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TABLE OF CONTENTS I. Introduction 1 II. Objectives2 III. Anatomy and Physiology 3-4 IV. Definition of Terms 5 V. Baseline Data 6 VI. Nursing History (Gordon’s Functional Health) 7-9 VII. Health History 10-11 VIII. Assessment (Cephalo- Caudal) 12-14 IX. Laboratory and Radiology 15-16 X. Pathophysiology 17 XI. Nursing Care Plan * Acute Pain 18-19 * Fluid Volume Deficit 20-21 * Risk for Ineffective Coping 22 XII. Drug Study * Propranolol Hydrochloride 23 * Cefuroxime Sodium 24 * Propylthiouracil (PTU) 25 * Paracetamol 26 Mefenamic Acid 27 XIII. Health Teaching (M. E. T. H. O. D. ) 28 XIV. Bibliography/ References 29 I. INTRODUCTION Every married couple wishes to have a child because there are unfortunate couples that can’t have even one. If the woman is pregnant everyone is very excited towards the baby especially the father. But what if the baby in your womb that you thought you has is not actually a real one; but a cluster of H-mole. The fetus or developing baby, the placenta (or after-birth), which has many functions including the feeding of the baby and the removal of its waste products.
The placenta is made of millions of cells called trophoblasts. These two parts normally develop together, in parallel, the end result being a healthy baby and a placenta which is no longer needed, so the latter is expelled just after the baby is born (afterbirth). In trophoblastic disease there is an abnormal overgrowth of all or part of the placenta, causing what is called a molar pregnancy or hydatidiform mole. The term seems strange but is similar to that used for a harmless growth on the skin, which is also called a mole. Although a hydatidiform mole is not cancer and rarely even becomes cancerous, it can behave in similar ways.
Most of the treatment is aimed at stopping the disease process long before any of these things happen. In the case presented, client discovered that she has an H-mole after having an ultrasound in the CLMMRH. The importance of studying this disease is for us women, enable for us to learn the complications that we may experience during our pregnancy state though this disease is of unknown cause, we will be able to know the precipitating factors and predisposing factors that may affect us and be prone to the risk of having molar pregnancy.
The researchers intend to deepen the understanding about hydatidiform mole. Our goal is to impart what we have learned during the exposure to others that they may be aware of this dysfunction of the reproductive system and even in simple ways they can apply it in their lives. II. OBJECTIVES General objectives: After 1-2 hours of case presentation, the student-nurses will be able to: * Justify how the nursing process was applied and utilized in the case of client with H-mole. Integrate the knowledge learned in rendering effective independent nursing care to future exposures to client with similar conditions. Specific Objectives: After 1-2 hours of case presentation, the student-nurses will be able to: * Discuss briefly the anatomy and physiology of the female reproductive system. * State patient’s Gordon’s Functional Health and health history. * Review client’s cephalocaudal assessment. * Discuss the pathophysiology of H-mole in relation to patient’s care. * Formulate effective nursing care plans as a basis for proper implementation of nursing interventions. Perform appropriate nursing interventions for specific patient’s complaints and signs and symptoms of the disease which the patient’s manifests. * Conduct accurate drug study for each drugs used. * Construct a structured health teaching plan based on client’s needs. III. ANATOMY AND PHYSIOLOGY The reproductive system The organs of the reproductive systems are concerned with the general process of reproduction, and each is adapted for specialized tasks. These organs are unique in that their functions are not necessary for the survival of each individual.
Instead, their functions are vital to the continuation of the human species in providing maternity gynecologic health care, you will find that it is vital to you career as a practical nurse and to the patient that you will require a greater depth and breadth of knowledge of the female anatomy and physiology than usual. The female reproductive system consists of internal organs and external organs. The internal organs are located in the pelvic cavity and are supported by the pelvic floor. The external organs are located from the lower margin of the pubis to the perineum.
The appearance of the external genitals varies greatly from woman to woman, since age, heredity, race, and the number of children a woman has borne determines the size, shapes, and color. The Uterus A hallow organ about the size and shape of a pear. It serves two important functions: it is the organ of menstruation and during pregnancy it receives the fertilized ovum, retains and nourishes it until it expels the fetus during labor. The uterus is located between the urinary bladder and the rectum. It is suspended in the pelvis by broad ligaments. The uterus measures about 7. cm. in length, 5 cm. in breadth, at its upper part, and nearly 2. 5 cm. in thickness; it weighs from 30 to 40 gm. It is divisible into two portions. On the surface, about midway between the apex and base, is a slight constriction, known as the isthmus, and corresponding to this in the interior is a narrowing of the uterine cavity, the internal orifice of the uterus. The portion above the isthmus is termed the body, and that below, the cervix. The part of the body which lies above a plane passing through the points of entrance of the uterine tubes is known as the fundus.
The uterus contains some of the strongest muscle in the female body. These muscles are able to expand and contract to accommodate a growing fetus and then help push the baby out during labor. These muscles also contract rhythmically during an orgasm in a wave like action. It is thought that this is to help push or guide the sperm up the uterus to the fallopian tubes where fertilization maybe possible. The walls are thick and are composed of three layers: the endometrium, myometrium, and the perimetrium. The endometrium is the inner layer or mucosa.
A fertilized egg burrows into the endometrium (implantation) and resides there for the rest of its development. When the female is not pregnant, the endometrial lining sloughs of off about every 28 days in response to changes in levels of hormones in the blood. This process in called menses. The myometrium is the smooth musclecomponent of the wall. These smooth muscle fibers are arranged. In longitudinal, circular, and spiral patterns, and are interlaced with connective tissues. During the monthly female cycles and during pregnancy, these layers undergo extensive changes.
The perimetrium is a strong, serous membrane that coats the entire uterine corpus except the lower one fourth and anterior surface where the bladder is attached. The primary function of the uterus is in reproduction; the conduit for sperm transport, and the site for implantation of fertilized ova, placentation,?? growth and development of the fetus, and parturition (labor and delivery). The shape and position of the uterus also deflects downward-directed, intra-abdominal pressures anteriorly toward the pubis, away from the pelvic loor. The endometrium is a target tissue for estradiol from the ovarian follicles, creating a smooth cellular, proliferative lining for sperm transport prior to ovulation. Progesterone from the corpus luteum of the ovaries, which changes the lining to a thicker, softer, secretory lining for blastcyst implantation. IV. DEFINITION OF TERMS * angiogenesis- the formation of new blood vessels, a process controlled by chemicals produced in the body that stimulate blood vessels or form new ones.
Angiogenesis plays an important role in the growth and spread of cancer. Angiogenesis also occurs in the healthy body for healing of wounds and restoring blood flow to tissues after injury. * chorionic villus – one of the tiny villi that stick out of the fetal chorion and combine with the mother’s uterine tissue to form the placenta * fertilization – union of male and female gametes to form the diploid zygote, leading to development of a new individual. * human chorionic gonadotropin (hcg) – a hormone excreted during the development of an embryo or fetus. hydatidiform mole – an abnormality during pregnancy; chorionic villi around the fetus degenerate and form clusters of fluid-filled sacs; usually associated with the death of the fetus * hyperthyroidism – an abnormality of the thyroid gland characterized by excessive production of thyroid hormone, which can result in an increased basal metabolic rate, causing weight loss, heart palpitations, and tremors * serology – the branch of medical science that deals with serums; especially with blood serums and disease * Thyroid-stimulating hormone (TSH) – activates the production of tetraiodothyronine (T4) and T3.
This process is under regulation. In the hypothalamus, T4 is converted to T3. TSH is inhibited mainly by T3. The thyroid gland releases greater amounts of T4 than T3, so plasma concentration of T4 are 40-fold higher than those T3. Most the circulating T3 is formed peripherally by deiodination of T4 (85%), a process that involves the removal of iodine from carbon 5 on the outer ring of T4. Thus, T4 acts as prohormone for T3. * trophoblast – the peripheral cells of the blastocyst, which attach the blastocyst to the uterine wall and become the placenta and the membranes that nourish and protect the developing organism
V. BASELINE DATA Name: AR Address: Brgy. Sum-ag Bacolod City Age: 24 years old No. of Dependents: 1 Birthdate: January 13, 1986 Birthplace: Sum-ag, Bacolod City Gender: Female Marital status: Single (with a live in partner) Religion: Roman Catholic Educational Level: High School Graduate Nationality: Filipino Occupation: Housewife Person next to kin: KR (live in partner) Date of Admission: January 18, 2010 Attending Physician: Dr. Gayatao Chief Complaints: vaginal bleeding Medical Diagnosis: Hydatidiform Mole VI. NURSING HISTORY (GORDON’S FUNCTIONAL HEALTH PATTERN)
I. Health Maintenance * Prior to admission, client AR is not so concern about her health, but whenever one member of the family got sick they usually used herbal plants. Client AR already felt uncomfortable and weakness before she is admitted. She is already suspecting that something wrong is happening to her. * Client AR doesn’t feel better when asked about her current health status. She felt pain on her abdomen due to the presence of H-mole. In order to improve her health she prays and talks to her siblings to distract her attention towards what she feels.
There’s a great financial concern in her family especially for her molar evacuation, her live in partner sees to it that they will pay their bills through borrowing from his employer. AR can also report the names of her medications and there purposes. II. Nutrition- Metabolic Pattern * Prior to admission, client AR doesn’t have good preferences regarding her food. She confirms that she usually buys their meals in a carinderia and most of the time she cooked fast foods like fried fish and anything that is cooked easily. During admission, patient AR looks weak and not well- nourished due to the reason that she decreased her appetite when she is admitted in the hospital. She only eats 2 times a day and revealed that she became thin starting from the development of her disease. She also stated that she liked her weight in her previous years unlike now. III. Elimination Pattern * Prior to admission, patient AR’s excretory functions are within normal range. She usually defecated every day. She doesn’t have any disease of the digestive system, urinary system and her perspiration is normal. When she is admitted, she doesn’t have a normal range of bowel movement. She defecates 2-3x a week. She also increased her perspiration due to exposure to hot environment inside the hospital. Her urine elimination is also decreased. IV. Activity and Exercise Pattern * Prior to admission, client’s daily activities are stress-free; her daily activity pattern is not very busy due to the fact that they only have one child. She’s a plain housewife and her usual activities are sleeping and eating since her live in partner is the major source of financing their daily needs.
She only performed household chores if she wanted to. * During admission, patient is still ambulatory, she can still manage to care for herself but sometimes she needs the assistance of her SO in dressing due to the fact that she have an IVF bottle attaching to her which makes it difficult for her to perform some activities and because of the pain she is experiencing. V. Sleep and Rest Pattern * Patient AR has a normal sleep- wake cycle. She will sleep early and wake up in the morning around 7am or 8am. She doesn’t take a nap at the afternoon prior and during admission. During her admission, she experiences difficulty in sleeping as a matter of fact she looks restless and not relaxed. She can’t sleep because of her environment, the ventilation is insufficient, and the hospital bed feels hot that increases her perspiration and makes her very irritable. VI. Cognitive and Perception Pattern * Patient AR doesn’t have any sensory deficits. She’s a high school graduate and can express herself clearly and logically. She is also experiencing pain in her abdomen due to the presence of H-mole; she describes it like the pain women felt when they have dysmenorrhea.
She also appears pallor. VII. Self Perception- Self- Concept Pattern * There’s nothing unusual at client’s appearance but she’s not that too comfortable with her appearance after she losses weight. She feels sorry about herself, her weight, her color, the pain that she felt on her IV site; but she’s very positive that all of these will just pass away. What really matter for her is to overcome and get well in order to go back home. VIII. Role Relationship Pattern * AR described her various roles in life as a mother and as a wife very challenging.
Even though she knew that she’s not the ideal mother and wife everyone wants to have; but she’s very happy that her husband and her child accept her despite of her imperfections. Her role model is her mother, since her father died when she’s still young. Her mother was very responsible enough and greatly sacrificed in order to raised up her 3 children. Her most important role is being a mother due to the fact that she only has one child so she really focused her attention towards her son. They have a close family relationship including her in-laws, so she felt lucky because of that. IX. Sexuality and Reproductive Pattern Patient AR is satisfied with her situation related to sexuality. She felt a little bit disappointed because she thought that she’s really pregnant but only to find out that it is just an H-mole. Good thing she knew it earlier. She a have dysfunction with her reproductive system which is a hydatidiform mole. She uses pills for 5 years. She usually experiences nausea and vomiting with headache as side effects of the pill. * Patient AR has presence of vaginal discharges before and during admission. During admission, there is a presence of bright red vaginal discharges approximately 90cc qShift for 4 days.
X. Coping Stress Pattern * Patient AR usually copes up with problems by sharing it to her siblings and not taking it seriously. These actions help her in coping with stress towards her problems and there is a slight fear for the outcome of the procedure that she will undergo. XI. Values and Beliefs Pattern * Before, patient AR and her husband were members of Couples for Christ. She felt joy, calmness, and secured whenever she’s in the church; but she can’t recall the reason why they stopped joining the said organization. She opened up to me that she prays very seldom, she really forgot about God.
She said that maybe one of the reason why she is given that kind of disease is for her to remember Christ in her life because she almost forgotten Him. She became faithful recently; I always saw her holding a picture of Christ and some scriptures about God. I know that she’s leaving it to God on what will happen to her. VII. HEALTH HISTORY 1. History of Present illness Two months prior to admission, patient had vaginal spotting of light red blood, associated with epigastric pain, no fever but with intermittent pelvic pain and nausea and vomiting but no consult done.
On the succeeding month, persistence of symptoms of vaginal bleeding become profuse, she seek consult to the OPD department thus ultrasound was requested and it revealed H- mole, thus prompted client for admission. 2. Past Health History A. Childhood Illness The patient had chicken pox as a child. Aside from that, she had no known childhood sickness aside from headaches, mild fever and common colds. She also has no known allergies. B. Past Hospitalization: Patient has previous hospitalization when she first gave birth to her son at Corazon Locsin Montelibano Memorial Regional Hospital last 2007. But it only ook a few days, after recovery for a day she was already discharged. C. Serious Illness The patient has no serious illness. D. Previous Surgery The patient has no previous surgery. 3. Family History Upon assessment and based on the interview with the client and client’s significant others, the client had history of cancer in her family. Her father died because of cancer. She is also a moderate smoker and an alcohol drinker. 4. Social History Patient’s health practices include: taking a bath everyday, sleeping early, washing of hands before and after eating, brushing of teeth, combing of hair, and perineal hygiene.
Patient drinks alcohol and smoke cigarette during weekends; but she stopped it. She has lots of friends within their neighbourhood to which she spends her time whenever she doesn’t have anything to do in their house. Socializing with neighbors was part of the patient’s daily activities. 5. Immunization The client has completed all the immunization since birth. 6. Obstetric History (+) pregnancy test Menarche: Age 15, regular, consumes 2 pads per day Coitarche: 18 years old No dysmennorhea LMP: August 15, 2009 AOG: 20 2/7 weeks by LMP VIII. CEPHALOCAUDAL ASSESSMENT (Review of System) January 24, 2009 12:00 AM (10PM ??? 6AM shift) A.
General Appearance: Adult female patient with straight shoulder length hair held tied at the side and wearing a white colored dress with flower pattern. Awake lying on bed and appears uncomfortable, untidy, dirty. The patient is coherent, reactive to verbal and nonverbal stimuli and oriented to time and place. B. Vital Signs: Date| 01/ 24/ 10| 01/25/10| 01/26/10| 01/28/10| 01/29/10| Blood Pressuremmhg| 12MN| 4Am| 12MN| 4Am| 12MN| 4Am| 8AM | 12NN| 8AM100/70| | 130/90| 130/100| 120/80| 120/90| 110/80| 120/80| 100/80 | 100/80| | Temperature??C| 12MN| 4AM| 12MN| 4AM| 12MN| 4AM| 8AM| 12NN| 8AM36. | | 37. 3| 36. 3| 36. 9| 36. 8| 38. 3| 36. 8| 38. 8| 36. 8| | Pulse RateBPM| 12MN| 4AM| 12MN| 4AM| 12MN| 4AM| 8AM| 12NN| 8AM101| | 72| 72| 80| 74| 92| 78| 110| 90| | RespiratoryCPM| 12MN| 4AM| 12MN| 4AM| 12MN| 4AM| 8AM| 12NN| 8AM29| | 23| 25| 22| 24| 35| 21| 40| 27| | C. HEENT: The head of the client is normocephalic, round and in midline, the pupils are equally round, reactive to light and accommodation, with anicteric sclera with pinkish conjunctiva. Ears are symmetrical with no secretions noted with no external tenderness and able to hear clearly.
The nose has no deformity, no septal deviation and no discharges noted and the throat has no discharges and there is no difficulty in swallowing. D. Neurological: The patient is awake lying on bed, conscious and coherent; responsive to verbal, non-verbal, painful stimuli and oriented to time person, place and situation and has a good insight and cognitive function. E. Cardiovascular: Patient has ongoing IVF #1 PNSS 1L x KVO infusing well at right metacarpal vein. Has a strong palpable radial pulse of 72bpm. Patient’s blood pressure is 130/90mmhg taken at left arm in lying position and with ood capillary refill which is less than 2 seconds. F. Respiratory : Patient breathes spontaneously to room air at 23cpm without difficulty and with normal and clear breath sounds upon auscultation on both lung fields with symmetrical rise and fall of the chest when breathing. G. Breast : Patient has symmetrical breast with dark brown colored areola with normal contour, no dimpling, no skin changes, no tenderness, and no nipple deformity and discharges. H. Abdomen: Patient has flabby, undistended abdomen with abdominal cramping. I. Gastrointestinal tract
Patient is on diet as tolerated with good appetite and shifted to NPO prior to surgery. She was not able to defecate upon initial assessment and was able to pass out flatus with normoactive bowel sounds of 10 times per minute. J. Genito-urinary tract Patient is unable to urinate upon initial assessment and able to urinate to a yellow colored urine at approximately 200cc upon final assessment. K. Reproductive The patient has a diaper with bright red vaginal discharges noted approximately 90cc. L. Musculoskeletal The patient was able to move upper and lower extremities without difficulty (e. . raising legs, combing her hair, wiping her face). Patient also able to change her position from side to side with minimal assistance. M. Endocrine Upon initial assessment the patient has a presence of thyrotoxicosis. N. Integumentary Patient has good skin turgor and the skin is pale. Hair is evenly distributed at the head. Body hairs are also finely distributed. Skin is warm to touch. Afebrile; 37. 3 degrees Celsius. The hair is long with black in color, and the nails are dirty and untrimmed. IX. LABORATORY AND RADIOLOGY CLMMRH DATE: January 11, 2010
Examination| Result| Normal Value| Interpretation| Implication| RBS| 84 mg/ dL| 60-110 mg/dL| normal| normal| Creatinine| 0. 6 mg/ dL| 0. 6-1. 2mg/dL| normal| normal| Potassium| 4. 5 mEq/ L| 3. 6-5. 4 mEq/L| normal| normal| Villanueva Clinical Laboratory DATE: January 12, 2010 * Serology Examination| Result| Normal Value| Interpretation| Implication| T3| 5. 05nmol/ L| 1. 30-3. 10nmol/L| increased| overactive tissue within the thyroid gland, resulting in overproduction and thus an excess of circulating free thyroid hormones: thyroxine (T4), triiodothyronine (T3), or both (hyperthyroidism)| T4| 226. nmol/ L| 66. 0-181nmol/L| increased| | TSH| 0. 006??Iu/mL| 0. 270-420??Iu/mL| Decreased| Indicates inhibition of the pituitary due to another illness| CLMMRH DATE: January 28, 2010 * Complete Blood Count Examination| Result| Normal Value| Interpretation| Implication| Hematocrit| . 26L/L| F: 37-0. 47L/L| decreased| Indicate blood loss| Hemoglobin| 91g/L| F:120-160g/L| decreased| Excessive blood loss due to vaginal bleeding. | WBC| 13. 3×10/L| 4. 5-11×10/L| increased| Bacterial infection| * Differential count
Test| Result| Normal Value| Interpretation| Implication| Neutrophils| 92%| 50-70%| increased| bacterial invasion of tissue or other causes results in the production and release of colony-stimulating factors,| Lymphocytes| 5%| 25-35%| decreased| indicates a viral infection. low lymphocyte count (lymphopenia) indicates a poor immune response. | Monocytes| 3%| 4-8%| decreased| monocytopenia can be a response to certain types of bacteria releasing toxins into the bloodstream. | De Asis Ob-Gyne Ultrasound Clinic DATE: January 04, 2010 * Transabdominal/ Transvaginal Ultrasound
The uterus is anteverted deviated to the left with smooth contour and homogenous echopattern measuring 14. 9(L) x 13. 8(W) x 11. 5(T) cm. cervix: 2. 4×3. 4×3. 3cm). the endometrial cavity is 9. 3cm open, filled with heterogeneous mass with multiple cystic spaces of varying sizes measuring 11. 3×11. 7×9. 3cm Comments: consider Hydatidiform Mole Ideal Diagnostic Test A pelvic exam may reveal a larger or smaller uterus, enlarged ovaries, and abnormally high amounts of the pregnancy hormone hCG A sonogram will often show a “cluster of grapes” appearance, signifying an abnormal placenta.
The levels of human chorionic gonadotropin (hCG), a hormone that is normally produced by a placenta or a mole= Abnormally high levels of hCG together with the symptoms of vaginal bleeding, lack of fetal heartbeat, and an unusually large uterus all indicate a molar pregnancy An ultrasound of the uterus to make sure there is no living fetus will confirm the diagnosis. Auscultation – no fetal heart beat X. PATHOPHYSIOLOGY Predisposing factors: * Female * Age over 40 yrs old, below 20 yrs old * History of molar pregnancy * History of miscarriage Precipitating factors: * Defects in the ova * Abnormalities in the uterus * Nutritional deficiency Diet low in protein * Deficient in folic acid during pregnancy Egg cell fails to change composition Penetration to egg Egg fertilized by 2 sperms Some chorionic villi formed All vesicular chorionic villi formed + Pregnancy test Trophoblast maturation Implantation Fertilization Incomplete implantation Abnormally high hCG Sonogram: Grape Shaped * Fatigue * Weight Loss * Muscle Weakness * Inc. HR * Diaphoresis * Anxiety * Thyroid Enlargement Hyperthyroidism Impaired trophoblast in angiogenisis bleeding Pelvic pain Infant development failure Empty egg fertilized by 1 / 2 sperms Entrance of multiple sperms XI. NURSING CARE PLAN
Assessment| Diagnosis| Rationale| Desired Outcome| Nursing Intervention| Justification| Evaluation| Actual Abnormal Cues: * “Gasakit akon suluk-sulok” as verbalized by the client * Pain scale of 6 out of 10 * Facial grimace * Irritability * Abdominal cramping * PallorRisk Factors * Poor maternal nutrition especially insufficient intake of protein and folic acidStrengths * Good family support * Compliance to medication| Acute pain R/T pressure on the abdominal wall AEB “gasakit akon suluk-sulok” as verbalized by the clientDefinition:Sudden onset of any intensity from mild to severe with an anticipated or predictable end and duration of less than six months. Source: Doenges, Moorhouse, Murr (2008). Nurse’s Pocket Guide. Diagnoses, Prioritized Interventions, and Rationales. Ed. 11. FA Davis Company, Philadelphia Pennsylvania. | Insufficient intake of protein and folic acid during pregnancy.
Trophoblastic villi cells rapidly increase in size, begin to deteriorate and fill with fluidImplants in the mother’s uterus for several months. Increase size of H-moleCreates pressure to the abdominal wallabdominal crampingAcute painReference:McKinney, James, Murray, Ashwill(2005). Maternal Child Nursing. 2nd edition, Elsevier Inc. Philadelphia PA, USA. | After 8hrs. of nursing intervention client will be able to: 1. Report pain is reduced. 2. Follow prescribed pharmacologic regimen. After 40hrs. of nursing intervention client will be able to: 1. Verbalize non-pharmacologic methods that provide relief. 2. Demonstrate use of relaxation skills and diversional activities as indicated. | INDEPENDENT: 1.
Obtain clients assessment of pain to include location, characteristics, onset/duration, frequency, quality, intensity, and precipitating factors. Reassess each time pain is reported. 2. Use pain rating scale appropriate for age. 3. Monitor skin color or temperature and vital signs (e. g. Blood pressure, respiration). 4. Provide comfort measures (e. g. Touch, repositioning, nurses presence), quiet environment ; calm activities. 5. Instruct use of relaxation techniques, such as focused breathing. 6. Encourage adequate rest periods. COLLABORATIVE: 1. Administer Mefenamic acid 500 mg q6H for pain, as indicated. 2. Identify specific signs ; symptoms and changes in pain characteristics requiring medical follow up. | 1. To rule out worsening of underlying condition. 2.
To assess the intensity of pain felt by the patient. 3. Which are usually altered in acute pain. 4. To promote non pharmacological pain management. 5. To distract attention and reduce tension. 6. To prevent fatigue. 1. To relieve pain. 2. To promote wellnessReference:Doenges, Moorhouse, Murr (2008). Nurse’s Pocket Guide. Diagnoses, Prioritized Interventions, and Rationales. Ed. 11. FA Davis Company, Philadelphia Pennsylvania| After 8hrs of nursing intervention client was able to: 1. GOAL METReport pain is reduced. 2. GOAL METFollow prescribed pharmacologic regimen, she sees to it that she will take her meds on time. After 40 hrs. of nursing intervention, client was able to: 1.
GOAL METVerbalized non-pharmacologic methods that provide relief like doing some relaxation techniques 2. GOAL METDemonstrated use of relaxation skills and diversional activities such as focus breathing and showed willingness and cooperation| Assessment| Diagnosis| Rationale| Desired Outcome| Nursing Intervention| Justification| Evaluation| Actual Abnormal Cues: * bright red vaginal discharges approximately 90cc qShift * Hct= 0. 27L/L [F:0. 37-0. 47L/L] * Hgb= 88 g/L [F:120-160g/L] * profuse sweating * dry lips * no urine outputRisk Factors: * Poor maternal nutrition especially insufficient intake of protein and folic acidStrengths * Good amily support * Compliance to medication| Fluid volume deficit R/T active fluid loss AEB bright vaginal discharges approximately 90cc qShift, profuse sweating, dry lips, no urine outputDefinition:Decreased intravascular, interstitial, and intracellular fluid. Source: Doenges, Moorhouse, Murr (2008). Nurse’s Pocket Guide. Diagnoses, Prioritized Interventions, and Rationales. Ed. 11. FA Davis Company, Philadelphia Pennsylvania. | Insufficient intake of protein and folic acid during pregnancyProliferation and degeneration of the trophoblast villiBecomes filled with fluid and distend like mole cystUterine BleedingFluid LossPresence of bright vaginal dischargesProfuse sweatingDry lipsNo urine outputFluid volume deficitReference:McKinney, James, Murray, Ashwill(2005).
Maternal Child Nursing. 2nd edition, Elsevier Inc. Philadelphia PA, USA. | After 8hrs of nursing intervention, client will be able to: 1. Maintain fluid volume at a functional level as evidenced by stable vital signs, scanty vaginal discharges, moist lips, and decreased perspiration. 2. Obtain adequate urine output with range of 200-240cc qShiftAfter 40hrs of nursing intervention, client will be able to: 1. Verbalize understanding of causative factors and purpose of individual therapeutic intervention. 2. Demonstrate behaviors to improve health condition. | INDEPENDENT: 1. Assess vital signs, noting rapid heart rate and thread peripheral pulse. 2.
Keep fluids within client’s reach and encourage frequent intake, as appropriate. 3. Discuss factors related to occurrence of the disease. 4. Note for signs of excess bleeding. COLLABORATIVE: 1. Administer IV fluids as indicated 2. Review laboratory data. 3. Assist in the preparation for Dilatation and curettage. | 1. To evaluate degree of fluid deficit. 2. Prevents peaks/valleys in fluid level. 3. To prevent recurrence of the disease. 4. Excess bleeding may cause to hypovolemia. 1. To replace losses. 2. To evaluate fluid loss and identify abnormalities 3. To relieve anxiety for the removal of H-mole. Reference:Doenges, Moorhouse, Murr (2008). Nurse’s Pocket Guide.
Diagnoses, Prioritized Interventions, and Rationales. Ed. 11. FA Davis Company, Philadelphia Pennsylvania. | After 8hrs of nursing intervention client was able to: 1. GOAL METMaintained fluid volume at a functional level as evidenced by BP=120/80mmHgT=36. 9oC, PR=80bpm, RR=22cpm, vaginal discharges became scanty=75cc, lips moisten, and perspiration decreased. 2. GOAL PARTIALLY MET. Obtained adequate urine output approximately 200cc during the last shift. After 40hrs of nursing intervention, client was be able to: 1. GOAL METVerbalized understanding of causative factors such as poor maternal nutrition and purpose of her therapeutic intervention such as increasing fluid intake. 2.
GOAL METDemonstrated behaviors to improve her condition such as positive behaviors and completion to necessary treatments like D;C. | ASSESSMENT| NURSINGDIAGNOSIS| RATIONALE| DESIREDOUTCOME| NURSINGINTERVENTION| JUSTIFICATION| EVALUATION| Risk Related Factors: * Trauma to genitalia organ * Possibility to unable to get pregnantStrength: * Good emotional and family support. * Positive attitude toward recovery * Participate and cooperate. | Risk for ineffective coping R/T outcome of the procedureDefinition:At risk to form a valid appraisal of the stressors, adequate choices of practiced responses, and use of available resources. Source: Nurse’s Pocket Guide (diagnosis, Prioritized Interventions and Rationales edition 11. Expected PregnancyvUnexpected Molar PregnancyvWill undergo dilatation and curettage procedurevOutcome of procedurevDepressionvRisk for ineffective copingReference:Mckinnery, Jams, Murray Ashwill, copy right at 2005 Elsevier Inc. Philadelpia PA, USA, 2005 Maternal- Child Nursing 2nd edition. | After 40hrs. the client will be able to: 1. Verbalize awareness of own coping capabilities. 2. Identify ineffective coping behaviors and consequences. 3. Meet psychological needs as evidence by appropriate expression of feelings. | Independent: 1. Active- listen and identify clients perceptions of what is happening. 2. Provide quite environment, equipment out of you as much as possible. 3. Give emotional support to elevate feeling of anxiety. Collaborative: 1.
Involve social services, psychiatric liaison, and pastoral care for additional and ongoing support with stress.. 2. Refer to outside resources and or professional therapy as individual or ordered. | 1. To assess coping abilities and skills. 2. When anxiety increase by noisy surroundings. 3. Alleviate anxiety. 1. Specialized services may be required to meet specific needs. 2. To promote wellness. Reference:Nurse’s Pocket Guide (diagnosis, Prioritized Interventions and Rationales edition 11. | After 40hrs. the client was able to: 1. Goal Met. Verbalized some of her awareness on own coping abilities like positive outlook and having a supportive family. 2. Goal Met.
Identified ineffective coping behaviors such as anxiety, fear and feeling of loneliness after the procedure. 3. Goal Partially Met. Prepared herself emotionally as verbalization of “mayo man gani para matapos na ni. ” But we were unable to assess the patient after the procedure. | XII. DRUG STUDY Medication | Route, Dosage, and Frequency| Mechanism | Indication | Contraindication | Adverse Effect | Nursing Responsibility| Generic Name:Propranolol Hydrochloride Brand Name:InderalClassification:Antianginals | 40mg PO, ? tab TID | A non-selective beta blocker that reduces cardiac oxygen demand by blocking catecholamine- induced increases in hear rate, blood pressure, and force myocardial contraction.
Depress renin secretion prevents vasodilatation of cerebral arteries| * Hypertension | Contraindicated in patients with bronchial asthma, sinus bradycardia, and heart block greater than first-degree, cardiogenic shock, and overt and decompensated heart rateIn patient with thyrotoxicosis, use drug cautiously because it may masks the signs and symptoms| CNS: fatigue, lethargy fever, vivid dreams, hallucinations, mental depression, light-headedness, dizziness, insomniaCV: hypotension, bradycardia, heart failure, intensification of AV block, intermittent claudicationGI: abdominal cramping, constipation, nausea, diarrhea, vomitingHematologic: agranulocytosisRespiratory: bronchospasmSkin:rash | C-ANTI-ANGINALS H- decreasedl BPE- (8am,1pm,6pm) TIDC- Give drug consistently with meals.
Food may increase absorption of propranolol – always check apical pulse before giving the drugK- Caution to continue taking this drug as prescribed even when she’s feeling better| Medication| Route, Dosage, and Frequency| Mechanism| Indication| Contraindication| Adverse Effect| Nursing Responsibility| Generic Name:Cefuroxime SodiumBrand Name:ZinacefClassification:Anti- infectives| 750mg, IVTT q8??| Second-generation cephalosporin that inhibits cell-wall synthesis, promoting osmotic instability; usually bactericidal| * infection| Contraindicated in patients hypersensitive to drug or other cephalosporinUse cautiously in patient hypersensitive to penicillin because f possibility of cross-sensitivity with other beta-lactam antibiotics| CV: phlebitis, thrombophlebitisGI: diarrhea, pseudomembraneous colitis, nausea, anorexia, vomitingHematologic: hemolytic anemia, thrombocytopenia, transient neutropenia, eosinophiliaSkin: maculopapular and erythematous rashes,urticaria, pain, induration, sterile abscesses, temperature elevation, tissue sloughingOther: anaphylaxis, hypersensitivity reaction, serum sickness| C-ANTI-INFECTIVES H-negative infection E-every 8 hoursC- Before giving the drug, ask pt if he is allergic to penicillin or cephalosporins – instruct pt to notify prescriber about rash and superinfections K- Instruct pt to notify prescriber about rash, loose stools, diarrhea, or evidence of superinfection -Instruct pt to complete entire meds as prescribed -Advise pt receiving drug IV to report discomfort at IV site|
Medication| Route, Dosage, and Frequency| Mechanism| Indication| Contraindication| Adverse Effect| Nursing Responsibility| Generic Name:Propyltiouracil (PTU)Brand Name:Propyl-Thyracil Classification:Thyroid Hormone Antagonist| 50mg/tab 4 tabs, PO q6??| Inhibits oxidation of iodine in thyroid gland, blocking ability of iodine to combine with thyroxine to form T4, and may prevent coupling of monoiodotyrosine and diiodotyrosine to form T3 and T4| * Thyrotic crisis| Contraindicated in patient hypersensitive to drug| CNS: headache, drowsiness, vertigo, paresthesia, neuritis, neuropathies, CNS stimulation, depression, feverCV: vasculitisGI: visual disturbances, loss of tasteGU: nephritisSkin: rash, urticaria, skin discoloration, pruritus, erythema nadosum, exfoliative dermatitis| C- THYROID-HORMONE ANTAGONISTH-decreased hyperthyroidismE-Every 6 hoursC-tell pt to report bleeding, fever sore throat, and skin eruptionsK- monitor CBC periodically| Medication| Route, Dosage, and Frequency| Mechanism| Indication| Contraindication| Adverse Effect| Nursing Responsibility| Generic Name:ParacetamolBrand Name: TylenolClassification: Nonopioid analgesics and antipyretics| 500mg/tab, PO PRN| Thought to produce analgesia by blocking pain impulses by inhibiting synthesis of prostaglandin in the CNS or of other substances that sensitize pain receptors to stimulation. The drug may elieve fever through central action in the hypothalamic heat-regulating center | * Mild fever| Contraindicated in pt hypersensitive to drug| Hematologic: hemolytic anemia, leukopenia, neutropenia, pancytopeniaHepatic: jaundiceMetabolic: hypoglycemiaSkin: rash, urticaria| C – NON- NARCOTICANALGESICS AND ANTIPYRETICSH – Decreased temperature or temperature regulated E – as necessary or when temperature is more than 37. 80CC – Instruct client to report any adverse reaction like allergies to the physician or nurse. Warn patient that high doses or unsupervised long ???term use can cause liver damage. K – Not to use for marked fever (temperature higher than 39. 50C). Fever persisting longer than 3 days. |
Medication| Route, Dosage, and Frequency| Mechanism| Indication| Contraindication| Adverse Effect| Nursing Responsibility| Generic Name:Mefenamic AcidBrand Name: Ponstel Classification:Non-steroidal Anti-Inflammatory Drugs| 500mg/cap, PO q6?? PRN| Decrease inflammation, pain, and fever probably through inhibition of cyclooxygenase| * Relief of moderate pain | Contraindicated in patients to whom aspirin iodides or any NSAID has caused allergic type reactions| GI: abdominal pain, diarrhea, nausea, stomach and intestinal upset, vomiting, ulcers, internal bleedingMS: fatigueSkin: jaundice, itching, flu-like symptomsRespiratory: breathing problems| C- NON-STEROIDAL ANTI-INFLAMMATORY DRUGSH- reduce painE-as necessary when pain is feltC- Instruct pt to take drug with meal or with a full glass of water K- Inform pt that if she suspects an overdose of Ponstel, seek medical attention immediately. -Symptoms of Ponstel overdose may include: Drowsiness, lack of energy, nausea, stomach or abdominal pain, vomiting | XIII. HEALTH TEACHING MEDICATIONS| EXERCISE| TREATMENT| HYGIENE| OUT-PATIENT| DIET| Cefuroxime (Zinacef)C= anti-infectives H=negative infection E=750mg IVTT q8??C= instruct pt to notify prescriber about rash and superinfections K= ask pt if she is allergic cephalosporins Propranolol HCL(Inderal) C= anti-anginals H= normal BPE= 40mg ? tab,PO TIDC= instruct pt to take drug with mealsK=always check apical pulse before giving the drugPropylthiouracil(PTU) C= thyroid-hormone antagonistH= negative yperthyroidismE=50mg (4tabs) PO q6??C=tell pt to report bleeding, fever sore throat, and skin eruptionsK= monitor CBC periodically| * Exercise regularly like stretching and active range of motion- to improve level of functioning * Repositioning each time she’s on bed * Breathing exercises * Focused breathing * Performing of activities of daily living like sweeping the floor/ cleaning the house as a basic form of exercise * Meditation/ spiritual therapy- spiritual intervention facilitate whole body functioning| * Oxytocin -to trigger the release of the mole that is not spontaneously aborted. * Vacuum aspiration- can be performed to remove the mole. Blood Transfusion -to replace blood lost during surgery or due to a serious injury and may be done if your body can’t make blood properly because of an illness * Intravenous therapy – Considered faster-acting than oral or other forms of medication, intravenous or IV therapy allows medicine to reach the heart quickly * Dilation and curettage ??? is not used as an abortion technique, and doctors instead prefer early term vacuum methods. * Hysterectomy-the uterus can be surgically removed because of the higher risk of cancerous moles to older women . * hCG levels will be checked every two weeks- If the levels don’t return to normal by that time, the mole may have become cancerous. If normal, the woman’s hCG will be tested each month for six months, and then every two months for a year. * Taking a bath regularly * Combing of hair * Oral care- brushing and flossing of teeth * Cleaning of ears, eyes, and nose regularly * Wearing of clean and comfortable clothes * Perineal hygiene from anterior to posterior to prevent invasion of bacteria from the anus to the urethra * Hand washing- before and after eating, and if necessary * Clean and calm environment conducive for easy recovery | * Completion of medication regimen * Follow-up procedures that monitor the hCG levels can occur monthly for six months or as your physician prescribes * Pregnancy should be avoided for one year after a molar pregnancy * Inform pt that if she had a molar pregnancy without complications, risk of having another molar pregnancy is about 1-2%. * Regular check-ups * Support groups and counseling is beneficial| * Diet high in protein, folic acid, and carotene * Protein= Milk, Eggs, Cheese ,Yogurt ,Peanut Butter Lean Meats, Fish, and Poultry Beans * Folic acid= Leafy green vegetables ,spinach and green cabbage, fruits such as citrus fruits and dried beans peas, Breakfast cereals . * Carotene= orange fruits and vegetables such as carrots. * Increase fluid intake| XIV. XV. BIBLIOGRAPHY Kluwer W. Nursing 2008 Drug Handbook (28th Edition).
Lippincott Williams & Wilkins, Philadelphia, 2008. Doenges, M, Moorhouse, M, Murr, A: Nurse’s Pocket Guide (Edition 11). F. A. Davis, Philadelphia, 2008 Daniels, R, Laura, N, Leslie, N: Contemporary Medical-Surgical Nursing. Delmar Learning, Singapore, 2007 Mckinney, James, Murray Ashwill (2005). Maternal Child Nursing. 2nd Edition. Elsevier Inc. Philadelphia. Pennsylvania Doenges, M, Moorhouse, M, Murr, A. (2006). Nursing Care Plan. Guidelines for individualized Care across the Life Span. F. A. Davis, Philadelphia http://www. drugs. com http://www. femalehealthmadesimple. com/implantation. html http. //www. google. com http. //www. freedictionary. com