Theory
TASK RESULT JUSTIFICATION
Ego Integrity vs. FULLY MET This task was fully met by our client since she
Despair is in a healthy relationship with her caring and
loving family. She stated that she already
forgave whoever have done something wrong
to her and accepted that there are instances in
her life for her mistakes. There were quite few
people that she stopped talking to for her peace
of mind and she verbalized “isupay nga nayon
panpanunutek isu baybayak lattan”.
According to her, if there is one thing that she
regrets is that she was not able to pursue her
dream course which was dress making, if only
she can turn back time, she will study again.
She stated that despite growing up in a less
fortunate family, she is now happy because she
has her family by her side that keeps
supporting her in all ways. If there is one thing
she wishes right now is for her to get better.
19
ANALYSIS:
Based on Mrs. Orange responses, she fully met the task that was accurate to her age and
based from her statement “isupay nga nayon panpanunutek isu baybayak lattan” it makes sense
that she is mature enough not to think about negativity and we can see that she is genuinely
happy and has a healthy relationship with her caring and loving family.
20
CHAPTER VI
PATHOPHYSIOLOGY
This chapter includes a discussion of the anatomy and physiology of the system/organ
affected by Pelvoabdominal mass and a schematic diagram of its development.
Figure 6.1 Anatomy of the Ovary
The Ovaries produce and release eggs (ova) and secreting hormones such as estrogen and
progesterone, crucial for regulating menstrual cycles, supporting pregnancy, and maintaining
reproductive health. It is located within the lower abdomen, just lateral to the uterus, ovaries
are left hanging by ligaments within the pelvic region. Each ovary is connected to the uterus
via the ovarian ligament and to the pelvic wall by the suspensory ligament.
21
HORMONAL FUNCTIONS OF THE OVARY
Hormone Function
It is responsible for the development and maintenance of female

reproductive structures such as the uterus, fallopian tubes, and vagina. It
Estrogen also regulates the menstrual cycle, promotes the growth of ovarian
follicles, and influences secondary sexual characteristics such as breast
development and distribution of body fat. (Cable, 2020)
Progesterone is primarily involved in preparing the uterine lining

(endometrium) for implantation of a fertilized egg. It helps maintain the
Progesterone endometrium during the second half of the menstrual cycle and
pregnancy. Progesterone also plays a role in breast development and
lactation. (Grider, 2019)
Androgens While primarily known as male hormones, small amounts of androgens

are also produced by the ovaries in females. These hormones contribute
to libido (sex drive) and are involved in the development of bone mass
and muscle strength. Androgens also play a role in the regulation of
follicle development and contribute to the maintenance of overall
reproductive health in women.
Inhibin Inhibin is a hormone produced by the ovaries that helps regulate the
secretion of follicle-stimulating hormone (FSH) from the pituitary gland.
It inhibits the production of FSH, thereby modulating the development
and maturation of ovarian follicles.
Stomach
The stomach is involved in the digestion of food. It secretes gastric acid and enzymes, which
break down food into a semi-liquid mixture called chyme. The stomach lining also produces
mucus to protect itself from the corrosive effects of gastric acid. (Lanas, A., & Chan, F. K. L,
2017)
22
Heart
The heart functions as the body's central pump, circulating blood throughout the body to
deliver oxygen and nutrients to tissues while removing metabolic waste products. By regulating
blood flow and oxygenation, the heart ensures proper tissue perfusion and maintains stable
blood pressure. (Williams, B., Mancia, G., Spiering, W., Agabiti Rosei, E., Azizi, M., Burnier,
Zanchetti, A, 2018).
Blood Vessels (Arteries)
Arteries carry oxygen-rich blood away from the heart to various parts of the body. They
have muscular walls that help regulate blood pressure by constricting or dilating in response to
hormonal and neural signals (Zanchetti, 2018).
Liver
The liver plays a central role in lipid metabolism. It synthesizes cholesterol and
triglycerides and regulates their levels in the blood by producing lipoproteins, which transport
lipids to various tissues (Grundy, 2019).
23
Figure 6.2 Pathophysiology of Pelvoabdominal mass
24
Figure 6.3 Legend for Pathophysiology of Pelvoabdominal mass
There are two risk factors that influence the Pelvoabdominal mass development of the client.
Modifiable risk factors include lifestyle which shows that the client is a previous tobacco user.
A meta-analysis conducted by Beral et al. (2012) reported a modest but statistically significant
association between smoking and the risk of developing ovarian cancer, emphasizing the
potential role of tobacco exposure in ovarian carcinogenesis. In addition, the non-modifiable
risk factor of the client includes age (68 years old) and sex which is female. According to the
American Cancer Society of 2021, individuals aged 68 years old are also within the age range
where the risk of developing adnexal masses, including ovarian tumors, remains elevated.
While the prevalence of adnexal masses tends to peak in individuals between the ages of 40
and 59, there is still a notable risk among older individuals. Ovarian cancer, in particular,
becomes more common with advancing age, with a significant proportion of diagnoses
occurring in individuals over the age of 65.
There are two risk factors that influence the Pelvoabdominal mass development of the client.
Modifiable risk factors include lifestyle which shows that the client is a previous tobacco user.
A meta-analysis conducted by Beral et al. (2012) reported a modest but statistically significant
association between smoking and the risk of developing ovarian cancer, emphasizing the
potential role of tobacco exposure in ovarian carcinogenesis. In addition, the non-modifiable
risk factor of the client includes age (68 years old) and sex which is female. According to the
25
American Cancer Society of 2021, Individuals aged 68 years old are also within the age range
where the risk of developing adnexal masses, including ovarian tumors, remains elevated.
While the prevalence of adnexal masses tends to peak in individuals between the ages of 40
and 59, there is still a significant risk among older individuals. Ovarian cancer, in particular,
becomes more common with advancing age, with a significant proportion of diagnoses
occurring in individuals over the age of 65.
Next, these risk factors can cause changes in the cells in the ovary. In this case, the
epithelial cells become dysplastic, which means they’re abnormal. These abnormal cells can
group and form clusters in the ovarian stroma, the connective tissue that supports the ovary.
This accumulation can result in cystic proliferation, or the formation of cysts. Thus, the
dysplastic epithelial cells can cause the stromal cells in the ovarian tissue to undergo reactive
changes.
This can lead to the formation of a microenvironment that is conducive to tumor growth
and the proliferation of dysplastic epithelial cells influencing protein expression due to the
dysregulation of various cellular pathways. According to (Gharu, 2018). Dysplastic cells often
exhibit altered gene expression patterns, leading to abnormal production of proteins involved
in cell cycle regulation, cell adhesion, and tissue differentiation. Thus, this results in an elevated
CA-125 (cancer antigen 125) blood test of the client of 1154.00 U/ml with a normal reference
range of Less than 35.
With the proliferation of dysplastic epithelial cells and creation of a microenvironment
conducive to tumor growth, angiogenesis is stimulated in the growing mass necessary to sustain
tumor growth. The formation of new blood vessels can lead to several downstream effects. It
can compress nearby gastric structures and obstruct lymphatic drainage. This can lead to
reduced blood flow to the stomach mucosa, or the lining of the stomach increasing gastric
26
secretion and the client’s complaint of abdominal pain resulting in a diagnosis of Acute
Gastritis. In lymphatic drainage obstruction, ascites are formed due to improper drain of tissues
of the lymph fluid leading to bloating.
The infiltration into surrounding tissue caused by the formation of new blood vessels
by endothelial cells for continuous growth and progression also influence compression of renal
blood vessels leading to the activation of the Renin-angiotensin-aldosterone system (RAAS),
due to decreased renal flow. The renin-angiotensin-aldosterone system (RAAS) is a complex
hormonal cascade that plays a crucial role in regulating blood pressure, electrolyte balance, and
fluid volume in the body. It involves a series of interactions between various organs, hormones,
and enzymes (Zhadid, 2017).
When this system is activated, it can stimulate the proliferation of smooth muscle cells
in arterial walls by Angiotensin II, a hormone and a potent vasoconstrictor, meaning it causes
blood vessels to narrow. This can lead to atherosclerosis or the thickening, narrowing, and
hardening of the arteries caused by a buildup of plaque in the inner lining of an artery. The
activation of the renin-angiotensin-aldosterone system (RAAS) also leads to lipid metabolism
alteration to which there is an increased production of triglycerides and LDL (low-density
lipoprotein) cholesterol leading to a diagnosis of Dyslipedemia.
In addition, the renin-angiotensin-aldosterone system can cause the kidneys to retain
sodium and water. This can lead to edema, or swelling caused by excess fluid trapped in tissues
and contribute to weight gain due to the expansion of total body water volume. It can also lead
to increased blood pressure and volume leading to impaired ability of the circulatory system to
deliver oxygen and nutrients. This can lead to decreased tissue perfusion, or poor blood flow
to tissues causing fatigue. This also leads to hypertension with a sign and symptoms of
headache and dizziness.
27
CHAPTER VII
PHYSICAL ASSESSMENT
This chapter involves a comprehensive evaluation of a client’s physical health, including
her vital signs, general appearance, and examination of her body systems. In addition, this
chapter aids in identifying any abnormalities or signs of illness that plays a vital role in
establishing a baseline of her health status.
1. General Appearance:
The client is 68-years old and as we entered her room during the assessment the
client was sitting with a good posture and she’s wearing a brown blouse and a black short.
Her skin is saggy with a brown complexion. Her hair is long and shiny, and appears to
be well-groomed. The client’s body type is ectomorph. She is alert and well-oriented and
is responsive to questions we asked her. There are no signs of distress.
Vital Signs
● Temperature: 36.2°C
● PR: 57 beats/min
● RR: 21 breaths/min
● BP: 110/80 mm-Hg
● Oxygen Saturation: 98%
2. Head and Face:
● Head is round and normocephalic
● The face is symmetric with an oval shape with no abnormal movement

noted.
28
● The head is normally hard and smooth, without lesions and no
tenderness upon palpation.
● The temporal artery is elastic and not tender upon palpation.
● No crepitation, swelling and tenderness on her temporomandibular

joint upon palpation.
3. Hair:
● Hair is brown-black in color and long.
● Scalp is white-pinkish, clean and there is no presence of lice
● Hair is shiny and smooth, thin, and equally distributed
4. Eyes:
● Eyebrows and Eyelashes are thin, symmetric and evenly distributed
● Eyeballs are symmetrically aligned as sockets without protruding or

sinking.
● The bulbar conjunctiva is pinkish
● Sclera is white
● The palpebral conjunctiva is pinkish.
● Iris is round and black in color.
● The lacrimal apparatus is not swelling and has no drainage.
● Pupil is round with a regular border, centered in the iris.
● Pupils are equally round and reactive to light and accommodation.
● Both eyes are well-coordinated
● Test pupillary reaction to light: There is bilateral reaction to light.
29
5. Nose:
● Nose is brown in color, flat and small and has no tenderness upon
palpation.
● The internal nose is white-pinkish in color, no swelling or redness.
● Nasal hair is present
● Nares is patent
6. Mouth:
● No distinctive odor.
● Lips are brown in color, no swelling and redness.
● Gums are light pink in color, no signs of hyperplasia.
● 18 healthy teeth and 4 teeth with cavities.
● Tongue is pinkish in color
● Tongue is in the midline and Uvula is tear-dropped in shape
7. Ears:
● Ear is brown in color.
● Ears are symmetrical in shape and size.
● Clear external auditory canal, and with no earwax.
● No tenderness upon palpation of auricle and mastoid process.
● Whisper Test: Hearing acuity is excellent.
● Romberg Test: The client can balance her body with her feet placed
together, closed eyes and her hand on her chest.
30
8. Neck:
● Neck has no presence of lumps and masses.
● The client was able to swallow.
● Good range of motion
● Trachea is in midline.
● Thyroid gland is smooth, and non-tender upon palpation.
● No bruise sound was heard.
9. Breast
● Both breasts are saggy, brown in color.

● Areola are dark-brown in color and no discharge is present.
● No rashes, infection, swelling and redness present.
● Texture is smooth, no edema, lumps and tenderness upon palpation.
● Loud, high-pitched bronchial breath sounds over the trachea.
10. Abdomen:
● Abdomen is brown in color.

● Striae and mass noted.
● Abdomen is round.
● Umbilicus is in midline.
● No abdominal movement.
● Bowel sounds are low pitched gurgling sounds.
● No vascular sound and friction rubs noted.
31
11. Extremities
Upper Extremities
● From shoulders to fingertips: equal limb circumference with no edema

or ulcers, skin color is consistent.
● Capillary bed refill in 2 seconds.
● Radial pulses are bilaterally strong.
● Good range of motion
Lower Extremities:
● Skin color is consistent from upper legs to toes, equal limb circumferences with
no edema or ulcers.
● No lesions in feet and legs.
● No presence of cyanosis or pallor on nails.
● Capillary bed refill in 2 seconds.
12. Genitalia:
The client didn't allow the examiner to examine her genitalia part.
According to the client, there are no discharges and lesions seen in her
genitalia part.
32
CHAPTER VIII
ON-GOING APPRAISAL
HEALTH CONCERN:
The client's primary complaint was abdominal girth and pain and the patient verbalized
“medyo nasakit ngem tolerable met. Adda 15 minutes na nukwa pinagsakit na'' and the client
rated the pain using the pain scale 1 being the lowest and 10 being the highest and the client
rated it as 5 out of 10.
COURSE OF CONFINEMENT:
The client was confined during our interview in february 19, 2024
February 17, 2024
The client’s Vital signs are monitored every 4 hours and for her vital signs no significant
changes or abnormalities are noted. No abnormalities noted in the characteristics of the client's
stool and Urine output. Doctor ordered to continue medications and Metoclopramide 10mg IV
q8 x u/v. The client was referred to an ophthalmologist for EOR (Error of refraction) due to
dizziness and rotatory on and off. No surgeries were conducted during this day and no new
signs and symptoms associated with the disease process.
VITAL SIGN:
12:00pm 4:00pm 8:00pm
T- 36. 5 T- 36.5 T- 36.6

PR- 88 bpm PR- 86 bpm PR- 65 bpm
RR- 20 bpm RR- 20 bpm RR- 20 bpm
BP- 110/70 mmHg BP- 110/70 mmHg BP- 110/80 mmHg
O2sat- 99% O2sat- 97% O2sat- 98%
33
MEAL:
For the client’s breakfast she ate 2 pcs. of bread and Energine. For her lunch the client had
1 fish and for dinner the client ate what was left for her lunch which is 1 fish and the client
verbalized that she at least drank 8 glasses of water.
February 18, 2024
There were no significant changes in the vital signs, all are at normal range. No
abnormalities noted in the characteristics of the client's stool and Urine output. The doctor
ordered medications of omeprazole 40mg IV OD, Losartan 50mg/tab OB, Trimetazidine 35/tb
OD, Rosuvastatin 20mg/tab ODHS, Enoxaparin 0.44cc SQ OD and Metrachlopromide 10mg
IV q8 x u/v. No Surgeries, Laboratory and Diagnostic Examination were conducted during this
day and no new signs and symptoms were associated with the disease process.
VITAL SIGNS:
12:00am 4:00am 8:00am 12:00pm 4:00pm 8:00pm
T- 36.6 T- 36.6 T- 36.8 T- 36.6 T- 36.8 T- 36.8

PR- 68 bpm PR- 66 bpm PR- 70 bpm PR- 68 bpm PR- 69 bpm PR- 68 bpm
RR- 20 bpm RR- 20 bpm RR- 20 bpm RR- 20 bpm RR- 20 bpm RR- 20 bpm
BP-110/80 BP- 110/80 BP-110/80 BP- 110/80 BP- 110/80 BP-110/80
O2sat- 98% O2sat- 98% O2sat- 98% O2sat- 98% O2sat- 98% O2sat- 98%
MEAL:
–The client’s breakfast was 1 pack of skyflakes ½ rice and 1 banana and Energine. For her
lunch she had Chicken and 1 cup rice and. For her dinner the patient ate Chicken and 1 cup of
rice. The patient reported that she approximately drank 6-8 glasses of water.
34
February 19, 2024
–The next day we were assigned to her to monitor the client's vital signs at 8:00am and conduct
the interview and as we took her vital signs and looked at her previous vital signs there were
no significant changes or abnormalities noted. Doctor ordered her to continue with the
medications given. No abnormalities noted of the patient's urine output and stool. No surgeries,
Laboratory and diagnostic examination were conducted in the morning and no new signs and
symptoms were associated with the disease process.
VITAL SIGNS:
12:00am 4:00am 8:00am
T- 36.4 T- 36.6 T- 36.3

PR- 88 bpm PR- 85 bpm PR- 92 bpm
RR- 20 bpm RR- 20 bpm RR- 19 bpm
BP- 110/80 mmHg BP- 110/80 mmHg BP- 110/80 mmHg
O2sat- 98% O2sat- 97% O2sat- 94%
MEAL
–The client’s breakfast was 2 pcs. of bread, Energine and 1 glass of water
ANALYSIS
The on-going appraisal was conducted over 3 days or 72 hours from 9:00am of february 19
back to 9:00am of february 17. The patient was confined during the interview conducted.The
patient's vital signs, urine output, and stool output remained within normal ranges. No new
signs and symptoms were reported, and the client’s medications were administered as
prescribed.
35
CHAPTER IX
PATTERNS OF FUNCTIONING
This chapter utilizes Gordon’s Functional Health Patterns as a method used by nurses in
the nursing process to provide a comprehensive nursing assessment of the client.
Health patterns Before Illness During Illness
Health Perception / The patient claims that The client stated “ The client
Health Management being healthy for her basibasit madi stated that “ ti
means being able to eat sumrek ken kasla ammok iddi
three times a day and haan nak nasalunat nak
doing things she mapalpalpaan, awan ngem haan
enjoys. The clients ramraman ti kanek gayam ken
enjoys eating iddi adda marikrikna tumtumarek
vegetables and also kon” She is allergic dagiti inbaga iti
meat and also the client to shrimp and if have doctor tapnun
stated “ haan nak ag allergic attacked she aglaingak” and
exexercise ta baket feels dizzy and hard also client
nakon “. she also stated to breath.The client stated “
that “basta awan stated “ haan ko madandanagan
marikriknak iddi ket ti malagip dagitay nak kadetoy
ammok nasalunat vaccine ko iddin ta kondisyon ko
nakon “. bumaket nak metten ita iso nga
“ also the client ubraek ammin
36
stated that “madlaw nga ibaga ti
ko iddin nga kaslang doctor ko”.
dumakdakkel detoy
buksit ko”.
Analysis:
The client's perception on being healthy before having an illness was eating three times a
day and doing the things she enjoys without any hindrance and after having the illness the
patient;s perception on health changes.
37
Health Patterns Before Illness During Illness
Nutritional- She doesn’t have any The client She stated “ mimmayat
Metabolic allergies to medication but stated “ awan pinnangan ko itan
patterns she has a food allergy. She is ramraman ti agkurkurang pay ti
using tobacco and she's not kanek iddi adda mesa labayanen“The
drinking any alcoholic marikrikna ammount of food
beverage. The client eats kon”. Shes not intake is restricted.
three times a day, she also taking any The client has a diet
stated “ mayat pinanagan ko medication. menu prescribed by
iddi ken panaginom ko, She also stated her physician. The
Addot mainom ko iddi “. The that she drinks ammount of food
client has a food allergy. She 4-6 glasses of intake is restricted. It
doesn’t have a diet. She water was also
doesn’t have vitamins everyday. recommended for her
to eat fruits as a desert
instead of eating it as
snack. She consumes 1
-2 liters of water.
38
Analysis:
There are significant changes in nutritional and metabolic patterns of the patient before
her illness. The client has a vice like tobacco and she can eat a lot before and after having an
illness. She stopped using tobacco and her eating pattern changed.
Elimination According to the client her Clients’ urine The clients stated
patterns urine discharge is 4-5 discharge 3-4 times a “haan nga kasla
times a day and there was day and there was no iddi nga inaldaw
no odor. The client stated odor. The client nak tumakki“and
“ inaldawak iddi stated “ marigatan also client stated
tumakki“. She doesn’t use nak tumakki ag 1 that she frequently
any laxatives. week pay nukwa iso urinates. she's not
nag anger nak ti drinking guyabano
guyabano leaves isot anymore.
inomek mamin tallo
ti makalawas ``.
drinking guyabano
leaves is
recommended by her
midwife niece. She
doesn’t use any
laxatives. She only
drinks guyabano to
39
help her defecate.
She also doesn’t
measure her urine
when discharging.
Analysis:
There are significant changes in the elimination pattern of the client. Before having an
illness the client’s urine discharge was 4-5 times a day and she defecated normally and after
having an illness the client’s urine discharge changes to 3-4 times a day and she has difficulty
in defecating also she stops drinking guyabano anymore.
40
Health Before Illness During Illness
Patterns
Activity and Client considered doing The client never Client stated that
Exercise household chores as her goes for walk “haan nak maka
pattern exercise every day. She also everyday and also garaw garawen ata
takes 5-10 mins walk in their she stated “haan ko adda nak met idtoy
backyard as part of her maubra amminen hospitalen “.
everyday routine. ata agulaw nak ken
agsasakit nukwa
toy buksit ko”.
Analysis:
There are significant changes in activity and exercise patterns of the client. Before she can
still go for a walk and do the household chores and after having an illness she can no longer
go for a walk and do the household chores she used to do.
41
Patterns
Cognitive and The client was well- The client stated Client is aware of her
Perceptual informed about what was “awan unay damag illness and also stated
pattern going on around her. She kon ti that “agalalo ita
also can recall some of mapaspasamakn ti naamwak toy sakit ko
her previous experiences aglawlaw ko a ta haan permi madandanagan
in her life. nak met unay nak metten, haan nak
rumrumwaren, detoy maka panononot nga
met marikrikna kon ti nasayaat”. She was
adda idtoy panonot able to focused and
kon”. she can speak communicate
fluently and totally fluently. She can
focused. remember things well
and is still attentive.
And also she can
understand us when
we do the interview
with her.
42
Analysis:
There are significant changes in cognitive and perceptual patterns of the client. Before she
was aware and well informed in her surroundings and now that she has an illness she can’t go
outside and she is no longer aware and well informed on what is happening in her surroundings.
Patterns
Sleep and Rest The client sleeps for an The client sleep for an The client stated that
pattern average of 6 hours a day average of 2-3 hours. “ makaturogak ngem
starting at 11pm in the She stated that “ apag biit lang nukwa
evening to 5am in the marigatan nak “. She sometimes
morning. Sometimes she makaturog, dadduma woke up because the
woke up in the middle of apag biit lang nukwa nurse take rounds in
the night to urinate and “ because she the middle of the
go back to sleep again. sometimes feel pain night to check the
She sometimes takes a in her abdomen. She patients beside her
nap in the afternoon at naps in the afternoon bed.
around 1pm to 2:30 in at around 1pm to
the afternoon. 3pm.
43
Analysis:
There are significant changes in the client’s sleeping pattern by not getting enough sleep
and rest at night because of her illness.
Self- The client expressed that she The client stated The client stated
Perception/Self enjoys being herself. She that “ kasla awan that she feels
Concept pattern does whatever she feels right serserbi kon ta useless because
and doesn’t necessarily hold haan nak met maka she can no longer
any meaning on how she kutikutin ta agsakit do household
looks. She is content with her met detoy buksit chores like she
overall appearance. ko no agkuti used to do before.
nakon”. Because
of what she is
feeling, she started
to feel more
conscious on her
body image.
44
Analysis:
The clients self-perception or self-concept pattern before and after having illness changes.
She used to enjoy being herself and was content with what she is doing and after having an
illness she no longer feels the same way as before.
Roles and The client considered her Although the client The client can no
Relationship family to be very important is living with her longer take care of
pattern in her life. Even though her son and three the three kids
parents and her husband are grandchildren, she because of her
no longer here. She is the one can no longer take hospitalization.
taking care of her care of the three The client stated
grandchildren since her kids because of her “Haan nak
daughter is working abroad. condition. The makapanen a nu
She enjoys joining senior client stated adda program kada
citizen gatherings. The client “Haanak unay meeting mi iti
stated “Permi maragsakan rumrumwaren, jak senior ta naka
nak nga makilangen langen makap apan nu confine nak met.
iti pamilyak ken iti padak a adda programs mi Haan ko pay
seniors”. iti senior makita dagitay
citizenen.” appoko kon imbag
Because of her lang ta adda tay
45
condition, she maysa nga kasinsin
bbecame inactive ko a mangkita
in her social kadakwada.”
relationships.
Analysis:
There are significant changes in roles and relationship patterns of the client. She can
still take care of her grandchildren and after having an illness she can no longer take care of
her grandchildren because of her condition.
46
Sexuality- She had her first menstrual The client doesn’t There are no
Reproductive period when she was in grade have any history of changes in her
pattern 6. She got pregnant at the age STD or any disease sexuality and
of 19 through NSD. She is no affecting genital reproduction
longer sexually active since area. She is not pattern.
her husband died already. sexually active.
Analysis:
There are no significant changes in the sexuality-reproductive pattern of the client. Because
the client is no longer sexually active even before and during her illness.
47
Coping/Stress The client handles her stress The client became The client is being
Tolerance well. Whenever she gets more sensitive stressed after
pattern angry with her three because of her knowing her
grandchildren, she just talks condition. Even illness. The only
to them and explains the small things can thing she can do
situation calmly. make her angry as for herself is to
if she cannot handle pray and believe
her stress anymore. that she will be
The client stated healed and
“Alisto nak nga treated.
agpungtot gapo ta
adu unay ti
panunotek aglalo
detoy
marikriknajk.”
Analysis:
There are significant changes in coping/stress tolerance of the client. Before she just talks
to her grandchildren and after having an illness she always prays.
48
Patterns
Value-Belief The client's religion is The client is no The client stated
pattern Roman Catholic. She goes to longer attending that she can no
church every Sunday and she Sunday mass longer go to church
always prays before going to because of her because she was
bed. condition. The admitted in the
client stated that “ hospital due to her
haan nak illness and also she
makapkapanen ata stated that “ haan
nasakit toy buksit nak makapanen ata
ko no agkutikuti adda nak met idtoy
nak ngem uray pay hospitalen ngem
kasta kanayon nak kanyon nak latta
latta agkarkararag agkarkararag nga
ken Apo”. aglaingak”.
Analysis:
The client is still religious before and during her illness but before her illness she always
goes to church every Sunday and now she can no longer attend Sunday mass.
49
CHAPTER X
MEDICAL MANAGEMENT
This chapter presents interpretation and analysis of data, and this segment discloses the
health regarding the client’s laboratory examinations and diagnostic procedures, treatments,
surgical interventions and drug study.
A. LABORATORY AND DIAGNOSTIC PROCEDURES
Table 10.1 Complete Blood Count
Date Ordered: February 13, 2024 Date Performed: February 13, 2024
Name of Diagnostic and Laboratory Examination:

Complete Blood Count
Definition:
A complete blood count (CBC) is a blood test that measures the cells of your blood. The
types of cells are red blood cells (RBCs), white blood cells (WBCs), and platelets.
Purpose of Procedure:
To assess overall health and aid in diagnosing various medical conditions such as anemia,
infections, and blood disorders like leukemia.
TEST NAME RESULT UNIT REFERENCE RANGE

HEMOGLOBIN 122.00 g/L 123 - 153
HEMATOCRIT 0.38 0.35 - 0.44
RED BLOOD CELL 4.56 10 ^12/L 4.5 - 5.1
MCV 83.30 fL 80 - 100
MCH 26.80 pg 27 - 32
MCHC 32.20 g/dL 31 - 35
RDW 15.30 % 12 - 16
50
WHITE BLOOD 8.31 10 ^ 9/L 4.50 - 11.00
CELL
Differential Count: 0.55 0.50 – 0.70
-Segmenters 0.34 0.20 – 0.40
-Lymphocytes 0.077 0.02 - 0.08
-Monocytes 0.03 0.01 - 0.04
-Eosinophil 0.01 0.00 - 0.01
-Basophil
PLATELET COUNT 339.00 10 ^ 9/L 150 – 450
-MPV 9.30 fL 9.2 - 12.2
-PDW 9.90 fL 9.7 - 15.1
ANALYSIS:
The table shows the result of CBC in which the hematocrit is within normal range. As for the
hemoglobin, it is lower than the normal range; this indicates fewer red blood cells carrying
oxygen throughout the body. As well as the red blood cell(RBC), mean corpuscular
volume(MCV), mean corpuscular hemoglobin(MCH), mean corpuscular hemoglobin
concentration(MCHC), and red cell distribution width(RDW), are also within normal range.
In white blood cells, the result 8.31 10^9/L is within normal range. The differential count under
white blood cells includes segmenters, lymphocytes, monocytes, eosinophil, and basophil. All
the differential counts under WBC are within normal range.
In the platelet count, it has a result of 399.00 10 ^ 9/L which means it is the normal range
level. In relation to the platelet count, the mean platelet volume (MPV) and platelet distribution
width(PDW) values are normal.
NURSING RESPONSIBILITIES RATIONALE
1. Inform the patient about the purpose of 1. Providing information to the patient
the CBC and the procedure involved. helps alleviate anxiety and promotes
51
cooperation during the blood
collection process.
2. Ensure that the patient understands 2. Informed consent is an ethical and legal
the purpose, benefits, and potential requirement that ensures patient autonomy
risks of the CBC and obtain and protects their rights.
their informed consent
3. Fill up the laboratory request properly and 3. To notify the medical technician
forward it to the laboratory
4. When the results are obtained, notify 4. It serves as the baseline data for the
the physician and attach it to the physician to accurately diagnosed the client
client’s chart and to determine the correct and proper
treatment necessary for the client
5. Carry out doctor’s order with regards 5. To address and correct abnormal results
to the management for abnormal results
6. Document the procedure 6. For legal purposes
Table 10.2 Urine Analysis
Date Ordered: Feb 13, 2024 Date Performed: Feb 13, 2024
Urine Analysis
52
Definition:
Urinalysis is the physical, chemical, and microscopic examination of urine. It involves a
number of tests to detect and measure various compounds that pass through the urine.
To assess potential underlying conditions such as kidney dysfunction which could be
indicative of malignancies or other pathological processes. It can also help monitor the
effects of the mass on kidney function and overall health.
PHYSICAL EXAM
Color YELLOW Specific Gravity 1.015
Clarity CLARITY
CHEMICAL EXAM
pH 7.0 Nitrite NEGATIVE
Glucose NORMAL Bilirubin NEGATIVE
Hemoglobin POSITIVE 2 Urobilinogen NEGATIVE
Ketone NEGATIVE Leuko Esterase
Protein NEGATIVE
MICROSCOPIC EXAM
CONVENTIONAL UNITS S.I UNITS
TEST RESULT UNIT REFERENCE RESULT UNIT REFERENC

RANGE E RANGE
WBC 0-2 /HPF 0.0 - 3.0 /uL 0.0 - 17.0
RBC 1-2 /HPF 0.0 - 2.0 /uL 0.0 - 11.0
Epithelial RARE /LPF /uL 0.0 - 26.0

Cells
53
Bacteria NUMEROUS /HPF /uL 0.0 - 278.0
Mucus RARE /LPF /uL

Threads
Yeast Cells /LPF /uL
ANALYSIS:
Based on the table under the physical exam, the color of the urine is yellow and the clarity
of the urine indicates that the client has adequate hydration. The specific gravity result of the
urine is 1.015, which is within the normal range.
In the chemical exam, the glucose level of urine of the client and the pH of the urine resulting
in 7.0 is within the normal range. Ketone, protein, nitrate, bilirubin, urobilinogen are all
negative. However, the hemoglobin results in positive 2 indicates blood in the urine which
means your body is breaking down red blood cells too quickly.
Lastly, in the microscopic exam, the white blood cells (WBC) resulting in 0-2/HPF and the
red blood cells (RBC) resulting in 1-2/HPF are within the normal range. The epithelial cell and
mucus threads resulting in rare are normal. The presence of numerous bacteria indicates an
infection in the urinary tract of the client.
1. Inform the patient about the procedure. Improper collection of urine directly affects
Provide proper instructions on how to the accuracy and reliability of urinalysis
collect clean and midstream urine. results.
54
2. Ensuring the proper identification of To ensure that the urine sample is accurately
the client attributed to the correct client. It helps prevent
errors and ensures patient safety.
3. Labeling the urine sample correctly To ensure accurate identification and prevent
mix ups or errors in the laboratory
4. Transporting the urine sample to the To helps prevent degradation of the sample and
laboratory in a timely manner ensures accurate test results
5. Documenting the procedure and any To maintain accurate record of the urine
relevant information analysis procedure
6. Assisting the client with proper hygiene To helps prevent contamination of the urine
before collecting the urine sample sample
7. Collaborating with the healthcare teamTo ensure appropriate interventions or further
to interpret and act upon the urinediagnostic tests based on the findings.
analysis results
Table 10.3 CT- SCAN, CHEST + ABDOMEN CONTRAST
CT- SCAN, CHEST + ABDOMEN CONTRAST
55
Definition:
It is an imaging test that helps healthcare providers detect diseases and injuries. It uses a
series of X-rays and a computer to create detailed images of your bones and soft tissues.
CHEST CT-SCAN: to visualize structures within the chest cavity, serving multiple
purposes in medical diagnosis and management. It enables the detection and diagnosis of
various lung conditions, including tumors, infections, and inflammatory diseases, often
revealing subtle abnormalities that may not be apparent on conventional X-rays.
ABDOMEN CT-SCAN: To evaluate various structures and conditions within the
abdominal cavity.
RESULT:
Multiple axial tomographic sections of the thorax and abdomen with and without IV contrast,
and with oral and rectal contrast were obtained.
The CT images reveal minimal left pleural effusion.
The rest of the lungs are well-aerated. No lung parenchymal nodules are seen.
The heart is not enlarged.
There are no enlarged nodes in the mediastinum.
The extrathoracic tissues are unremarkable.
The bony thorax, including the ribs, vertebrae and sternum are intact.
A left abdominopelvic cystic mass lesion is seen measuring 19.6 x 9.2 x 17.6 cm. (CC x W
x AP).
A smaller slightly hyperdense cyst-like lesion is seen in the pelvic region measuring 8.3 x
7.2 x 7.8 cm.
Ascites noted.
The bowels are unremarkable. No bowel obstruction is seen.
56
The liver, pancreas and spleen are of normal size and tissue homogeneity.
Few small hepatic cysts are seen.
The gallbladder is unremarkable.
There are no enlarged nodes in the abdomen.
The adrenal glands are normal.
The kidneys are of normal size, position and configuration.
The urinary collecting structures and urinary bladder are normal.
The uterus is intact. A heterogeneous hypodense lesion is seen in the uterine fundus
measuring 2.3 x 2.7 x 1.6 cm.
Vascular calcifications are seen.
Vertebral spurs are noted.
IMPRESSION:
Minimal left pleural effusion.
Abdominopelvic masses as described, may represent ovarian neoplasms. Correlate with
tissue diagnosis.
Ascites.
Small hepatic cysts.
Myoma uteri, considered.
Atherosclerosis.
Degenerative spondylosis.
ANALYSIS:
The patient's abdominal CT scan reveals several significant findings. Firstly, there is
minimal left pleural effusion, indicating a potential accumulation of fluid in the pleural space
surrounding the left lung. Additionally, abdominopelvic masses are noted, which could
potentially signify ovarian neoplasms, though further correlation with tissue diagnosis is
advised for confirmation. Ascites, the accumulation of fluid within the abdominal cavity, is
also observed. Small hepatic cysts are present in the liver, while a myoma uteri is considered,
57
suggesting the presence of a benign uterine tumor. Furthermore, evidence of atherosclerosis, a
condition characterized by the hardening and narrowing of arteries due to plaque buildup, is
noted. Finally, degenerative spondylosis, a common age-related condition affecting the spine,
is observed. These findings collectively provide valuable insight into the patient's abdominal
and pelvic health, warranting further investigation and potential medical intervention as
deemed necessary.
1. Preparing the client for the procedure To ensure that they understand the
procedure, know what to expect , and can
provide informed consent.
1. Educating the client about procedure To help ensure their cooperation and
and necessary preparations understanding.
2. Verifying the clients identification To prevent errors and ensure the scan is
and confirming the correct procedure performed on the correct client. Also it helps
maintain patient safety and prevent
misdiagnosis or incorrect treatment
3. Providing emotional support to the To help alleviate anxiety and promote a
client during the procedure positive patient experience.
4. Documenting the procedure To maintain an accurate record
58
Table 10. 4 CT-SCAN, HEAD/SKULL/CRANIAL
CT-SCAN, HEAD/SKULL/CRANIAL
Definition:
A medical imaging technique used to create detailed cross-sectional images of the brain,
skull, and surrounding structures. It utilizes X-rays to produce multiple images from
different angles, which are then processed by a computer to generate comprehensive views
of the head.
To assess head injuries, severe headaches, dizziness, and other symptoms of aneurysm,
bleeding, stroke, and brain tumors. It also helps doctor to evaluate face, sinuses, and skull or
to plan radiation therapy for brain cancer.
CT- SCAN REPORT
Multiple axial tomographic sections of the cranium without contrast media were obtained.
The CT images reveal small focal cortical-subcortical hypodensity in the right occipital
parasagittal region.
The cortical sulci, cerebral sulci, lateral fissures, and ventricles are intact for age.
The midline structures are not displaced.
Calcifications line the internal carotid and vertebral arteries.
Physiologic pineal gland, basal ganglia, and choroid plexus calcifications are seen.
59
The sella and posterior fossa including the brainstem, cerebellopontine angles and basal
cisterns are unremarkable.
No extra-axial fluid collection is noted.
The visualized paranasal sinuses, mastoid air cells, and orbits appear intact.
The calvarium and the extracarvarial soft tissues are unremarkable.
IMPRESSION:
Right occipital parasagittal focal cortical-subcortical hypodensity, may represent
inflammatory vs metastatic process.
Contrast-enhanced MRI study is recommended for further evaluation.
Atherosclerosis.
ANALYSIS:
The patient's medical imaging results reveal a notable finding of a right occipital parasagittal
focal cortical-subcortical hypodensity, suggesting a potential inflammatory or metastatic
process affecting the brain tissue in this region. Given the ambiguity surrounding the etiology
of this hypodensity, further investigation is warranted, and a contrast-enhanced MRI study is
recommended to provide a more detailed evaluation and better delineation of the lesion.
Alongside this focal brain abnormality, evidence of atherosclerosis, a condition characterized
by the buildup of plaque in the arteries, is also noted. These findings underscore the importance
of comprehensive evaluation and management to address both the neurological and vascular
aspects of the patient's health condition.
60
Explain the procedure to the patient It is essential to inform the patient about the
CT scan procedure, including its purpose,
potential risks, and what to expect during the
test. This helps reduce anxiety and ensures the
patient's cooperation during the test.
Verify the patient's identification To ensure the test is done on the correct
individual.
Position the patient properly Proper positioning helps in obtaining accurate
and clear images for diagnosis.
Observe for any immediate reactions Prompt identification and management of any
adverse reactions are crucial for patient safety.
Provide post-procedure care instructions Clear instructions help ensure the patient's
well-being post-CT scan.
Document the CT scan findings and Comprehensive documentation is essential for
patient response continuity of care and communication with
healthcare providers.
61
Table 10.5 Chemistry Section
Chemistry Section
Definition:
Chemistry section is where patients’ blood and other body fluids are checked for various
chemical components.
BLOOD UREA NITROGEN TEST - measures the amount of urea nitrogen that’s in your
blood. It reveals important information about how well your kidneys are working.
CREATININE TEST - it is done to see how well the kidneys are working. Creatinine in
the urine can be measured with a urine test. A measurement of the serum creatinine level is
often used to evaluate kidney function.
SODIUM TEST- it is a routine test to check your general health. It may be used to help find
monitor conditions that affect the balance of fluids, electrolytes, and acidity in your body.
POTASSIUM TEST- it is a test to monitor or diagnose conditions related to abnormal
potassium levels. These conditions include kidney disease, high blood pressure, and heart
disease.
Test Name Result Unit Reference Range
Blood Urea Nitrogen 2.91 mmol/L 2.8 - 7.20
Creatinine 53.96 umol/L 49 - 115
62
Sodium 137.46 mmol/L 136 - 145
Potassium 3.54 mmol/L 3.5 - 5.1
ANALYSIS:
In the chemistry section, the blood urea nitrogen resulting in 2.91, creatinine resulting in
53.96, sodium resulting in 137.46, and potassium resulting in 3.54 are within normal range.
1. Ensuring proper identification of the To ensure that the laboratory test results are
client accurately attributed to the correct client.
2. Collecting and labeling the To maintain the integrity of the samples and
specimens correctly prevent mix-ups or errors in the laboratory
3. Following proper specimen To ensures that the specimens are not
collection techniques contaminated and that accurate results are
obtained
4. Transporting the specimens to the To helps maintain the integrity of the
laboratory in a timely manner samples and ensures reliable findings
5. Documenting the process and any To maintain accurate record of the
relevant information collection process
6. Educating the client about the To helps promote their understanding and
purpose and significance of the cooperation
laboratory process
63
Table 10.6 CA-125 and CEA Test
CA-125
Definition:
CA 125 test measures the amount of protein cancer antigen 125 in the blood. The test may
be used to look for early signs of ovarian cancer in people with a very high risk of the disease.
High levels of certain tumor markers in your blood may be a sign of cancer. CA-125 is a
type of tumor maker.
The CEA test, or carcinoembryonic antigen test, is a blood test used to measure the levels
of carcinoembryonic antigen in the bloodstream.
CA-125 Test: The purpose of this test is to measure the amount of protein called CA-125
(cancer antigen 125) in the blood.
CEA Test: A carcinoembryonic antigen test measures CEA, a specific blood glycoprotein.
It means a protein with a lot of sugars added to it by normal or cancerous cells.
Test Name Result Unit Reference Range
CA-125 1154.00 U/mL Less than 35
CEA 1.37 ng/mL Less than 3.0
64
ANALYSIS:
The table above shows that the carcinoembryonic antigen result is within normal range.
However, the CA-125 is high compared to the normal range. The result 1154.00 indicates that
there is the presence of cancer antigen 125 in the body of the client. High levels of CA-125 in
conjunction with a pelvic-abdominal mass can raise suspicion for ovarian cancer. CA-125 is a
tumor marker often associated with ovarian cancer and an elevated level may indicate the
presence of abnormal growth in the pelvic or abdominal region.
1. Inform the patient about the - Empowers the patient to make
purpose of CA-125 test informed
2. Obtaining informed consent - To respect the client’s autonomy and
from the client ensure they fully understand the
implications and potential risk of the
test
3. Assisting the client in - To help obtain reliable results
preparing the test
4. Verifying the client’s - To prevent errors and ensure the test
identification and confirming is performed to the correct client
the correct test
5. Labeling the blood sample - To ensure accurate identification and
correctly prevent errors in the laboratory
65
6. Transporting the blood - To helps prevent degradation of the
sample to the laboratory in a sample and ensures accurate test
timely manner results
7. Documenting the procedure - To maintain accurate record of the
and any relevant information CA-125 test procedure
Table 10.7 Gynecologic Ultrasound
Gynecologic Ultrasound
Definition:
Gynecological ultrasound is a painless, non-invasive imaging test that uses sound waves to
create images of the internal reproductive structures, including the ovaries, fallopian tubes,
and uterus.
The purpose of gynecologic ultrasounds is for identifying abnormalities of the reproductive
organs such as uterine fibroids or ovarian cysts.
UTERUS Position: Anteverted
Texture: Homogenous
66
Corpus: 4.35 x 2.98 x 3.53 cm
Findings: 2.43 x 1.95 x 1.96 cm
CERVIX Findings: Intact and closed endocervical canal
ENDOMETRIUM Thickness: The endometrium is dilated measuring 2.3 x 3.0 x 1.9
cm (volume = 7 cc) with minute cystic spaces interspersed within.
Findings: Intact subendometrial halo
RIGHT OVARY:
Size: 1.61 x 1.03 x 1.61 cm (Volume: 1.40 mL). Lateral to the uterus.
Findings: Normal size and echotexture with several follicles noted.
LEFT OVARY:
Size: At the left adnexa is a solid mass measuring 7.8 x 9.1 x 7.8 cm. Doppler showed no
color.
Findings:
OTHERS:
There’s fluid up to the inferior border of the liver.
IMPRESSION:
-ATROPHIC ANTEVERTED UTERUS WITH HYPERPLASIA.
-LEFT ADNEXAL MASS PROBABLY OVARIAN IN ORIGIN; 70% CHANCE OF
MALIGNANCY BY IOTA ADNEX MODEL.
- NORMAL RIGHT OVARY.
- MASSIVE ASCITES.
67
ANALYSIS:
Based on the ultrasound, the client showed an atrophic anteverted uterus with hyperplasia,
indicating potential abnormal uterine tissue growth. Additionally, a left adnexal mass, likely
originating from the ovary, was detected with a 70% likelihood of malignancy according to the
IOTA adnex model, highlighting a significant concern for ovarian cancer. However, the right
ovary appeared normal. Furthermore, the presence of massive ascites, an abnormal
accumulation of fluid in the abdominal cavity, suggests a widespread pathology potentially
associated with advanced stage malignancy, warranting urgent and comprehensive medical
intervention.
B. TREATMENTS
1. Intravenous Therapy of PNSS 1L x 10 hours
Intravenous Therapy is administering fluids directly into a vein. It benefits treatment and
enables water, medication, blood, or nutrients to access the body faster through the circulatory
system. They act rapidly within the body to restore fluid volume and deliver medications.
Choose an appropriate vein for cannulation, To reduce the risk of complications, such as
considering factors such as vein size, infiltration or phlebitis, and ensure the
accessibility, and the intended duration of IV effective delivery of fluids and medications.
therapy.
Perform hand hygiene before and after To prevent the transmission of
handling IV equipment and during any microorganisms, reducing the risk of
breaks in the procedure. infection for both the patient and healthcare
68
provider.
Perform a thorough assessment of the To help identify potential risks, ensures
patient's overall condition, including vital patient safety, and allows for the selection of
signs, allergies, and the status of the vascular appropriate IV fluids and medications.
access site.
D. DRUG STUDY
DRUG STUDY NO. 1
Generic Name: Omeprazole
Brand Name: Prilosec
Dosage/Route/Frequency: 40 mg IV OD
Physiologic Classification: Antisecretory compounds
Pharmacologic Proton Pump Inhibitors (PPIs)
Classification:
Mechanism of Action: Inhibits activity of acid (proton) pump and binds to
hydrogen-potassium adenosine triphosphatase at secretory
surface of gastric parietal cells to block formation of gastric
acid.
69
Indication: It helps in reducing the production of stomach acid,
providing relief from symptoms such as heartburn and
stomach pain. Additionally, omeprazole can also be
beneficial for patients with hypertension and dyslipidemia,
as it has been shown to potentially lower blood pressure and
improve lipid profiles.
Desired Effect: Help alleviate symptoms of nausea and abdominal
discomfort often associated with gastric tumors.
Omeprazole may have potential benefits in managing
hypertension and dyslipidemia, possibly due to its anti-
inflammatory properties that can help reduce cardiovascular
risk factors
Contraindication: Contraindicated in patient’s hypertensive to drug or its
components.
Side Effects: nausea, vomiting, stomach pain, gas, and constipation also
headaches, dizziness, and rash while taking omeprazole.
Adverse Effect: CNS: headache, dizziness, asthenia
GI: diarrhea, abdominal pain, nausea, vomiting,
constipation, flatulence
Musculoskeletal: back pain
Respiratory: cough, upper respiratory tract infection
Skin: rash
70
NURSING RESPONSIBILITIES
Action Rationale
Before:
1. assess the patient's medical history, 1. to ensure it is safe to administer the
allergies, and current medications medication.
2. assess the patient's symptoms and 2. to confirm the diagnosis before
determine the appropriateness of administering the medication
omeprazole as a treatment option.
3. explain the purpose of the medication 3. This allows the patient to make an
to the patient and discuss potential informed decision about their
side effects. treatment and be aware of what to
expect.
During:
1. ensure the correct dosage is given and 1. to identify any complications early
monitor the patient for any signs of and provide prompt intervention if
allergic reactions or adverse effects. needed.
2. educate the patient on how to take 2. To maximize its effectiveness and
omeprazole properly, such as taking it reduce the risk of side effects.
on an empty stomach at least 30
minutes before a meal.
After:
1. continue to monitor the patient for any
signs of improvement in symptoms
71
and assess for any potential side 1. to ensure the medication is working
effects. as intended and make any necessary
2. provide patient education on lifestyle adjustments to the treatment plan.
modifications that can support the
effectiveness of omeprazole, such as 2. To help the patient manage their
avoiding trigger foods and condition effectively and reduce the
maintaining a healthy diet. need for long-term medication use.
DRUG STUDY NO. 2
Generic Name: Losartan
Brand Name: Cozaar
Dosage/Route/Frequency: 50 mg/tab PO OD
Physiologic Classification: Angiotensin Receptor Antagonists
Pharmacologic Classification: Antihypertensive
Mechanism of Action: Prevents angiotensin II binding to the AT1 receptor
in tissues like vascular smooth muscle and the
adrenal gland.
72
Indication: Indicated to treat hypertension to reduce the risks of
fatal and non-fatal cardiovascular events, primarily
stroke and myocardial infarctions.
Desired Effect: Relaxes the blood vessels.
Contraindication: Contraindicated with patient’s hypertensive to the
drug and its components.
Side Effects: Diarrhea, constipation, nausea, vomiting, dizziness,
vertigo, headache, migraine, cough, nasal
congestion, pruritus, photosensitivity, rash.
Adverse Effect: CNS: dizziness, insomnia
EENT: nasal congestion, sinusitis
GI: renal failure, renal insufficiency, hyperkalemia
Hema: anemia, angioedema
Cardio: chest pain, atrial fibrillation, palpitations
Neuro: Tinnitus
Action Rationale
Before:
1. Check the doctor's order. To avoid errors.
73
2. Monitor blood pressure. To prevent further complications and
misdiagnosis. Changes in blood pressure
could indicate a problem.
During:
1. Verify the patient's identity. 1. To avoid errors and to ensure you
have the right patient.
2. Ensure that you give the right dose, 2. To avoid errors and problems, and to
right medication, right time, right ensure you give the right dose,
route to the right patient. medicine, and route to the right
patient
3. Explain the purpose of the medication 3. To educate the patient about the
to the patient. purpose of the medicine and to
promote patient-centered care and
contribute to better treatment
outcomes.
4. Tell the patient that it can be 4. To help improve absorption and
administered with food or water. effectiveness in the body.
5. Regularly assess the patient's renal 5. Regular assessment of renal function
function. is essential for detecting adverse
74
effects and preventing
complications.
6. Tell the patient to avoid salt 6. Too much salt can cause high
substitutes. potassium levels in patients taking
losartan.
After:
1. Monitor vital signs. 1. To evaluate the effectiveness of the
drug.
2. Monitor adverse effects. 2. To detect adverse effects and
complications associated with
hypertension.
3. Document medication administration 3. For patient's safety and continuity of
correctly and accordingly. care.
4. Advice the patient to immediately 4. To prevent further complications and
report any breathing difficulty or problems.
swelling of the face, lips, eyes or
tongue.
75
DRUG STUDY NO. 3
Generic Name: Trimetazidine
Brand Name: Angirel MR
Dosage/Route/Frequency: 35 mg/tab PO OD
Physiologic Classification: Anti-anginal
Pharmacologic Classification: fatty acid oxidation inhibitors
Mechanism of Action: inhibits β-oxidation of fatty acids by blocking long-
chain 3-ketoacyl-CoA thiolase, with the effect of
enhancing glucose oxidation, resulting in more
efficient production of ATP with less oxygen demand.
It prevents a decrease in intracellular ATP levels by
preserving energy metabolism in cells exposed to
ischaemia or hypoxia, thus ensuring the proper
functioning of ionic pumps and transmembrane Na-K
flow without changing haemodynamic parameters.
Indication: Used to treat heart related conditions
Desired Effect: Helps to maintain the energy metabolism of heart
muscle cells, protecting them from the effects of
76
reduced oxygen supply. Preserving myocardial high-
energy phosphate intracellular levels.
Contraindication:
Parkinson's disease, parkinsonian symptoms, restless
leg syndrome, tremors, and other related movement
disorders.
Side Effects: Dizziness, headache. Abdominal pain, diarrhea,
dyspepsia, nausea and vomiting. Rash, pruritus,
urticarial and asthenia.
Adverse Effect: Dizziness, headache
Action Rationale
Before:
1. Check the doctor’s order 1. To ensure the patient is receiving the
correct medication
2. Asses the patient medical history 2. To patient safety and to determine if
the patient has allergies
During:
1. Administering the medication as 1. To ensure that the medication is
prescribed given at the correct dose and via the
77
correct route as prescribed by the
healthcare provider.
2. Monitoring for side effects or adverse 2. It is important to monitor the patient
effects for these side and adverse effects and
report them to the healthcare
After: provider if they occur
1. Educating the patient on proper
administration 1. It is important to instruct the patient
to take the medication with a full
glass of water and to avoid taking
other medications or supplements at
the same time.
2. Document and record accordingly 2. To ensure the patient understands the
importance of taking the medication
as prescribed, potential side effects
to watch for, and when to seek
medical attention if needed.
78
DRUG STUDY NO. 4
Generic Name: Rosuvastatin
Brand Name: Crestor
Dosage/Route/Frequency: 20 mg/tab PO ODHS
Physiologic Classification: Antihyperlipidemic drug
Pharmacologic HMG-CoA reductase inhibitor
Classification:
Mechanism of Action: A fungal metabolite that inhibits the enzyme (HMG-CoA)
that catalyzes the first step in the cholesterol synthesis
pathway, resulting in a decrease in serum cholesterol, serum
LDLs and either increase or no change in serum HDLs.
Indication: Adjunct to lipid-lowering therapies; to reduce LDL,
cholesterol, apolipoprotein B, and total cholesterol levels in
homozygous familial hypercholesterolemia.
Desired Effect: To help lower bad cholesterols and fats and raise good
cholesterol in the blood.
79
Contraindication: Contraindicated with allergy to any component of the
product, active liver disease or persistent elevated serum
transaminase, pregnancy, and lactations.
Side Effects: Nausea, headache, stomach pain, dizziness, weakness,
constipation.
Adverse Effect: CNS: dizziness, insomnia, headache, anxiety, depression
CV: chest pain, angina pectoris, hypertension, palpitations,
vasodilation
GI: abdominal pain, constipation, diarrhea, nausea,
vomiting, gastritis
GU: UTI
Hematologic: anemia
Metabolic: DM
Musculoskeletal: myalgia, neck pain
Respiratory: asthma, cough, dyspnea
80
Action Rationale
Before:
1. Obtain a thorough medical history, 1. Allows the nurse to identify any
including any allergies, current potential contraindications or risks of
medications, and past medical adverse reactions to rosuvastatin,
conditions, as rosuvastatin may thus ensuring the patient's safety.
interact with certain medications and
medical conditions.
2. Evaluate the patient's lipid profile to 2. To confirm the necessity of
determine the appropriateness of rosuvastatin therapy and ensure that
prescribing rosuvastatin. the medication is being prescribed at
an appropriate dose for the patient's
specific needs.
During:
1. Monitor the patient for any signs or 1. To identify and address any potential
symptoms of adverse reactions. risks to the patient's health and well-
being.
2. Educate the patient on the importance 2. To help the client to optimize the
of adhering to a heart-healthy diet and effectiveness of rosuvastatin therapy
lifestyle modifications in conjunction and reduce the risk of cardiovascular
with taking rosuvastatin. events, ultimately promoting the
patient's overall health and well-
being.
81
After:
1. Follow up with the patient to assess 1. To track the client’s progress in
the medication's efficacy in lowering response to rosuvastatin therapy and
cholesterol levels and reducing the make any necessary adjustments to
risk of cardiovascular events. the treatment plan to optimize its
effectiveness.
2. Continue to monitor the patient for 2. to ensure the client’s safety and well-
any signs or symptoms of adverse being while taking rosuvastatin, as
reactions, even after the initial some side effects may not manifest
administration of rosuvastatin immediately and require continued
vigilance to detect and address
promptly.
DRUG STUDY NO. 5
Generic Name: Enoxaparin
Brand Name: Lovenox
Dosage/Route/Frequency: 0.4 cc SQ OD
Physiologic Classification: Anti-coagulation
82
Pharmacologic Classification: Low molecular weight heparins
Mechanism of Action: Binds to antithrombin III, a serine protease inhibitor,
forming a complex that irreversibly inactivates factor
Xa, which is frequently used to monitor
anticoagulation in the clinical setting
Indication: Prevention of ischemic complications in unstable
angina and in non Q-wave myocardial infarction
Desired Effect: prevent blood clots from forming in the arteries of the
heart during certain types of chest pain and heart
attacks
Contraindication: contraindicated in patients with active major bleeding,
in patients with thrombocytopenia associated with a
positive in vitro test for anti-platelet antibody in the
presence of enoxaparin sodium, or in patients with
hypersensitivity to enoxaparin
Side Effects: Anemia (not having enough healthy red blood cells),
bleeding, swelling in the legs, pain and bruising at the
site on the skin where you give the injection
Adverse Effect: Dizziness, headache, insomnia, edema, constipation,
nausea, vomiting, urinary retention, alopecia, anemia,
rash, fever, irritation
83
Action Rationale
Before:
1. Verify the patient's prescription and 1. to ensure that enoxaparin is the
assess their medical history appropriate medication for them.
2. Check the patient's vital signs, 2. to establish a baseline and monitor for
including their blood pressure and any changes after administering the
heart rate, medication and this will help in
detecting any potential side effects or
complications of enoxaparin.
3. Educate the patient on the purpose 3. to ensure their understanding and
of enoxaparin, the dosage regimen, compliance with the treatment plan
and potential side effects and this will help in improving the
patient's adherence to the medication
and overall treatment outcomes.
4. Ensure that the correct dosage of 4. To ensure that the client receives the
enoxaparin is prepared and ready for appropriate dose of enoxaparin.
administration, following proper
medication administration
procedures and safety protocols.
84
During:
1. Administer enoxaparin as 1. To ensure the medication is delivered
prescribed by the healthcare effectively and safely. This will help
provider, following proper injection in optimizing the therapeutic effects of
techniques and guidelines enoxaparin and reducing the risk of
complications.
2. Monitor the patient for any 2. To help the client in early detection
immediate reactions or side effects and management of any adverse
after administering enoxaparin events associated with enoxaparin
3. Document the administration of 3. To track the client’s response to the
enoxaparin, including the dosage medication and ensure accurate and
given, the injection site, and any up-to-date documentation of their
observations made during and after treatment.
administration.
4. Provide ongoing support and 4. To help in promoting the patient's
reassurance to the patient comfort and compliance with the
medication regimen, leading to better
treatment outcomes.
85
After:
1. Monitor the patient for any delayed 1. To early identify and managing of any
or long-term side effects of complications
enoxaparin
2. Assess the patient's response to 2. To ensure that the patient receives the
enoxaparin most appropriate and effective care.
3. Educate the patient on the 3. To empower the client to take an
importance of adherence to their active role in their own care and
prescribed dosage regimen facilitate their recovery process.
DRUG STUDY NO. 6
Generic Name: Metoclopramide
Brand Name: Reglan and Metozolv ODT
Dosage/Route/Frequency: 10 mg IV q8 x UV
Physiologic Classification: Prokinetic Agents
Pharmacologic Classification: Dopaminergic GI stimulant
86
Mechanism of Action: Metoclopramide works by antagonizing central
and peripheral dopamine-two receptors (D2) in
the medullary chemoreceptor trigger zone in the
area postrema, usually stimulated by levodopa
or apomorphine
Indication: Used to treat nausea and vomiting
Desired Effect: Metoclopramide is a dopamine receptor
antagonist and has been approved by the FDA
to treat nausea and vomiting in patients with
gastroesophageal reflux disease or diabetic
gastroparesis by increasing gastric motility. It is
also used to control nausea and vomiting in
chemotherapy patients.
Contraindication: Metoclopramide is contraindicated in patients
with the following: Known hypersensitivity to
metoclopramide or excipients. Gastrointestinal
bleeding. Obstruction.
Side Effects: Feeling sleepy and a lack of energy, low mood,
feeling dizzy or faint (low blood pressure),
diarrhea
Adverse Effect: Restlessness, drowsiness, fatigue, insomnia,
dizziness, anxiety
87
Action Rationale
Before:
1. Perform a thorough patient 1. help the nurse identify any potential
assessment contraindications or interactions with
other drugs the patient may be
taking.
2. Obtain informed consent 2. to explain the purpose of
metoclopramide to the patient, as
well as its potential side effects and
risks.
During:
1. Monitor the patient for adverse 1. Prompt recognition and intervention
reactions can help prevent further
complications.
2. Ensure proper administration 2. To ensure that the medication is
technique given according to the prescribed
route and dosage, and follow proper
aseptic technique to prevent
infection.
After:
1. Document the administration
88
1. To serve as a baseline data for the
next administration of the drug.
2. Educate the patient
2. To help the patient understand how
to effectively manage their condition
and report any adverse reactions to
their healthcare provider
89
X1. NURSING CARE PLAN
NURSING CARE PLAN NO. 1
Nursing Assessment
Subjective Data:
Patient verbalization of "medyo nasakit nukwa ngem tolerable met. Adda 15 minutes na nukwa
pinagsakit na" and a pain scale of 5 out of 10, 10 being the highest and 1 as the lowest.
Objective Data:
Hard abdomen upon palpation, appearance of enlarged abdomen
Nursing Diagnosis:
Acute pain related to pelvoabdominal mass as evidenced by hard abdomen upon palpation,
appearance of enlarged abdomen, a pain scale of 5 and patient's verbalization of "medyo nasakit
nukwa ngem tolerable met. Adda 15 minutes na nukwa pinagsakit na".
Nursing Inference:
An abdominal mass is any abnormal growth in the abdomen. A pelvoabdominal mass causes
acute pain by pressing on nearby tissues, leading to inflammation, stretching, or blockage of
organs, which triggers pain signals.
Nursing Goal:
After 12-24 hours of rendering nursing interventions, the patient will report decreased pain and
the patient will appear relaxed and calm, and will express feelings of comfort.
90
Nursing Interventions:
Intervention Rationale
1. Encourage the patient to To promote relaxation and eradicate pain and
do relaxation techniques such as muscle tension.
deep breathing.
2. Provide comfort To promote relaxation and eradicate pain and
measures such as positioning the muscle tension.
patient in a comfortable way.
3. Administer analgesic for To help relieve pain felt by the patient.
relief of pain as ordered by the
doctor.
4. Refer or collaborate with To reduce the patient's pain, prevent further
other healthcare teams for any complications and to implement interventions for
diagnostic plan and interventions. pain management.
Nursing Evaluation:
After 12 hours of rendering nursing interventions, the goal was partially met. The patient
verbalized decreased pain.
91
NURSING CARE PLAN NO. 2
Nursing Assessment
Subjective Data:
Patient verbalization of "hannak unay makakuti kuti nasayaat gapo ta nu agkuti nak ket medyo
sumakit"
Objective Data:
Limited range of motion in lower extremities
Nursing Diagnosis:
Impaired Physical Mobility related to discomfort as manifested by difficulty in walking due to
pelvoabdominal mass and a patient’s verbalization of hannak unay makakuti kuti nasayaat gapo
ta nu agkuti nak ket medyo sumakit"
Nursing Inference:
A pelvoabdominal mass can impair physical mobility by exerting pressure on surrounding
structures, such as muscles, nerves, or blood vessels. This pressure can cause discomfort, pain,
or even functional limitations, hindering movement. Overall, the presence of pelvoabdominal
mass disrupts the normal functioning of the pelvis and abdomen, impacting physical mobility.
Nursing Goal:
After 6-7 hours of rendering nursing interventions, the patient will report decreased discomfort
and the patient will show a small improvement in her mobility.
92
1. Provide assistance with mobility, such

- Supporting the patient in safe and
as transferring, ambulation, or
controlled movements helps promotes
repositioning, as needed.
independence, and encourages
increased activity.
2. Implement fall prevention measures,

- Impaired mobility increases the risk of
such as using assistive devices,
falls, and preventing falls is crucial to
maintaining an organized area and
avoid additional injury and
providing supervision as necessary.
complications
3. Modify the patient’s environment to - An adapted environment reduces
enhance accessibility and safety, physical barriers, promoting ease of
considering factors like furniture movement and minimizing risk of
arrangement. accidents.
4. Administer prescribed pain - Effective pain management promotes
medications and implement non- improved mobility by reducing
pharmacological pain relief measures. discomfort.
93
Nursing Evaluation:
After 6 hours of rendering nursing interventions, the goal was partially met. The patient
verbalized decreased discomfort and the patient will show a small improvement in her mobility.
NURSING CARE PLAN NO.3
Nursing Assessment
Subjective Data:
Patient verbalization of "mabuteng nak ma opera lalo ket baket nakon. Baka haan ko kaya"
Objective Data:
Extraneous movements like fidgeting and uneasiness
Nursing Diagnosis:
Anxiety related to upcoming surgery as evidenced by expressed concerns and patient's
verbalization of "mabuteng nak ma opera lalo ket bake nakon. Baka haan ko kaya".
Nursing Inference:
The physiological distress caused by the presence of a pelvoabdominal mass can aggravate the
feelings of anxiety.
Nursing Goal:
After 30-60 minutes of therapeutic nursing interventions, the patient will be able to appear
relaxed and verbalize readiness about her surgery.
94
1. Explain the purpose

To ensure that the client understands the reason behind the
of the surgery.
procedure, potential risks and benefits.
2. Encourage the patient

To acknowledge and express their feelings is essential for
to acknowledge and to
holistic care. It allows the client to process emotions,
express feelings.
reduce anxiety, and feel supported.
3. Provide accurate To help the client to identify what is reality based.
information about the
situation.
4. Provide comfort To help reduce stress which can aid in pain management
measures such as and improve overall well-being. It can also promote better
providing calm and sleep.
quiet environments.
5. Encourage deep Helps in promoting relation,
breathing exercises as
needed.
Nursing Evaluation:
After 30-60 minutes of therapeutic nursing interventions, the goal was partially met. The
patient appears relaxed and verbalized anxiety is reduced and is ready for her upcoming surgery.
95
XII.
GENERAL EVALUATION
This chapter describes the condition of the client from the 8-hour activity which highlights
the condition on the day of the visit which signifies improvement or deterioration of the
condition as outcome of management done.
Based on the available data, the client’s appraisal period over the 8-hour period from
February 17, 2024, to February 19, 2024, indicates that her condition is stable and well-
controlled. The client has a complaint of increased abdominal girth and abdominal pain and
rated at an intensity of 5 out of 10. The client's vital signs were monitored every four hours
during the 8-hour period, and her temperature, pulse rate, respiratory rate, blood pressure, and
blood sugar levels were all within normal ranges.
No new signs or symptoms were reported during the 8-hour period, and the client reported
compliance with her medication regimen, which includes Omeprazole 40mg IV OD, Losartan
50mg/tab OD. Trimetazidine 35/tab OD, Rosuvastatin 20mg/tab ODHS, Enoxaparin 0.44 cc
SQ OD and Metrachlopromide 10 mg IV q8 x u/v. The client's meals were well-balanced and
nutritious, and she drinks 8 glasses of water every day. The client's bowel and bladder
movements were also monitored, and she reported defecating once during the day with no
abnormalities noted in the characteristics of her stool, passing soft brown stool. The client's
complaint of increased abdominal girth and abdominal pain may require further monitoring
and management to ensure that it does not develop into a more severe condition.
In conclusion, the available data suggest that the client's condition is stable and well-
managed. However, ongoing monitoring and management will be necessary to ensure that her
condition continues to be well-controlled. The client's compliance with her medication regimen
96
and diet, and maintaining regular bowel and bladder movements, all indicate that she is taking
an active role in her management and care. The client’s health and well-being will continue to
be monitored, and any changes or developments will be addressed promptly to ensure the best
possible outcomes for the client.
97
REFERENCES
Pelvic Mass: Symptoms & Causes | Tampa General Hospital. (n.d.).
https://www.tgh.org/institutes-and-services/conditions/pelvic-masses
Cable, J. K., & Grider, M. H. (2023, May 1). Physiology, progesterone. StatPearls -
NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK558960/
Follicle stimulating hormone | You and Your Hormones from the Society for
Endocrinology. (n.d.). https://www.yourhormones.info/hormones/follicle-stimulating-
hormone/
Institute for Quality and Efficiency in Health Care (IQWiG). (2016, August 21). How
does the stomach work? InformedHealth.org - NCBI Bookshelf.
https://www.ncbi.nlm.nih.gov/books/NBK279304/
Chaudhry, R., Miao, J. H., & Rehman, A. (2022, October 16). Physiology,
cardiovascular. StatPearls - NCBI Bookshelf.
https://www.ncbi.nlm.nih.gov/books/NBK493197/
Human development. (n.d.). Google Books.
https://books.google.com.ph/books/about/Human_Development.html?id=9rNXPwAA
CAAJ&redir_esc=y
Havighurst, R. J. (1972). Developmental tasks and education. New York David McKay.
- References - Scientific Research Publishing. (n.d.).
https://www.scirp.org/reference/ReferencesPapers?ReferenceID=537633
Charmley, S. (2023, March 27). What to know about IV therapy.
https://www.medicalnewstoday.com/articles/iv-therapy
CA 125 test - Mayo Clinic. (2022, March 31). https://www.mayoclinic.org/tests-
procedures/ca-125-test/about/pac-
20393295#:~:text=Overview,high%20risk%20of%20the%20 disease.Radiological
98
Society of North America (RSNA) and American College of Radiology (ACR). (n.d.).
Pelvis Ultrasound. Radiologyinfo.org. https://www.radiologyinfo.org/en/info/pelvus
99

Gyne G1

Uploaded by

Gyne G1

Uploaded by

In partial fulfillment of the requirements in NCM 109 Care of Mother & Child at Risk w/

Problem (Acute & Chronic)

NURSING CASE ANALYSIS

PELVOABDOMINAL MASS PROBABLY MALIGNANT; ACUTE GASTRITIS;

process of the client.

A pelvoabdominal mass, probably malignant, refers to an abnormal growth or swelling

suspicion for malignancy, necessitating prompt and thorough evaluation.

To further understand and gain extensive knowledge regarding Pelvoabdominal Mass

analysis concerning the disease with the following objectives:

factors or contributing factors.

results within 24 hours.

6. Assess the patient's patterns of functioning to identify any disruptions or limitations in

functioning caused by the pelvoabdominal mass or its treatment.

client’s recovery and promoting their overall well-being.

and treatment goals.

Importance and impact on the nursing practice

It helps nurses to better understand and manage complex conditions like

collaboration ensuring comprehensive and coordinated care delivery.

pelvoabdominal masses suspected to be malignant.

Name: Mrs. Orange

Age: 68 years old

Date of Birth: February 19, 1955

Place of Birth: Dimaguiba

Civil Status: Widow

Religion: Roman Catholic

Educational Attainment: 4th year high school graduate

Date Admitted: February 13, 2024

Time Admitted: 4:35 pm

Admitting Diagnosis: G3P3(3002) Pelvoabdominal Mass Probably Malignant; Acute

The family structure, characteristics, and relational dynamics significantly shape a

Strawberry. The family is currently residing at La Paz, Abra.

grandchildren are the ones living with Mrs. Orange.

agkwarkwarto iti rabii.”

or jeep fare and cellular load.

A. FAMILY HEALTH HISTORY

Figure 4.1 Genogram

i. PAST HEALTH HISTORY

take the vaccination.

ii. PRESENT HEALTH HISTORY

manage her dizziness and have adequate rest.

deteriorating intellectually, becoming narrow minded and attaching new significance to

spouses (e.g., Schulz and Beach, 1999).

2. Adjusting to retirement and reduced income.

3. Adjusting to the death of a spouse.

4. Establishing an explicit affiliation with one’s age group.

5. Meeting social and civil obligations.

6. Establishing satisfactory physical living arrangements.

OLD AGE (60 Years and Over)

TASKS RESULT JUSTIFICATION

FULLY Our client verbalized “baket nakon

agpanpanunutak kadetoy kinabaket

ko ngem gapo ta ay ayaten dak dgty

annak kn appokok, umanay a ragsak

kon uray kastoy ti sakit ko isuda lng

mangpalpalag an riknakon”. Thus,

the result is fully achieved because

according to her, being positive is

what keeps her going.

hanko met nairadwar pinagbasak,

ngem nu pay kasta naragsak nak ta

adda trabaho dagitay annak ko isu

nga isudat mangtultulong kanyak

ita”. Thus, the result is partially

achieved since she hasn’t gone to

PARTIALLY Our client verbalized “narigat

ta 2 tawen nga awan isuna idi

maawat kon, maikawa nak ununay

idi ta awan katinnulungakon,

narigat ngem kasta lang ti byag”.

Thus, the score is partially achieved

since she did not easily move on

from the death of her husband and it

took her some time. Widowhood is

events (Holmes and Rahe 1967).

FULLY Our client verbalized “aktibo nak

score is fully met since she was