SAINT LOUIS UNIVERSITY

COLLEGE OF NURSING
Baguio City

Case Presentation:
Hydrosalpinx, Acute appendicitis

Presented to:
Mrs. Melody D. Baliang, RN

Presented by:
Ayugat, Roland
Alcantara, Nadine
Ceriaco, Chedan
Gonzales, Bianca
Macayan, Katrin
Rayray, Ciara

Date:
June 17, 2008
 PATI EN T P ROFI LE

Name: Mrs. M. T. M. (Initials for anonymity)

Age: 42 years old
Citizenship: Filipino
Birth date: September 15, 1965
Religion: Roman Catholic
Birth Place: Baguio City, Philippines
Address: San Vicente, Baguio City
Educational Attainment: High School Graduate
Admitting Physicians: Dr. Bibat,
Dr. Catalan
Attending Physician: Dr. Malinit
Date and Time Admitted: June 13, 2008; 11:10AM
Room and Bed Number: Pay ward, 025

Impression Diagnosis: Adnexal Mass, Left, to consider ectopic pregnancy, G7P6

(6016)

Operations performed: Salpingectomy

Elective Appendectomy
(Both done last June 14, 2008)

Final Diagnosis: Hydrosalpinx, Left, s/p sapingectomy, G7P6 (6016), Acute

appendicitis, congestive s/p Appendectomy

HIS TORY OF P RESE NT IL LN ESS

Patient’s condition started one month before admission, when she experienced profuse
vaginal bleeding with discharge amounting to approximately two fully soaked diapers and had been
diagnosed of threatened abortion 10 weeks AOG. She had then undergone completion curettage
last May 08, 2008 at the Sto. Nino Hospital, Baguio City. The bleeding was controlled but resumed
a few days after the curettage with discharge amounting to approximately 1 to 2 minimally soaked
pads. The patient had not taken any medications and verbalized to have no associated abdominal
pain, dysuria, or fever accompanying her existing condition.

Six days prior to admission, the patient complained of experiencing abdominal pain with an
intensity of 5 out of 10 and no radiation. No medications were taken and there had been no
accompanying symptoms such as fever, dysuria, nausea and vomiting.

About two days before admission, patient’s condition persisted, prompting her to seek
advice from a private physician. A complete blood count, urinalysis and pelvic ultrasound were then
requested for further diagnosis. The complete blood count revealed no significant health
deviations, while the urinalysis suggested the presence of a urinary tract infection and the Pelvic
ultrasound showed left adnexal mass, suspicious for ectopic pregnancy, mild hydrosalpingitis. Due
to these findings, the patient was advised for admission, hence admitted.

PAST M EDI CAL H IS TOR Y

The patient verbalized to have been previously hospitalized at Sto. Nino Hospital for her
completion curettage and named no other succeeding condition necessitating hospitalization apart
from her present admission at Saint Louis University - Hospital of the Sacred Heart. She also
claimed to have no existing allergies to food and drugs and has had no previous intake of
maintenance drug for any serious health complication.
Furthermore, she has had no history of ovarian carcinoma, dysfunctional uterine bleeding,
myoma, Hydatidiform mole, pelvic inflammatory disease, cervicovaginitis, or polycystic ovarian
syndrome.

FAMI LY ME DI CAL H IS TORY

The patient claimed to have no existing history of heredofamilial disease conditions such
as hypertension, cerebrovascular diseases, asthma, diabetes mellitus, cancer, peptic ulcer
disease, hyperthyroidism, or arthritis. She has no family member with an existing contagious
disease such as with pulmonary tuberculosis.

COU RS E OF C ONF IN EM EN T

This nursing care plan presents the case of Mrs. M. T. M., 42 year-old female, Filipino, a
Roman Catholic, married, born on September 15, 1965, a resident of San Vicente, Baguio City,
with a chief complaint of flank pain and vaginal bleeding. This was her second hospitalization, but
had been admitted for the first time in Saint Louis University - Hospital of the Sacred Heart last
June 13, 2008 at 11:10 am by Dra. Catalan and Dra. Bibat, with an impression diagnosis of
Adnexal Mass, Left, to consider ectopic pregnancy, G7P6 (6016).
The patient was admitted with the following diagnostic tests: hematology dated June 11,
2008; complete blood count dated June 11, 2008; urinalysis dated June 11, 2008; whole abdominal
sonogram dated June 11, 2008; and a specimen histopathology that had been reported last May
18, 2008.
During the second day of hospitalization, June 14, 2008, the patient had undergone the
following operations: Salpingectomy, Elective Appendectomy both with duly accomplished consent
forms with proper pre-operative preparation.
 During Hospitalization, the patient received the following medications: Nalbuphine (10mg);
Cefalozine (1gm); Metoclopramide (10mg); Ranitidine (50mg); Ketorolac (30mg) and Tranexamic
Acid (500mg). The patient had been infused with and consumed 2 bottles of D5LRS (1L) and 1
bottle of PLRS (1L).

DIA GNO ST IC S AN D IM PLI CATION S

Hematology (June 11, 2008)

Result: blood type “O” Rh positive

 The hematology test was completed to identify the patient’s blood type and Rh blood
group. Laboratory technicians determine the patient’s blood type and then either cross
match it to the potential donor or screen it for the presence of antibodies; this is done to
avoid blood type mismatches which may trigger damaging antigen-antibody responses
(agglutination) or rupture of red blood cells (hemolysis).
Reference: Tortora, et. al.; Principles of Anatomy and Physiology; 11th edition

Complete Blood Count (June 11, 2008)

Normal values Patient Value

Hgb 120-160 g/L 127 g/L
Hct 0.37-0.47 Vol % 0.38 Vol%
Leukocyte 5-10 10^9/L 10.15 10^9/L
Neutrophils 0.5-0.7 0.82
Lymphocytes 0.2-0.4 0.17
Eosinophils 0-0.07 0.01
Platelet 150-440 x10^9/L 383 x 10^9/L

 The complete blood count was done to identify if the patient’s active bleeding has taken
effect on the present level of blood components, apparently, no significant deviation is
seen.
Reference: Smeltzer, et. al.; Textbook of Medical Surgical Nursing; 10th edition

Urinalysis (June 11, 2008)

Color: dark yellow Pus cells: 40-50/hpf
Appearance: turbid RBC: 20-30/hpf
Reaction: acidic (ph6) Bacteria: some/hpf
Specific Gravity: 1.015 Yeast Cells: none found
Albumin: (+) Mucus threads: loaded
Sugar: (-) Epithelial cells: some
Amorphous Urates/Phosphates: few

 A urinalysis is a diagnostic physical, chemical, and microscopic examination of a urine

sample (specimen). Specimens can be obtained by normal emptying of the bladder
(voiding) or by a hospital procedure called catheterization. Red blood cells in the patient’s
 urine can be due to bleeding in the genitourinary tract as a result of systemic bleeding
disorders or bacterial infections while pus in the urine may be indicative of urinary tract
infection.

Reference: http://www.healthatoz.com/healthatoz/Atoz/common/standard/transform.jsp?requestURI=/healthatoz/Atoz/ency/urinalysis.jsp

Ultrasound- whole abdominal Sonogram (June 11, 2008)

The uterus is midline, anteverted and normal in size, measuring 5.9 x 3.4 x 4.9 cm. It shows
homogenous echotexture. The endometrial stripe is thin (5.0mm). A complex mass is noted at the
left adnexal area adjacent to the ovary, measuring 3.0 x 2.3 cm. There is mild dilation of the right
fallopian tube which is fluid filled. The right ovary is intact. The cul-de-sac is clear.
IMPRESSION: Left adnexal mass, suspicious of ectopic pregnancy
Mild Hydrosalpingitis, Right
Unremarkable Sonogram of the liver, gallbladder, pancreas, spleen,
kidneys, urinary bladder

 Medical sonography (ultrasonography) is an ultrasound-based diagnostic medical imaging

technique used to visualize muscles, tendons, and many internal organs, their size,
structure and any pathological lesions with real time tomographic images. An adnexal
mass is a lump in the tissues near the uterus, usually in the ovary or fallopian tube, which
usually include ovarian cysts, ectopic (tubal) pregnancies, and benign (noncancerous) or
malignant (cancerous) tumors. A hydrosalpinx is a distally blocked fallopian tube filled with
serous or clear fluid. The blocked tube may become substantially distended giving the tube
a characteristic sausage-like or retort-like shape.

References: http://en.wikipedia.org/wiki/Hydrosalpinx; http://en.wikipedia.org/wiki/Hydrosalpinx; http://en.wikipedia.org/wiki/Ultrasound

Histopathology (Submitted- May 12, 2008) (Reported- May 18, 2008)

Diagnosis: Abortion, incomplete, 11 weeks age of gestation, G8P7 (7016); status completion
curettage
Histopathologic Diagnosis: Uterine Curettings- Decidual tissues, chorionic villi, blood clots
Gross description: Specimen consists of irregular fragments of tan membranous and spongy
tissues admixed with blood clots forming an aggregate measuring 3 x 3 x 3 cm

 Histopathology refers to the examination of a biopsy or surgical specimen by a pathologist,

after the specimen has been processed and histological sections have been placed onto
glass slides. This is the most important tool of the anatomical pathologist in routine clinical
diagnosis of cancer and other diseases. This was done to identify the tissues extracted
 during the patient’s completion curettage. The test seems to have identified tissues
resembling the products of conception hence the identified diagnosis suggests an
incomplete abortion.

Reference: http://en.wikipedia.org/wiki/Histopathology

MEDI CATION LI ST

Ranitid ine (5 0mg)

 Histamine H2 receptor antagonist

 Indication: Relief of heartburn associated with acid indigestion and sour stomach.
Treatment of GERD.
 Action: competitively inhibits gastric acid secretion by blocking the effect of histamine on
H2 receptors. Both daytime and nocturnal basal gastric acid secretion, as well as food-
and pentagastrin – stimulated gastric acid are inhibited.
 Contraindications: cirrhosis of the liver, impaired renal or hepatic function
 Side effects: Headache, abdominal pain, consitipation, diarrhea, nausea and vomiting.
 Nursing Considerations:
o Give antacids concomitantly for gastric pain although they may interfere with ranitidine
absorption.
o Assess stomach pain
o Avoid alcohol, aspirin – containing products, caffeine containing products (may
increase stomach acid)

Cefazolin ( 1gm)
 First generation cephalosporin
 Indication: UTI
 Action: Antibacterial – interferes with the final step in cell wall formation, resulting into
unstable cell membranes that undergo lysis. Also, cell division and growth are inhibited
First generation – effective activity against gram – positive microorganisms (S. aureus) and
relatively mild activity against gram – negative microorganisms( E.coli).
 Side effects: Diarhhea, N/V, abdominal pain, rash, fever
 Nursing considerations:
o Take as directed/ complete subscription
 o Report adverse effects

Tranexamic Aci d (500m g)

 Antifibrinolytic agent
 Indication: Active vaginal bleeding
 Action: Tranexamic acid is a competitive inhibitor of plasminogen activation, and at much
higher concentrations, a noncompetitive inhibitor of plasmin.
 Contraindications: active intravascular clotting, acquired defective color vision, since this
prohibits measuring one endpoint that should be followed as a measure of toxicity
 Side effects: Gastrointestinal disturbances, Hypotension
 Nursing Considerations:
o Use cautiously on pregnant women
o Patients with a previous history of thromboembolic disease may be at increased
risk for venous or arterial thrombosis.

Nalb uphi ne (10 mg)

 Brand name: Nubain
 Drug Classification: Opioid analgesic
 Indications: Management of moderate to severe pain. Also used as an analgesic during
labor, as a sedative prior to surgery, and as a supplement in balanced anesthesia.
 Action: Binds to opiate receptors in the CNS. Alters the perception of and response to
painful stimuli, while producing generalized CNS depression. In addition, has a partial
antagonist property, which may result in opioid withdrawal in physically dependent patients.
 Contraindications: Hypersensitivity to nalbuphine or bisulfites. Patients who are physically
dependent on opioid analgesics and have not been detoxified (may precipitate withdrawal).
 Caution: Head trauma, increased intracranial pressure; severe renal, hepatic, or
pulmonary disease; hypothyroidism; geriatric/debilitated patients.
 Adverse reactions: Sedation, headache, dizziness, vertigo, respiratory depression, nausea
and vomiting, clammy feeling.
 Nursing Considerations:
o Assess type, location, and intensity of pain.
o Assess BP, PR, and RR before and periodically during administration.
o Prolonged use may lead to physical and psychological dependence and tolerance.
o Patient teaching:
 Instruct on how and when to ask for pain medication.
 Advise to call for assistance when ambulating.
Ketor olac (30 mg)
 Brand name: Toradol, Ketomed
 Drug Classification: Non-opioid analgesic; NSAID
 Indications: Short term management of pain. Management of ocular itching due to
seasonal allergic conjunctivitis.
 Action: Inhibits prostaglandin synthesis producing peripherally mediated analgesia. It also
has an antipyretic and an anti-inflammatory property.
 Contraindications: Cross-sensitivity with other NSAIDs may exist. Lactation.
 Caution: History of GI bleeding, CVD, and renal impairment.
 Adverse reactions: Drowsiness, abnormal vision, asthma, pallor.
 Nursing Considerations:
o Assess pain, noting type, location, and intensity.
o Patients with asthma, aspirin-induced therapy, and those with nasal polyps are at
increased risk for developing hypersensitivity reactions.
o Patient Teaching:
 Instruct on how and when to ask for pain medications.

Metoclop ramide ( 10 mg)

 Brand name: Plasil
 Drug Classification: Anti-emetic
 Indications: It is used short-term to treat heartburn caused by gastroesophageal reflux in
people who have used other medications without relief of symptoms. It is also used to treat
slow gastric emptying in people with diabetes (also called diabetic gastroparesis), which
can cause nausea, vomiting, heartburn, loss of appetite, and a feeling of fullness after
meals.
 Action: Metoclopramide increases muscle contractions in upper digestive tract. This
speeds up the rate at which the stomach empties into the intestines.
 Contraindications: In patients with a history of hypersensitivity to metoclopramide or any of
the components. In the presence of GI hemorrhage, mechanical obstruction, or
perforation. In those with pheochromocytoma, in epileptics and in those with
extrapyramidal reactions.
 Caution: Pregnancy and lactation.
 Adverse reactions: Restlessness, drowsiness, fatigue and lassitude. Less frequent
reactions are insomnia, extrapyramidal symptoms, headache, dizziness, nausea,
galactorrhea, gynecomastia, rash and urticaria, or bowel disturbances.
 Nursing Considerations:
 o Extract from history if the patient has epilepsy, GI perforation, pheochromocytoma,
or bleeding in the intestines.
o The drug can pass into the breast milk and may harm the baby.
o Metoclopramide is usually taken before meals and at bedtime.
o Patient Teaching:
 Instruct to take with a full glass of water.

THI RTE EN AR EAS OF ASSESS MEN T

I. Psycholog ical St atus

Mrs. M. T. M. is 42 years old. She is an Igorot and was born and raised in San Vicente,
Baguio City. Her parents are also from San Vicente, Baguio City. Presently, her family is residing in
San Vicente, Baguio City. They live in an owned, concrete 1-storey house with two rooms. The
patient is a Roman Catholic and verbalized that she has no beliefs or practices that may hinder
health care rendered to her. She is married and was blessed with 6 children. She is a retailer of
ready-to-wear clothes or mostly commonly known as “wagwag”. According to her, she avails of the
dry goods from Manila.
The patient is accommodated at the Pay ward section of the OB ward of Saint Louis
University-Hospital of the Sacred Heart.
The patient is a mother to 6 children. She verbalized that they have good family
relationships. The patient’s second child is the one staying with her in the hospital. All in all, there
are 9 members of her family and they live together. Prior to hospitalization, she was independent;
however, during her confinement, her daughter had been assisting her in performing ADLs as the
patient’s condition necessitated dependency since the procedures performed rendered her to be
temporarily in need of assistance in doing activities she used to do alone. Her diversional activities
include taking care of her children, doing household chores, or managing in her business.
Her OB history is as follows:
*OB score-G7P6 (6016)
G1: 1984, home delivery, NSD, term baby boy
G2: 1989, home delivery, NSD, term baby boy
G3: 1991, home delivery, NSD, term baby boy
G4: 1996, home delivery, NSD, term baby girl
G5: 2001, home delivery, NSD, term baby boy
G6: 2006, home delivery, NSD, term baby girl
G7: 2008, spontaneous abortion, 12 weeks AOG

II . Mental and Em otional Status

 The patient is awake and coherent, oriented to time, place, and person. She is a high
school graduate and is able to read, write, comprehend and follow directions.
Regarding her health problem, she is grateful in having undergone left salpingectomy and
appendectomy which afforded her relief from pain. She has no unusual beliefs about the cause of
her health problem. This is her second hospitalization.
Her chronological age is directly proportional to her developmental age as she is open and
approachable, and is able to converse with the student nurses without any observable signs or
significant inconsistencies such as speech defects, stuttering or inability to understand or follow the
conversational framework with difficulty.

II I. E nvironm ental Status

The patient is in need of assistance when standing and going to the comfort room.
There are two more patients in the room. There is adequate lighting and ventilation. The
comfort room is approximately less than 10 feet away from the patient’s bed. Side tables are
located at the right and left upper head of the bed where her things are readily accessible. There
was no presence of side rails but there are head and foot rails. The patient is with an intravenous
line on her right hand. An IFC was inserted last June 14, 2008 in preparation for her operation and
was ascetically removed after her surgery on June 15, 2008.

IV. S ensory Status

a. Visual status: the patient has no known visual deficits. She also has no unusual sensations
like blurring of vision. The patient does not use any corrective like contact lenses or
eyeglasses or prosthetic devices like artificial eyeballs. She has pale palpebral conjuctiva
and 2-3 mm pupils, equally round and reactive to light and accommodation. Her eyes are
normally symmetrical and in level with each other. There are also symmetrical eye
movements.
b. Auditory status: the patient is able to distinguish and respond to voices. She verbalized
that she has no known auditory deficits and unusual sensations like ringing or buzzing.
She has no auditory corrective devices. The patient’s pinnae are bilaterally symmetrical
with the lateral canthus of the eyes and in line with each other.
c. Olfactory status: the patient is able to discriminate odors and there are no unusual
sensations. The patient has no colds.
d. Gustatory status: the patient is able to discriminate sweet, salty, bitter and sour tastes. She
has no unusual sensations. She verbalized that there was no change in her appetite.
e. Tactile status: the patient is able to discriminate different tactile sensations and has no
unusual sensations.
 f. Speech formulation and perception: the patient has intact speech organs. The patient
verbalized that her whole set of upper jaw teeth is a denture. The patient is able to
understand and initiate speech and has no deficits in phonation.
g. Sensory environment: the hospital setting and routine such as vital signs taking are
tolerated well by the patient.

V. Motor St atus
Upon admission, the patient was weak. Upon assessment, the patient is unable to
ambulate properly and needs assistance when standing and going to the comfort room. There was
good body coordination as well as stability. The patient can tolerate range of motion exercises.
There are no muscular abnormalities and there is good muscle tone and mass. The patient’s
muscle strength is as follows:

5/5 5/5

4/5 4/5

The patient was instructed to remain flat on bed for a few hours after the
surgery. However, there were no further medical restrictions on activity and early ambulation was
encouraged. The patient has an abdominal binder over her wound dressing and is patient is right
handed.

VI. Nutritio nal Status

The patient usually has three main meals and two snacks. She prefers vegetables
(highland or lowland), coffee, and soda drinks particularly coke. She also prefers bread for snacks.
According to her, she has good appetite prior to and even during hospitalization. However, prior to
and after her surgery, she was on NPO. On the morning of June 15, 2008, she had already passed
flatus and stool. There was no further physician’s order regarding her diet.
The patient has a medium structured body. She has moist skin as well as moist
buccal cavity. She has good capillary refill and good skin turgor.
The patient has a denture. She has intact oral cavity. The patient is awake and is
able to swallow but was remained on NPO, a day after her surgery.

VII. Elim ination Status

 The patient has been diagnosed with urinary tract infection as seen and implied by
increased pus cells in her urinalysis. During her operation last June 14, 2008, she was inserted
with an IFC draining yellowish urine and is adequate with urine output of more than 30cc/hour. The
IFC was eventually removed on June 15, 2008 in the presence of flatus. During the night shift of
her 1st day post operatively, the patient was however observed to have decreased urinary output
and was then therefore referred to the resident on duty for further management. The patient had
remained on bed for a number of hours and was hesitant to ambulate due to the discomfort and
pain she felt hence reported that she had defecated once.

VIII . Fl uid an d Electrolyte St atus

On average, she drinks for about 8-10 glasses of water a day. She also drinks additional
coffee and carbonated drinks. The patient was maintained on NPO after her operation but her
presence of flatus and that she already defecated may indicate progress on her nutritional intake.
The patient has good skin turgor.

IX. Circu latory St atus

Pulse rate is of regular rhythm, ranging from 70 – 75 beats per minute. Blood pressure
range is from 110/70- 120/80. Her capillary refill was 2 seconds. Client manifests good, adequate
and effective circulation as seen by the absence of cyanosis and dizziness. In addition the client is
awake and alert which manifests good level of consciousness.

X. Temp eratur e Status

Before and upon admission, patient’s temperature is within normal (range of 36.4 – 37.5
C). The patient’s temperature was stable during hospitalization; no fever was experienced.

XI. Integum entary St atus

The patient has a fair complexion. The patient had a dry and intact binder over wound
dressing on the abdominal area due to her appendectomy and salphingectomy. No signs of muscle
wasting or clubbing nails were observed. The patient has a good skin turgor.

XII. Comfort and Rest Status

 Normally, she sleeps for about 8 hours. During hospitalization, she verbalized that she
does not have any concern regarding her hours of sleeping but was observed to be awakened from
sleep on several occasions to converse with the other patient beside her. She was maintained flat
on bed immediately after her operation but already advised and assisted to be on her desired
comfortable position as ordered by her physician. She claimed to feel post-operative pain over her
abdomen. She described it to be non-radiating and of moderate intensity.

XIII . Respiratory Status

The patient has no problems regarding her respiratory status. Her respiratory rate has a
range of 20-25 breaths per minute. She has an effective airway clearance and has an effective
breathing pattern which provides adequate gas exchange and results to a good level of
consciousness and non-cyanotic peripheral status.

LIS T O F P RI OR ITIZ ED P RO BL EM S

Actual problems
1. Acute pain related to tissue trauma secondary to surgery
2. Impaired skin integrity related to trauma secondary to surgical incision
3. Impaired tissue integrity related to trauma to integumentary and subcutaneous tissues
secondary to abdominal surgery
4. Activity intolerance related to temporary immobility secondary to previous surgery
5. Impaired physical mobility related to discomfort upon movement secondary to surgery
6. Impaired transfer ability related to trauma and discomfort upon moving secondary to effects of
surgery
7. Self-care deficit: bathing/hygiene, and dressing related to discomfort upon moving secondary to
effects of surgery
8. Acute urinary retention may be related to use of a medication (opioid) with side effects of urinary
retention
9. Ineffective role performance related to physical health alterations
10. Interrupted family process related to situational changes secondary to physical health
alterations
11. Disturbed sleeping pattern related to interruptions for therapeutic, monitoring and other
generated awakening

Potential problems
1. Risk for constipation related to insufficient physical mobility
2. Risk for infection related to inadequate primary defenses (broken skin integrity)
3. Risk for injury related to altered mobility status secondary to surgery
4. Risk for imbalance nutrition: less than body requirements related to decreased volume of
ingested food during hospitalization
5. Risk for imbalanced body temperature related to trauma affecting temperature regulation

PRI OR ITI ZA TIO N OF PRO BL EM S

Abraham Maslow (1954) attempted to synthesize a large body of research related to

human motivation. Prior to Maslow, researchers generally focused separately on such factors as
biology, achievement, or power to explain what energizes, directs, and sustains human behavior.
Maslow posited a hierarchy of human needs based on two groupings: deficiency needs and growth
needs. Within the deficiency needs, each lower need must be met before moving to the next higher
level. Once each of these needs has been satisfied, if at some future time a deficiency is detected,
the individual will act to remove the deficiency. The first four levels are:

1) Physiological: hunger, thirst, bodily comforts, etc.;

2) Safety/security: out of danger;

3) Belonginess and Love: affiliate with others, be accepted; and

4) Esteem: to achieve, be competent, gain approval and recognition.

According to Maslow, an individual is ready to act upon the growth needs if and only if the
deficiency needs are met. The fifth level is Self-actualization. It means to find self-fulfillment and
realize one's potential. Self-actualized people are characterized by: 1) being problem-focused; 2)
incorporating an ongoing freshness of appreciation of life; 3) a concern about personal growth; and
4) the ability to have peak experiences.

 LIST OF PRIORITIZED PROB LEMS

CLASSIFICATION
PRIORITIZED PROBLEMS
(Actual/Potential)
1. Acute pain related to tissue trauma secondary to surgery Actual
2. Impaired skin integrity related to trauma secondary to surgical
Actual
incision
3. Impaired tissue integrity related to trauma to integumentary and
Actual
subcutaneous tissues secondary to abdominal surgery
4. Activity intolerance related to temporary immobility secondary to
Actual
previous surgery
5. Impaired physical mobility related to discomfort upon movement
Actual
secondary to surgery
6. Impaired transfer ability related to trauma and discomfort upon
Actual
moving secondary to effects of surgery
7. Acute urinary retention may be related to use of a medication
Actual
(opioid) with side effects of urinary retention
8. Disturbed sleeping pattern related to interruptions for therapeutic,
Actual
monitoring and other generated awakening
9. Self-care deficit: bathing/hygiene, and dressing related to
Actual
discomfort upon moving secondary to effects of surgery
10. Ineffective role performance related to physical health alterations Actual
11. Interrupted family process related to situational changes
Actual
secondary to physical health alterations
12. Risk for constipation related to insufficient physical mobility Potential
13. Risk for imbalance nutrition: less than body requirements related
Potential
to decreased volume of ingested food during hospitalization
14. Risk for infection related to inadequate primary defenses (broken
Potential
skin integrity)
15. Risk for imbalanced body temperature related to trauma affecting
Potential
temperature regulation
16. Risk for injury related to altered mobility status secondary to
Potential
surgery
NU RS IN G C ARE P LAN S
 Assessment Explanation of the problem Objectives Interventions Rationale Evaluation
LTO : After hospitalization, Diagnostics: Diagnostics:
P: s/p Salpingectomy, The patient had undergone an the patient will
Elective Appendectomy abdominal ultrasound with the 1.Monitor vital signs
following results: Left adnexal a) assume ADLs without pain > For establishment of
S: “ Complained to have mass suspicious of ectopic or discomfort baseline data and an objective
pain felt over the pregnancy and Mild parameter/ indication of
abdominal; area, Hydrosalpingitis, Right b) verbalize that she is increasing pain.
characterized as stabbing completely pain free 2. Use a pain assessment scale to
in nature, with no radiation, Comprehensively assess and > baseline for assessing
rated as 7/10, aggravated record pain using objective criteria changes in pain level and
by movement, and Salpingectomy, and Elective ST O : Within the shift the such as location, characteristics, evaluating interventions
alleviated by rest” Appendectomy was performed patient will be able to onset/duration, frequency, quality,
to repair the assessed damage severity and precipitating or
O: >Appears weak a) identify and describe pain aggravating factors before and
felt after performing nursing
>Confines self to bed and interventions.
moves minimally A Surgical incision was done b )verbalize that her pain
decreased from to 3. Note location of surgical
>Groans upon movement Incisions >Location of Surgical incisions
c) enumerate at least 3 can influence the amount of
>Hesitant to initiate strategies of pain relief post operative pain felt, this
movement Nociceptors or free nerve correctly also serves as a medium of
endings in the skin responded to comparison with the clients
>Asks for assistance in the potentially damaging stimuli d) perform deep breathing pain rating
ADL’s (surgical cutting) exercises for pain 4. Assess patient perception and
management correctly beliefs about pain felt > Identify factors influencing
>Facial Grimacing the pain response
observed upon movement Therapeutics: Therapeutics:
Nociceptive actions are
> Seen holding abdomen transmitted to the peripheral 1. Inform patient that the health
nervous system worker acknowledges that the
>Vital signs: patient’s pain is real by:
BP: 110/70 mmHg
RR: 25 cpm a. Listening to the patient’s >Promotes a feeling of
PR: 75 bpm The brain receives the stimuli subjective complaints assurance, therefore
T: 36.5 C and interprets pain depending decreasing the burden
the type of fiber delivering the
impulse b. Conversing >Distracts the patient from
A: Acute pain related to therapeutically with the concentrating on the pain
tissue trauma secondary to patient
surgery
Acute pain related to tissue
trauma secondary to surgery c. Anticipating and attending >Decreases the patient’s
Reference: Smeltzer et. al.; Textbook of Medical Surgical Nursing;10th edition
Doenges et. al; Nurses Pocket Guide; 9th edition
 Assessment Explanation of the problem Objectives Interventions Rationale Evaluation
P: s/p Salpingectomy, The patient had undergone an LTO Diagnostics: Diagnostics:
Elective Appendectomy abdominal ultrasound with the After hospitalization:
following results Left adnexal >Monitor for signs of >infection, through
S: “Kakatapos lang ng mass suspicious of ectopic -the patient’s surgical site will not have any infection production of toxins and
operasyon ko kanina” pregnancy and Mild complications such as infection wastes increases the
Hydrosalpingitis, Right -the patient’s wound will heal normally and well probability of tissue
O : >Status post approximated. damage.
Salpingectomy, and >Monitor vital signs every >Provides a baseline that
Elective Appendectomy , ST O: 4 hours allows quick recognition
day 1 Salpingectomy, and Elective After 8 hours of nursing interventions: of deviations in
Appendectomy was performed subsequent
>With dry and intact to repair the assessed damage -the patient’s suture site will remain intact and measurements
abdominal dressing and free from contamination
binder >Assess skin integrity >Serves as baseline data
-the patient or a skilled significant other will be to evaluate the efficiency
> No foul odor noted in Surgical procedure required able to demonstrate at least 4-7 steps of proper of nursing intervention
the surgical site cutting into her skin and tissue wound dressing techniques
and removing her appendix >Assess wound dressing >early recognition of
>(+) facial grimace and and affected fallopian tube for drainage undesirable signs and
guarding behavior noted symptoms such as
when ambulating profuse bleeding is vital in
>Vital signs: preventing further
BP: 110/70 mmHg complications
RR: 25 cpm Skin and Tissue trauma
PR: 75 bpm secondary to the surgery > Monitor dietary intake, >these substances may
T: 36.5 C and avoid irritant food and cause irritation to the
fluid intake patient’s skin and oral
mucous membranes and
Presence of abdominal wound may cause complications
A: >Impaired skin integrity (surgical site) in the healing process of
related to trauma the abdominal wound
secondary to surgical
incision

>Impaired tissue integrity >Impaired skin integrity related Therapeutics: Therapeutics:

related to trauma to to trauma secondary to
integumentary and surgical incision >Avoid handling and >pressure predisposes
subcutaneous tissues placing direct pressure on skin breakdown
secondary to abdominal >Impaired tissue integrity the suture area
surgery related to trauma to
integumentary and >Ensure safety by >to maintain the patency
subcutaneous tissues constantly checking on the of the patient’s tubings
secondary to abdominal patient and assisting when like the Epidural catheter