I. INTRODUCTION

Condyloma acuminata refer to all epidermal manifestation attributed to

epidermotropic vulvar papilloma virus. Condyloma acuminata are also referred to as

venereal warts, genital warts and papilloma acuminatum. Approximately 90% of the

cases of condyloma acuminata are related to HPV 6 and 11. These 2 types are benign

and/or the least likely to have neoplastic potential. Certain types such as HPV 33, 35,

39, 40, 43, 45, 51-56, 58, have moderate potential for neoplastic conversion, and

some have high potential for dysplasia such as HPV type 16 and 18. Condyloma

acuminata is a sexually transmitted disease. It is manifested by the presence of warts

in the vulvar, genital, and anal area. If left untreated in pregnant women, it could

cause complication to the baby because the warts could be propagated to the airway

passages of the child. Even if the disease is treated initially, it has a high chance of

recurrence.

In the hospitals we were affiliated, condyloma acuminata cases are very

limited. In the first week of our exposure in Jose B Lingad Memorial Regional

Hospital (JBLMRH), we were given a chance to handle a case of condyloma

acuminata. We chose the disease for our study for several reasons. First, cases of

this kind of venereal disease are very rare. Although we had encountered other types

of sexually transmitted disease such as syphilis and gonorrhea in our previous

exposure, we never encountered such derange this kind of manifestations. Second,

because of the limited cases, we do not have much knowledge about the disease, and

the curiosity that we had motivated us to conduct a case study regarding the ailment.

Lastly, we chose condyloma acuminata because of the increasing number of cases of

sexually transmitted diseases.

In the United States of America, annual cases of condyloma acuminata is 1%.

Prevalence had reported to exceed 50%. Health experts estimate there are more cases

of genital HPV infection than any other STI in the United States. According to the

American Social Health Association, approximately 5.5 million new cases of sexually

transmitted HPV infections are reported every year. At least 20 million people in this

country are already infected.

In this study, we are to deal with the pathophysiology of condyloma

acuminata, the interpretation of abnormal results based on the diagnostic and

laboratory procedures done to the patient. We will also deal with the appropriate

interventions, nursing diagnosis for clients with the said disease condition, the

suggested medical and surgical management including the diet, exercise, and

medication we are to administer when caring for the patient. This case study warrants

to widen our knowledge of the occurrence of the specific disease. It will also assist

us in developing our clinical and academic competence by giving us a new array of

knowledge about nursing interventions, and responsibilities appropriate for clients

having, not only condyloma acuminata, but other STD’s as well. The study will also

enable us to enhance our resourcefulness as nurses, and our critical thinking

considering the limited client information that are available and presented. It will

also help us develop our leadership skills and the flexibility that we have if we are

presented with different unexpected situations by widening our knowledge and

developing our nursing judgment. Most importantly, this study will enable us to

show and evaluate the effectiveness and productiveness that we have as student

nurses in applying preventive, curative, and rehabilitative measures for the patient

with this disease.

II. NURSING ASSESSMENT

1. Personal Data

a. Demographic Data

Ms JS is a 29 year old female Filipino patient. She was born on

December 28, 1976 in their home at Paligui Apalit, Pampanga. Her parents

are Mr. Leonardo Santos and Mrs. Melisa Santos. She is the 5 th child in the

family of 12 children. Years back, she was living together with Mr. Alfred

Ocampo. They were able to raise a family of 6 children even though they are

unmarried. Their eldest child is 12 years old and youngest are the twins

wherein one of the twins died on the date of July 18, 2006. Due to an

undelivered baby boy in transverse lie (one of the twins) she was brought/

rushed to Jose B Lingad Memorial Regional Hospital (JBLMRH) on the same

date (July 18, 2006) with a hospital number of 149044..

b. Socio-economic and cultural factors

A year ago, Ms JS is employed in a school canteen earning about

P120 per day. Her partner is a jeepney driver and is earning P300/day. In one

month, they earn estimately P12, 600. Their monthly earnings is not being

consumed only for food and daily needs. A portion of the income is meant for

their monthly bills (electricity and water) and a portion for other necessities

such as replacement for damage parts of their jeepney and mostly payment for

their rented apartment in Apalit Pampanga. When it comes to dietary habits,

the patient is fond of eating salty foods. They occasionally eat meat and

preserved foods, in most cases of family financial crisis they simply eat rice

with soysouce and salt. She is also fond of drinking coffee at least 3 cups per

day and is able to consume the required 8-10 glasses of water/day.She also

smokes at least1pack a day.

Ms JS also believe in some superstitions and sayings, she does not

take a bath or shower during her menstrual period believing that doing so

could lead to insanity. After performing sexual intercourse, she does not take

a bath either because of her misconception that it could result to what is

known as “pasma” and lastly, she believe in “hilot”.

c. Environmental factors

The patient was raised in Paligui Apalit, Pampanga. The said

place nearly situated beside a creek (“sapa”). Upon living together with Mr.

Alfred Ocampo, they rented an apartment in the same area in Apalit,

Pampanga.

2. Maternal-Child Health History

She had her menarche at the age of 12 years old and lasted for a

week. Form then on, she had regular menstrual period every month and each

period and lasted for 5-7 days. She also experience premenstrual

dysmenorrhea and has heavy menstrual flow on the fist 2 days of onset. She

started to engaged in sexual activity at the age of 16 y/o. She gave birth to her

first baby at the age of 17. From then on, they decided to live together not

bounded by marriage/matrimony. When she was still living together with

partner, they perform sexual intercourse twice weekly. Ms JS does not take

oral contraceptives, neither her partner practice the use of condoms.

a. Maternal-obstetric record

Ms JS has an obstetric record of gravida 7, partum 6. She has

TPAL record of 6, 1, 0, 6. Her children were born via NSD except for the

latest twin pregnancy. Two of which are twin pregnancies. The first twin

pregnancy is the fifth pregnancy, both of the babies died due to premature

delivery. They were born via vaginal birth but survived only for a short

period of time. All the births she had was performed at home by a “hilot”.

Her latest twin pregnancy was in full term. One of the twins was delivered at

home with the midwife’s assistance. She was unable to deliver the second of

the twins due to a transverse lie. Unfortunately, the second baby did not

survive and was diagnosed to be an intrauterine fetal death (IUFD).

b. Antepartal/ Prenatal preparation

The patient had her monthly check-up for the latest twin pregnancy

in a barangay health center with the attending registered midwife. There were

circumstances, especially at the second trimester, wherein she was unable to

completely comply with her prenatal monthly check-ups. She received 3

doses tetanus toxoid vaccine in the barangay health center.

c. Significant Trimester changes (1st to 3rd trimester)

On the first trimester of the latest pregnancy (twin pregnancy),

experienced episodes of nausea and vomiting. She is knowledgeable that

nausea and vomiting is a natural discomfort of pregnancy. She neither did nor

performed any home remedy/management in order to relive the discomfort.

She also felt/experienced early fatigability and manage it through rest.

Straining to defecate or constipation is also experienced by Ms JS on the third

month. This was a result of the compression of the large intestine, restricting

normal bowel movement. She was advised to drink an ample amount of

liquid (8-10 glasses of water) and high fiber food such as papaya in order to

relieve the discomfort. She accepted and followed the said advice and

constipation was gradually relieved.

On the second trimester of her pregnancy, she had complained of

frequent episodes of backache which was caused by the weight of the

developing babies. She also experience early fatigability and headache which

is a result of hindered maternal blood flow caused by the fetal growth and

development. These second trimester discomforts were managed by the

patient through bed rest.

Third trimester pregnancy discomforts the patient experienced

shortness of breath and manage it by rest and proper ventilation.

Lolita Santos

Vilma Santos

Tony Santos

Bernadette Yang

Janet Santos

Luisa Santos

Bernardo Santos

Aileen Santos

Maricel Santos

Eunice Santos

Michael Santos

Leonardo Santos

Alfred Ocampo

HPN (+) TB, Smoker

(+) DM

HPN, condyloma acumintata, UTI

Daisy Santos

(08-29-93)

Judith Santos

(09-04-05)

Ronald Santos

(08-12-00)

Rodel Santos

(10-24-99)

Mark Santos

(05-14-95)

Jaira Santos

Joshua Santos

(12-30-04)

Baby Boy Santos

Baby Boy Santos

(07-18-06)

Deceased- premature Deceased

Lolo Santos

Lola Santos

Leonardo Santos

Died of natural cause Binangungot

Lola Lopez

Lolo Lopez

Melisa Lopez

Asthma, Smoker Stroke, paralysis, & HPN

HPN

3. Family Health Illness History

4. History of Past Illness

Ms JS is unknowledgeable of the vaccination that she had during

her childhood. She had a history of having chicken pox at the age of 8. She

acquired german measles at the age of 14. She had a history of urinary tract

infection at the year 2004 and was prescribed to take antibiotics (ofloxacin).

Aside from the major illnesses she experienced, she usually have cough and

colds, and fever. The patient also self medicate upon experiencing simple

health discomforts like such and never seek medical attention.

5. History of Present Illness

During the nurse patient interaction, the patient stated that she had

relationship problem with her partner. She accuses her partner of infidelity

months before they separated, and there was even one circumstance of having

her problem caught/seen with another woman. This is the reason of their

separation. This is a significant information because her disease condyloma

acuminata is caused by the Human Papilloma Virus which is a sexually

transmitted disease. She also mentioned experiencing pain in the urinary

meatus during urination but she was unaware of having genital warts until she

was brought to JBLMRH.

6. Physical Examination (IPPA-Cephalocaudal Approach)

Physical assessment done by the doctor

Vital signsBP- 180/100 mmhgPR-92bpmRR-24bpmTemperature- 36.0oC

Skin- (+) pallor- (-) rashes- (-) cyanosis- (-) jaundice

Head (EENT)- anicteric sclera- palpebral conjunctiva- pale

lymphnodes- lymphadenopathies

Chest- symmetrical- chest expansion (-) retractions

Lungs- slow breath sounds

Cardio- (-) murmur

Breast- (+) engorgement

Abdomen- NABS- Soft non-tender

Rectum- (-) hemorrhoids

Genitals- Cervix open and fully

Physical Assessment done by the student nurse (07-21-06)

SKIN - Temperature 36.4 oC

- Medium brown in color- with poor skin turgor- (+) pallor- (+) dryness- (-) edema

HEAD- skull symmetrical in shape- (-) lumps or masses- (-) tenderness- (-) pain when palpated

EYES- Eyelids are equal in movement- Anicteric sclera- Palpebral conjunctiva pink in color- (+) PERRLA- (-) external lesion- Able to move up and down and right to left

EARS- With adequate responses to normal sounds- Presence of dry wax buildup - (-) external lesions

NOSE AND SINUSES- Regular breathing with mouth closed- Can breath using both nostrils- (-) pain upon palpation of sinuses- (-) discharge

MOUTH AND THROAT- Teeth- with dental caries on almost all teeth

- with plaque deposition- Oral mucosa dry and yellowish in color- Tonsils- not inflamed- (-) dysphagia

NECK- nontender lymph nodes- Can turn the head from side to side without difficulty- (-) stiffness- (-) pain- (-)lumps

RESPIRATORY- RR= 23 breaths/ minute- Chest - relaxed breathing; rib cage moves symmetrically with

respiration- equal expansion noted- (-) retractions

- (-) adventitious breath sounds upon auscultation- (-) colds

CARDIAC- PR= 73 beats/ min.- BP= 120/80 mmHg- Peripheral pulses (radial and brachial) easily palpated

- (-) chest pain- (-) murmur

GATROINTESTINAL- no bowel movement occurs - (-) diarrhea- (-) food intolerance

URINARY- urinates 2x during the shift- (-) dysuria- (-) urinary retention- (+) pruritus

GENITALS- (+) warts (looks like a cauliflower) spread around the vulvar area- Reddish or almost dark in color- (+) foul odor- (+) lochia serosa

MUSCULOSKELETAL- (-) pain- (-) cramps - Slow in movement

NEUROLOGIC- Alert, mood appropriate to situation- Responds to verbal command- Speaks clearly

HEMATOLOGIC- Hgt and Hct low (hgt= 77, hct=0.33)- With lochia serosa

ENDOCRINE- (-) history of diabetes- (-) thyroid problem- (-) excessive sweating and thirst

PSYCHIATRIC- (-) history of psychiatric disorder

7. Diagnostic and Laboratory Procedures

 

Hematologic Examinations- test/procedures done to patients to determine the ranges/count of blood components.

 

Diagnostic

Procedure

Date Ordered Indication/Purpose Results Normal Values Analysis and Interpretation

Hemoglobin Count  July 18, 2006

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Used to determine Hgb

content of blood.

Hemoglobin is the iron

containing and the oxygen

carrying pigment/CO2

carrying pigment of the

blood/RBC formed in the

bone marrow.

>evaluates blood loss,

erythropoietin

activity/ability, anemia, and

therapy response.

 77g/L

 

 

 

 

 

 

 

 

 

 

Female:

115-155 g/L

The hemoglobin content of the blood of the patient is

below the normal range. This is indicative of anemia

which is a result of the patient’s blood loss during the

surgical procedure she underwent (CSIII & BTL).

Another reason of the deviation from the normal

values is the post partum condition of patient. During

her latest/last pregnancy, there was a higher/increase

demand of nutrients because of the growing baby in

her womb. Due to the inadequate intake of nutrients

including Fe, the maternal absorption of Fe was

compromised by fetal development causing

inadequacy resulting to anemia. The patient’s intake

of medications such as antibiotics (Cefuroxime) also

precipitated to reduce levels of hemoglobin.

 

Diagnostic

Procedure

Date Ordered Indication/Purpose Results Normal Values Analysis and Interpretation

Hematocrit Count  July 18, 2006

 

 

 

 

 

 

 

 

 

 

Hematocrit count evaluates

blood loss, anemia, food

replacement therapy, and

fluid balance, and screens

RBC status. It measure the

concentration of RBC within

the blood volume and is

expressed in percentage.

 0.23/23%

 

 

 

 

 

 

 

 

 

Female:

0.38 (38%) to 0.48

(48%)

.Blood hematocrit content is directly proportional to

the hemoglobin count. The decrease in the patients

hemoglobin count is directly related of the increase in

the hematocrit counts. The decrease in hematocrit is

also caused by the same factors namely:

1. blood loss related to intra-operative period.

2. Decrease Fe absorption related to increase

demands secondary to pregnancy (altered

maternal absorption)

3. inadequate Fe intake

4. medications specifically antibiotics

5. the patients significant increase in WBC

levels (findings of WBC: 23.0[NV: 5-10 x 10 3/L])

White Blood Cell with differential count

Indication

This evaluates the number of conditions and differentiation causes of alterations in the total WBC count including inflammation, infection, and

tissue necrosis. The differential white cell count identifies the 5 specific types of WBC present in blood. These reflect the integrity of the client’s immune

system.

Diagnostic

Procedure

Date Ordered Indication/Purpose Results Normal Values Analysis and Interpretation

WBC count July 18, 2006 This is used to

determine/detect the

presence of infection or

inflammation and to monitor

the patient’s response to

antibiotic/anti-microbial

therapy.

23.00x103/L 5-10,000/cumm The increased in the patient’s WBC count (leukocytosis)

is caused by an skin integrity as evidenced by lower

abdominal midline incision (Due to CS & BTL

procedure) and excision sites in the vaginal area.

> also caused by the inflammation reaction of the

patient’s body as a cardinal sign of infection.

Diagnostic

Procedure

Date Ordered Indication/Purpose Results Normal Values Analysis and Interpretation

 Neutrophil Count July 18, 2006   Used to evaluate/detect the

presence of bacterial

infection, STD’s such as

gonorrhea, syphilis, and

other inflammatory

condition.

0.87  0.45-0.65  The increase in the neutrophil count is caused by the

inflammatory response of the body of the patient due to

infection. It is also caused by the presence of syphilis

(HPV) as manifested by genital warts (condyloma

acuminata)

> also, neutrophil count is directly proportional/related

to the WBC count. The increase in neutrophil count is

also caused by the following factors:

1. tissue trauma as evidenced by surgical incision and

excision site

2. poor response of the patient’s body to anti-microbial/

antibiotic therapy (cefuroxime).

Lymphocyte July 18, 2006 A test used to determine

lymphocyte count.

Lymphocytes count is an

indicator of immune

function, provides a gross

measures of nutritional

status. This is obtained by

venous blood sample.

0.13 0.20-0.35  The patients decrease in lymphocyte count is indicative

of/caused by immunodeficiency secondary to inadequate

nutrition caused by the following factors:

1. altered maternal nutrient absorption secondary

to recent pregnancy/ postpartal status.

2. inadequate intake of foods rich in vitamins

minerals, & calories

Diagnostic

Procedure

Date Ordered Indication/Purpose Results Normal Values Analysis and Interpretation

Platelet Count July 18, 2006 Measures the number of

thrombocytes per cubic

milliliter in order to

determine if the patient

have abnormal blood

clotting capabilities and to

obtain data if patient is at

 359 x 109 /L 150-400x109 /L > Normal

risk for bleeding tendencies

specially in her post

operative condition/state.

Diagnostic

Procedure

Date Ordered

Date Results In

Indication/Purpose Results Normal Values Analysis and Interpretation

Venereal Disease

Research

Laboratory (VDRL)

July 21, 2006

July 23, 2006

This test was indicated for

the patient in order to

determine if the patient,

aside from the HPV

infection, has syphilis, with

blood as a specimen.

 Non reactive Non reactive/

negative

> Normal

Nursing Responsibilities:

Pre-Procedure:

- Explain the procedure to the client.

- Place the patient in a comfortable position.

- Properly clean the skin of the selected puncture site with alcohol.

- Tourniquet the distal site.

During:

- Gently extract/collect blood specimen using a collecting media (syringe).

- Remove the tourniquet before withdrawing the needle.

Post:

- Apply firm gentle pressure on the extraction site to avoid bleeding/hematoma.

Urinalysis

            - is one of the oldest and most common laboratory test. It is economical and results are obtained immediately. The procedure is non-invasive with urine as

specimen.

 

Diagnostic

Procedure

Date Ordered Indication/Purpose Results Normal Values Analysis and Interpretation

Urinalysis 01-08-06

 

 

 

 

 

 

 

 

 

01-21-06

Urinalysis screens for

abnormalities with the

urinary system as well as

systemic problems that

may manifest symptoms in

the urine. Visual

examination, microscopic

examination, regent strip

testing, and refractometry

are various methods used

in performing complete

urinalysis.

Color: yellow

Sugar: positive

Protein: ++

Transparency:

clear

Urine pH: 6

Specific: 1.020

(+) albumin

trace

Analysis

WBC-1-2

Epithelial cell:

none

RBC: over 10 

 

 

 

Color: clear to

slightly hazy,

amber yellow,

yellow to deep

amber

Sugar: negative

Protein: (-)

Transparency:

clear

Urine pH: 4.5-8

Specific: 1.002-

1.035

(-) albumin trace

Analysis

WBC-none-4

Epithelial cell:

none

The patient’s urinalysis indicated both normal and

abnormal results in different aspects. The patient had

normal values in the following: (1) color of urine; (2)

urine pH, & (3) specific gravity. On the other hand,

considerable deviation were evident in the urinalysis

results. The following are the abnormal results in the

urine test together with their analysis:

1. sugar:

> The patient has positive sugar in the urine because

lactation may occur a false positive due to the lactose or

galactose. As a supporting detail, researcher show a

temporary glycosuria that appears to be no clinical

significance, could be present in post partal women and

in intrapartal women. (_booktitle _)

> The client’s intake of multivitamins also may produce

a false positive because of the ascorbic acid content of

the multivitamins.

 

 

Color:

Appearance:

Albumin:

Reaction:

RBC: none 

2. transparency/ appearance

> The turbid/slightly turbid appearance is caused by the

disease condition of the patient which lead to vaginal

contamination. Vaginal contamination is a common

cause of turbid or cloudiness.

3. RBC: Urine Hemoglobin

> The presence of urine hemoglobin in the patient is

caused by the urinary tracts ulceration particularly in the

urinary meatus which were caused by genital warts.

4. Urine Albumin (Albuminuria)> The presence of urine albumin (albuminuria) in the patient’s urine is caused by several factors. Enumerated below are the factors contributing to patient’s albuminuria.

1. Acute infection (blood result of 23.0 [5-10x109/L

2. Trauma 3. Hypertension (180/100 mmHg)4. Dehydration5. Mixture of pus and urine Hgb/RBC due to

vaginal infection/UTI brought about by the genital warts

Nursing Responsibilities

Mode of collection used in the patient: collection from an indwelling catheter

Before

1. If client is conscious and coherent, explain procedure, if sedated, explain the procedure to the significant others.

2. Drain the urine standing inside the collection bag because long standing will undergo chemical changes thus interfering with results.

During

1. Aspirate urine from the catheter itself using a sterile syringe slanting the needle towards the drainage tubing.

2. Place specimen in a sterile urine collection cup.

After

1. Immediately send the specimen collected to the laboratory.

2. Avoid exposing the urine to air and avoid making the urine stand for a long period of time in the cup.

3. Follow-up the results of urinalysis.

4. Document findings/place lab results in the patient’s chart properly.

Aside from the initial diagnostic tests that were performed to the patient, follow-up blood examinations and urinalysis were ordered by the patient’s

attending physicians in the date of July 19, 2006. But due to the patient’s lack of financial capabilities and deficient knowledge about their importance, the

patient did not comply with the follow-up laboratory and diagnostic procedures and was made to sign a Home Against Medical Advise (HAMA) on the same

date. The patient also refused to undergo HBs Ag reaction test screening and Chest Xray and also signed the HAMA form for her refusal.

12-Lead Electrocardiogram

Diagnostic

Procedure

Date Ordered Indication/Purpose Results Normal Values Analysis and Interpretation

12-Lead

Electrocardiogram

- July 19, 2006

(Refused and

Signed HAMA)

>July 21, 2006

An ECG procedure was

ordered to be performed to

the patient because of the

episode of hypertension

and chest pains she

experience. Aside from this

it was indicated to evaluate

the effectiveness of the

medication given to

manage the above

mentioned discomforts.

Lastly, it was indicated to

determine the underlying

factor causing chest pains

and hypertension results.

 

> Cardiac Rate

100 bpm

>Normal QRS,

PR, QT.

>Cardiac Rate 60-

100

>Normal QRS, PR,

QT.

>Normal

Nursing Responsibilities:

Pre-procedure:

- Record client age, height, weight, and if she take cardiac medication.- Instruct patient to remove all metal materials/ other conductors such as jewelries, belt, coins, cellphones, metal dentures, and ask client if she did

not undergo heap replacement (other metallic implants, or if she have a cardiac pacemaker, for it may hinder the electrical flow of ECG.

- Place all valuables within clients supervision or in care of SO.- Explain the test that it helps to evaluate the Heart Status by recording its electrical activity.- Proper attach the electrical nodes/ electrodes in the patients skin- Connect the electrodes properly to the ECG machine.

During:

- Monitor and ensure proper attachments of electrodes to the patient skin.- Refrain form talking to the patient.

Post:

- Disconnect the equipment.- Remove tapes or conductive gels use on the client skin.- Place ECG strips to the patients chart properly and label accordingly.

Diagnostic

Procedure

Date Ordered Indication/Purpose Results Normal Values Analysis and Interpretation

Chest X-ray > July 19, 2006 The CXR was performed in

order for the physician to

determine if the patient has

cardiac enlargement and to

determine if she has

existing pulmonary disease

or disorders.

> Both lung

fields clear

> Heart and

great vessels

are within

normal

configuration.

> Other chest

structure not

remarkable.

> Both lung fields

clear

> Heart and great

vessels are within

normal

configuration.

> Other chest

structure not

remarkable.

> Normal Chest findings.

Nursing Responsibilities:

Pre-procedure:- Ask client to remove any radio opaque objects such as jewelries (necklace) in order to obtain a clear CXR result.- Position the patient properly to the x-ray board.- Ask client to inhale/breath deeply and hold breath while she is instructed to release breath.

During:- Ensure patient is properly position in front of the x-ray board.- If the image is taken, instruct patient to release his breath.

Post:-Follow up CXR result.

ANATOMY AND PHYSIOLOGY

The female reproductive organs consist of the ovaries, uterine tubes (or fallopian

tubes), uterus, vagina, external genitalia, and mammary glands. The internal reproductive

organs of the female are located within the pelvis, between the urinary bladder and the

rectum. The uterus and the vagina are at the midline, with an ovary to each side of the

uterus. The internal reproductive organs are held in place with the pelvis by a group of

ligaments. The most conspicuous is the broad ligament, which spreads out on both sides

of the uterus and to which the ovaries and uterine tubes attach.

Female External Structure

Mons Veneris- the mons veneris is a pad of adipose tissue located over the

symphysis pubis, the pubic bone joint. It is covered by a triangle of coarse, curly hairs.

The purpose of the mons veneris is to protect the junction of the pubic bone from trauma.

Labia Minora- just posterior to the mons veneris spreads two hairless folds of

connective tissue. The area is abundant with sebaceous glands, so localized sebaceous

cyst may occur here.

Labia Majora- the labia majora are two folds of adipose tissue covered by loose

connective tissue and epithelium, they are positioned lateral to the labia minora, serves as

protection for the external genitalia and the distal urethra and vagina.

Other external organs:

Vestibule- is the flattened, smooth surface inside the labia.

Clitoris- is a small (approximately 1 to 2 cm) rounded organ of erectile tissue at

the forward junction of the labia minora. Center of sexual arousal and orgasm in the

female.

Skene’s gland- located just lateral to the urinary meatus.

Bartholin’s gland- located just lateral to the vaginal opening on both sides,

secretions from both these glands help to lubricate the external genitalia during coitus.

Secretions from both these glands help to lubricate the external genitalia during coitus.

Fourchette- is the ridge of tissue formed by the posterior joining of the two labia

minora and the labia majora. This is the structure that is sometimes cut (episiotomy)

during childbirth to enlarge the vaginal opening.

Hymen- is a tough but elastic semicircle of tissue that covers the opening to the

vagina in childhood. It is often torn during the time of first sexual intercourse.

Female Internal Structure

Ovaries- the ovaries is approximately 4 cm long by 2 cm in diameter and

approximately 1.5 cm thick, or the size and shape of almonds. They are grayish-white

and appear pitted. The function of the two ovaries (the female gonads) is to produce,

mature and discharge ova (the egg cells). In the process, the ovaries produce estrogen

and progesterone and initiate and regulate menstrual cycles.

Fallopian Tubes- the fallopian tubes arise from each upper corner of the uterine

body and extend outward and backward until each opens at the distal end next to an

ovary. Their function is to convey the ovum from the ovaries to the uterus and to provide

a place for fertilization of the ovum by sperm.

Uterus- the uterus is a hollow, muscular, pear-shaped organ located in the lower

pelvis, posterior to the bladder and anterior to the rectum. It is approximately the size of

an olive. The function of the uterus is to receive the ovum from the fallopian tube;

provide a place for implantation and nourishment during the fetal growth, furnish

protection to a growing fetus; and at maturity of the fetus, expel it from the woman’s

body.

Cervix- a neck like part, especially the cervix uterine (neck of the uterus), which

projects into the vagina. The cervical canal passes through it, linking the cavity of the

uterus with the vagina. The canal normally contains mucus, the viscosity of its changes

through out the menstrual cycle. The cervix is capable of wide dilatation during child

birth.

Uterine and Cervical Coats- the uterine wall consists of three separate coats or

layers of tissue: an inner one of mucous membrane (the endometrium), a middle one of

muscle fibers (the myometrium), and an outer one of connective tissue (the perimetrium).

The endometrium layer of the uterus is important in terms of menstrual function

and childbearing. It is not a single structure but is rather formed by two layers of cells.

The layer closest to the uterine wall, or the basal layer, is not much influenced by both

estrogen and progesterone. This is the layer that grows and becomes so thick and

responsive each nth under the influence of estrogen and progesterone that it is capable of

supporting a pregnancy. If pregnancy does not occur, this is the layer that is shed as the

menstrual flow.

The mucous membrane lining of the cervix is termed the endocervix. The

endocervix, continuous with the endometrium, is also affected by hormones, but changes

are manifested in a more subtle way. The cells of the cervical lining secrete mucus to

provide a lubricated surface so spermatozoa can readily pass through the cervix; the

efficiency of this lubrication increases or wanes depending on hormone stimulation. At

the point in the menstrual cycle when estrogen productin is at its peack, as much as 700

ml of mucus per day is produced; at the point that estrogen is very low, only a few

milliliters are produced. Because mucus alkaline, it helps to decrease the acidity of the

upper vagina, aiding in sperm survival. During pregnancy, the endocervix becomes

plugged with mucus, forming a seal to keep out ascending infections.

The lower surface of the cervix and the lower third of the cervical canal are lined

not with mucous membrane but with stratifies squamous epithelium similar to that lining

the vagina. Locating the point at which this tissue changes from epithelium to mucous

membrane is important when obtaining a Papanicolaou smear (a test for cervical cancer)

because this tissue interfere is most often the origin of cervical cancer.

The myometrium, or muscle layer of the uterus, is composed of three interwoven

layers of smooth muscle, the fibers of which are arranged in longitudinal, transverse, and

oblique directions. This network offers extreme strength to the organ. The myometrium

serves the important function of constricting the tubal junctions and preventing

regurgitation of menstrual blood into the tubes. It also holds the internal cervical os

closed during pregnancy to prevent a preterm birth. When the uterus contractrs at the end

of pregnancy to expel the fetus, equal pressure is exerted at all points throughout the

cavity because of this unique arrangement of muscle fibers. After childbirth, this

interlacing network of fibers is able to constrict the blood vessels coursing through the

layers, thus limiting loss of blood in the woman. Myomas, or benign uterine tumors, arise

from the myometrium. The perimetrium, or outermost layer of the uterus, offers added

strength and support to the structure.

Vagina is a hollow musculmembranous canal located posterior to the bladder and

anterior to the rectum. It extends from the cervix of the uterus to the external vulva. Its

function is to act as the organ of intercourse and to convey sperm to the cervix so sperm

can meet with the ovum in the fallopian tube. Wtioh childbirth, it expands to serve as the

birth canal.

Cells in the body, such as skin cells, undergo cell division by mitosis, or daughter

cell division. In this type of division, all the chromosomes are duplicated in each new cell

just before cell division, giving every new cell the same number of chromosomes as the

original parent cell. Oocytes divide in intrauterine life by mitotic division. Division

activity then appears so halt until at least puberty, when a second type of cell division,

meiosis (cell reduction division), occurs. In the male, this reduction division occurs just

before the spermatozoa mature. In the female, it occurs just before ovulation. Following

this division, an ovum has 22 autosomes and an X sex chromosome; a spermatozoon has

22 autosomes and either X or a Y sex chromosome. A new individual formed from the

union of an ovum and an X-carrying spermatozoon will be female (an XX chromosome

pattern); an individual formed from the union of an ovum and a Y-carrying spermatozoon

will be male (an XY chromosome pattern)

Precipitating factors:-smoking-diet -multiple sexual partners or partner with multiple sexual partners.-early age of Sexual Intercourse-previous/recurrent STD’s-intake of oral contraceptives

Predisposing Factors:-immunosuppression-pregnancy-age 17-33

Sexual contact with infected person

Transfer of HPV

Innoculation in the Stratified Squamous epithelium.

Incubation period (6-8 months)

Latent Viral PhaseMonths to years

Production of viral DNA and capsids

Infections of Host Cells

Morphological Atypical Koilocytosis of Condyloma Acuminata

Legend:

- pathophysiology

- clinical manifestation

- complications

VDRL examination/ HPV exam

WBC, neutrophils, hyperthermia, (X) presence of discharge

IV. PATHOPHYSIOLOGY

Abnormal PAPsmear

Oropharynx

Extremities HPV-6

Trachea

Larynx

Vulvar area

Anus/ Perineal Area

Cervix

Vulvar Cancer

Anal Cancer

Cervical Cancer

Penis

Urethra / Bladder

Rectum

Pubic Area

Penile Cancer

Purulent Discharge

Polyuria

Anus/ Perineal Area

Oral Cancer

Males: Pruritus in the: Females: pruritus in the Uncommon Sites: Mucosal Lessions in the:

-activation of numerous large cells.

- in lesions

- difficult vaginal delivers

- easy bleeding

- easy bleeding

- spontaneous rupture of lesions after delivery

Transfer of Human Papilloma Virus to the child via Birth canal, During Pregnancy

Laryngeal Papillamotomasis

Breathing Passage Obstruction

Infant Death

In Pregnant Women with Condyloma Acuminata

V. PATIENT AND HIS CARE

1. Medical Management

a. IVFs, BT, NGT feeding, Nebulization, TPN, O2 Therapy, etc.

Medical Management

Treatment

Date Ordered Date(s)

Performed DateChanged/discontinue

General Description Indication(s) or Purposes(s) Client’s response to the treatment

Intravenous fluid:

D5LRS 1L x 31-

32 gtts/min

a. July 18, 2006

b. July 18, 2006

c. Discontinued July

23, 2006

- Lactated

Ringer Solution with

5 % dextrose is a

hypertonic

intravenous fluid

solution because it is

a combination of 2

solutions namely

D5W and LR

- - in the case of the patient,

D5LRS is indicated in order to

replace ECF volume deficit

which was caused by bleeding

during the intraoperative

phase and bleeding caused by

retained dead baby boy and

placenta in her uterus. It is

also indicated because of its

modest calorie content which

would be helpful in

decreasing/shortening the

course of the viral disease

(HPV) the patient has.

> the clients extracellular fluid volume was restored

as evidenced by normal skin turgor and normal vital

signs. The calorie content of D5LRS also assisted in

gradually regaining the client’s energy.

Nursing Responsibilities

Before

1. Assess for client’s level of dehydration, bleeding, and V/S

2. Explain to client the importance and indication of the treatment

3. In insertion of intravenous catheter, maintain aseptic/sterile technique

4. Secure the placement of the IV catheter by proper taping

5. Regulate IVF as ordered by the physician

During

1. Properly check the regulation and level of the IVFs and document findings

2. Monitor intake and output

3. Replace the IVF bottle if empty and change to the recently/latest prescribed IVF

4. Check patency of IV cath regularly

5. Watch for bulging on IV site

After

1. Apply firm gentle pressure on the insertion site after removing the IV catheter

2. Instruct patient to apply warm compress to site to relieve discomfort

Medical Management

Treatment

Date Ordered Date(s)

Performed DateChanged/discontinue

General Description Indication(s) or Purposes(s) Client’s response to the treatment

Oxygen Inhalation

@:

first, 2-3 L/min

second, 4 L/min

a. July 18, 2006

b. July 18, 2006

c. Disccontinued after

2 days.

- Delivery of oxygen via

nasal canula, facial mask,

venture mask and other

forms of O2 delivery

medium. This is ordered

by the physician in units

of Liter’s per minute.

The mode of delivery as

mentioned above are also

used based on the

physician order.

- O2 therapy is indicated for our

patient due to her postoperative

contion. O2 therapy is necessary

because of the temporary

respiratory depression caused by

anesthesia. The amount of O2

administered to the patient was

increased from 2-3L/min to

4L/min due to the slow

compensation of the patient’s

body which was a result of

decrease hemoglobin and

hematocrit count.

> After the increase in O2 administration (from

3L/min to 4L/min) the patient’s respiratory system

gradually compensated and was able to restore its

normal and optimal functioning.

Nursing responsibility

Before

1. Check for patient respiratory status, monitor V/S especially RR.

2. Prepare all materials needed; cannula, O2 tube and O2 tank

3. Place O2 away from plugs and other materials that could initiate fire

4. Connect tubings properly form the O2, to the humidifier, the tubing/nose and the cannula

5. Administer O2 as prescribed by the physician

During

1. Monitor V/S especially RR

2. Ensure that there are no kinks in the tubings

3. Monitor level of administration

4. Monitor for sign of a need for more O2

5. Keep or maintain an ample amount of water in the humidifier to avoid drying of nasopharyngeal mucosa

6. Monitor/assess for signs of improve respiratory status

7. Place O2 tank away from materials that could initiate fire.

8. Avoid creating sparks/fire near O2 tank because O2 is flammable

After

1. Monitor V/S especially RR

2. Assess for improvement of respiratory status

Medical Management

Treatment

Date Ordered Date(s)

Performed DateChanged/discontinue

General Description Indication(s) or Purposes(s) Client’s response to the treatment

Blood transfusion

(PRBC)- Pact Red

Blood Cell

a. July 18, 2006

a. July 21, 2006

b. July 22, 2006

c. Discontinued July

22, 2006.

- Transfusion of blood

units containing blood

contents particularly

RBC, One unit of PRBC

should increase

hematocrit by 3% and

hemoglobin by 1 g/dL.

- To replace the blood lost

during surgery and the blood loss

caused by retained placenta and

DBB in the patient’s uterus in

order to prevent hypovolemia,

shock or anemia and other

complications.

> Refused and signed a Home Against Medical

Advise (HAMA) form.

> Absence

Nursing Responsibilities

Before

1. Secure consent for BT.

2. Check for proper blood typing, cross matching and serial #.

3. Obtain baseline V/S data

4. Explain procedure to the client and its side effects

5. Double check blood product compatibility and cross matching

6. Prepare all materials needed

7. Administer pre BT meds such as Diphenhydramine or Antamin if prescribed

During

1. Monitor V/S frequently Q15 min/Q 30 min

2. Watch out for anaphylaxis reaction

3. Administer blood product as prescribed (gtts/min)

4. If anaphylaxis reaction occurs such as hypernatremia, immediately terminate transfusion and notify physician

After

1. Monitor V/S frequently

2. Assess for effectivity of treatment/management

Medical Management

Treatment

Date Ordered Date(s)

Performed DateChanged/discontinue

General Description Indication(s) or Purposes(s) Client’s response to the treatment

Foley

Catheterization

a. July 18, 2006

b. July 18, 2006

c. Discontinued July

20, 2006

- Indwellling

foley catheter is an

alternative way of

allowing urine to

flow from the

bladder to a

specimen/urine bag.

It has a long

hose/tubing with 2

ports. The first port

is for the attachment

of the urine tube and

urine bag, and the

other port is the site

for the injection of

sterile water in order

to secure and to

avoid dislodging the

catheter from the

urinary bladder.

- - Foley catheterization is

indicated for our client

because of the following

reasons:

- 1. Postoperative condition of

the client requiring a flat on

bed status as ordered by the

physician on the dates of July

18 to July 19, 2006.

- 2. To avoid contact of urine

to the sites of genital warts

excision in the vulvar and

vaginal area and the area of

urinary meatus, hence,

avoiding infection.

- 3. The spinal anesthesia used

during the surgery (CS &

BTL) caused suppression of

normal bladder function

resulting to urinary

> Catheter was always in place and connected to the

urinary bladder.

> the patient was able to adjust with mild discomfort

caused by the indwelling foley catheter.

> client was not resistant in the duration of the foley

catheter.

> no output abnormalities such as hematuria were

observed all throughout the duration of the indwelling

catheter.

> possible infections that urine may cause were

avoided.

incontinence.

Nursing Responsibilities

Before

1. Explain the procedure to the client and also explain the discomfort it may cause.

2. Place the client in a supine position with her knees flex and separated.

3. Wear sterile gloves before preparing the catheter.

4. Check the catheter balloon for appropriate filling, and then set aside on the sterile field.

5. Clean the labia and the meatal opening one side at a time using downward stroke.

6. Apply lubricant such as KY jelly on your hand and lubricate the foley catheter.

During

1. Ask patient to breathe deeply and insert the well lubricated catheter into the meatal opening.

2. When urine return (presence of backflows), insert another inch of the foley catheter.

3. Inflate the balloon with 5 to 10 cc of sterile water or saline solution using a sterile syringe.

4. Gently pull back to seal the catheter.

5. *** if accidentally inserted in the vagina never reused the catheter.

After

1. Assess the presence of blood in the urine.

2. Secure/reinforce the tapes to avoid dislodging the catheter.

3. Monitor intake and output.

4. Drain the urine bag as necessary or every shift.

5. Document all findings.

b. Pharmacotherapy

Name Action Contraindications Side effect Adverse reaction Nursing ResponsibilityGeneric Name:Tramadol

Brand Name:Tramal

Drug classCentrally acting analgesic

Binds to mu-opoid receptors

Inhibits reuptake of serotonin and norepinephrine in the CNS.

Contraindicated in: Hypersensitivity Cross-sensitivity

with opioids may occur

Patients who are acutely intoxicated with alcohol, sedative/hypnotics, centrally acting analgesics, opioid analgesics, or psychotropic agents

Pts. Who are physically dependent on opioid analgesic (may precipitate withdrawal)

Not recommended for use during pregnancy or lactation.

>CNS: Sedation, dizziness/vertigo, headache, confusion, dreaming, sweating, anxiety,

>CV: Hypotension, >Dermatologic:

Sweating, pruritus, rash, pallor, urticaria

>GI: Nausea, vomiting, dry mouth, constipation, flatulence

>Other: Potential for abuse,

Seizures, anaphylactoid reactions, tachycardia, bradycardia

Assess blood pressure and respiratory rate before and periodically during administration.

Assess type, location, and intensity of pain before and 2-3 hr (peak) after administration.

Assess bowel function routinely. Prevention of constipation should be instituted with increased intake of fluids and bulk and with laxatives to minimize constipating effects.

Tramadol is not recommended for pts. Who have previously received opioids for more than 1 wk; may cause opioid withdrawal symptoms.

Monitor patient for seizures. May occur within recommended dose range. Risk is increased with higher doses and in patients taking antidepressants, opioid analgesics, or other drugs that decrease the seizure threshold.

Overdose may cause respiratory depression and seizures.

May cause dizziness and drowsiness. Caution pt to avoid driving or other activites requiring alertness

Advise patient to change positions

slowly to minimize orthostatic hypotension.

Caution pt to avoid concurrent use of alcohol or other CNS depressants with his medication.

Name Action Contraindications Side effect Adverse reaction Nursing ResponsibilityGeneric Name:Cefuroxime

Brand Name:Zinacef

Drug classesAntibioticCephalosporin (second generation)

Antimicrobial drugs

Bind to bacterial cell wall membrane, causing cell death.

Allergy to cephalosporins or penicillins, renal failure, lactation, pregnancy

>CNS: Headache, dizziness, lethargy, paresthesias

>GI: Nausea, vomiting, diarrhea, anorexia, abdominal pain, flatulence,

>Local: Pain, at injection site, phlebitis, inflammation at IV site

>GI: pseudomembranous colitis, liver toxicity

>GU: Nephrotoxicity

>Hematologic: Bone marrow depression

>Hypersensitivity: Ranging from rash to fever to anaphylaxis, serum sickness reaction

>Hematologic: decreased WBC, decreased platelets, decreased Hct

>Other: Superinfections,

Assess patient for infection (vital signs; appearance of wound, sputum, urine, and stool; WBC) at beginning and during therapy.

Before initiating therapy, obtain a history to determine previous use of and reactions to penicillins or cephalosporins. Persons with a negative history of penicillin sensitivity may still have an allergic response.

Cefuroxime may also cause false-negative blood glucose results with ferricyanide tests. Use glucose enzymatic or hexokinase tests to determine blood glucose.

(IV) Change site every 48-72 hr to prevent phlebitis. Monitor site frequently for thrombophlebitis, pain, redness, swelling).

Administer slowly for 3-5 min. Advise pt to report signs of

superinfection (furry overgrowth on

disulfiram-like reaction with alcohol

the tongue, vaginal itching or discharge, loose or foul-smelling stools) allergy.

Instruct pt to notify health care professional if fever and diarrhea develop, especially if stool contains blood, pus or mucus. Advise pt not to treat diarrhea without consulting health professional.

Name Action Contraindications Side effect Adverse reaction Nursing ResponsibilityGeneric Name:Tranexamic Acid

Brand Name:Hemostan

Hemostatics/ Anti-hemophilia

Patient predisposed to thrombosis. Prophylaxis during pregnancy and before delivery.

>nausea, vomiting, diarrhea

>Ophtalmological problem

Monitor for Gastrointestinal disturbances (nausea, vomiting, diarrhea)

Advise patients who are to be treated continually for longer than several days, an ophthalmological examination, including visual acuity, color vision, eye-ground and visual fields, is advised, before commencing and at regular intervals during the course of treatment. Tranexamic acid should be discontinued if changes in examination results are found.

Name Action Contraindications Side effect Adverse reaction Nursing ResponsibilityGeneric Name:Ferrous Sulfate

Brand Name:Feosol, Fergan

> Iron Supplement

*Provides elemental iron, an essential component in the formation of hemoglobin.

>Contraindicated to patients receiving repeated blood transfusions.

> Use cautiously on long term basis.

>GI: epigastric pain vomiting, constipation, black stools, diarrhea,

>Others: temporary teeth staining if in liquid form

anorexia Fe Preparation should be administered with food to reduce gastric irritation through absorption may be impaired.

Antacid and tetracyclines may impair absorption of Fe.

Advice pt to take this medication with a full glass (8 oz or 240 ml) of water, unless your doctor directs you otherwise. Do not lie down for 30 minutes after taking this medication.

This medication may cause mild nausea or unpleasant taste. Consult your doctor if any of these effects persist or become severe.

Do not crush or chew this medication before swallowing. This timed-release product must be swallowed whole.

Name Action Contraindications Side effect Adverse reaction Nursing ResponsibilityGeneric Name:Nifedipine

Brand Name:Calcibloc

Drug classesCalcium channel-blockerAntianginal agentAntihypertensive

>Use cautiously to patients with heart failure or hypotension. Use extended release tablets cautiously in patients with GI narrowing.

>CNS: Dizziness, light-headedness, headache, asthenia, fatigue, nervousness, sleep disturbances, blurred vision>CV: hypotension

> angina, * Do not exceed a single dose of 30 mg.

*Before increasing the dose, carefully monitor BP.

* No rebound effect noted when nifedipine is discontinued. However if

*Thought to inhibit calcium ion influx across cardiac and smooth muscle cells, decreasing contractility and oxygen demand. Also may dilate coronary arterioles and arteries.

>Dermatologic: Flushing, rash, dermatitis, pruritus, urticaria

>GI: Nausea, diarrhea, constipation, cramps, flatulence, hepatic injury

>Other: Nasal congestion, cough, fever, chills, shortness of breath, muscle cramps, joint stiffness,

to were stopped decreased dosage gradually.

* During initial therapy and when dosage is increased, may experience an increase in frequency, duration, or severity of angina.

* Food may decrease the rate but not the extent of absorption; can be taken without regard to meal.

* Advise patient to report any symptoms of any persistent headache, flushing, palpitations, nausea, weight gain, dizziness, lightheadedness, or lack of response.

* Keep log of BP reports. Perform weekly weights and note any extremity swelling.

Name Action Contraindications Side effect Adverse reaction Nursing ResponsibilityGeneric Name:MethyldopaBrand Name:Aldomet, Novo-medopa, Dopamet

> Anti- Hypertensive

*Thought to inhibit the central vasomotor

>Use cautiously to breastfeeding women.

>CNS:dizziness, light headedness, headache,sedation, weakness>CV: bradycardia, palpitations, orthostatic

> angina>Musculo-skeletal: arthralgia > Hematologic: Thrombocyto-penia, hemolytic

> Monitor blood pressure regularly and note for hypotension.> Patients who need blood transfusions should undergo Coomb’s test to avoid problems in cross matching.

centers, thereby decreasing sympathetic outflow to the heart, kidneys, and peripheral vasculature.

hypotension, >EENT: nasal congestion>GI:nausea,vomiting, constipation, dry mouth

>Respiratory: dyspnea>Skin: rashes, pruritus

anemia, bone marrow depression

Name Action Contraindications Side effect Adverse reaction Nursing ResponsibilityGeneric Name:metronidazole

Brand Name:Flagyl,

Drug classesAntibioticAntibacterialAmebicideAntiprotozoal

*Bactericidal: inhibits DNA synthesis in specific (obligate) anaerobes, causing cell death; antiprotozoal-trichomonacidal, amebicidal:

Contraindicated with hypersensitivity to metronidazole; pregnancy (do not use for trichomoniasis in first trimester).

Use cautiously with CNS diseases, hepatic

>CNS: Headache, dizziness, ataxia, vertigo, incoordination, insomnia, seizures, peripheral neuropathy, fatigue

>GI: Unpleasant metallic taste, anorexia, nausea, vomiting, diarrhea, GI upset, cramps

>GU: Dysuria,

> Severe, disulfiram-like interaction with alcohol, candidiasis (superinfection)

Administer oral doses with

food.

Instruct the patient regarding the side effects: dry mouth with strange metallic taste (frequent mouth care, sucking sugarless candies may help); nausea, vomiting, diarrhea (small, frequent meals may help).

Instruct the patient that urine may appear dark; this is expected.

biochemical mechanism of action is not known.

disease, candidiasis (moniliasis), blood dyscrasias, lactation.

incontinence, darkening of the urine

>Local: redness, burning, dryness, and skin irritation (topical)

Name Action Contraindications Side effect Adverse reaction Nursing ResponsibilityGeneric Name:famotidine

Brand Name:Pepcid

Drug classHistamine 2 (H2) antagonist

* Competitively blocks the action of histamine at the histamine (H2) receptors of the parietal cells of the stomach; inhibits basal gastric acid secretion and chemically induced

Allergy to famotidine; renal failure; pregnancy; lactation.

>CNS: Headache, malaise, dizziness, somnolence, insomnia

>Dermatologic: Rash

>GI: Diarrhea, constipation, anorexia, abdominal pain

> increase in total bilirubin, sexual impotence

Instruct patient regarding the side effect of the drug: constipation or diarrhea; loss of libido or impotence (reversible); headache (adjust lights, temperature, noise levels).

Instruct patient to report sore throat, fever, unusual bruising or bleeding, severe headache, muscle or joint pain.

gastric acid secretion.

Name Action Contraindications Side effect Adverse reaction Nursing ResponsibilityGeneric Name:Ranitidine

Brand Name:Zantac

Drug classHistamine 2 (H2) antagonist

* Competitively blocks the action of histamine at the histamine (H2) receptors of the parietal cells of the stomach; inhibits basal gastric acid secretion and chemically induced gastric acid secretion.

Contraindicated with allergy to ranitidine, lactation.

Use cautiously with impaired renal or hepatic function.

>CNS: Headache, malaise, dizziness, somnolence, insomnia, vertigo

>Dermatologic: Rash, alopecia

>GI: Constipation, diarrhea, nausea, vomiting, abdominal pain,

>Local: Pain at IM site, local burning or itching at IV site

>Hematologic: Leukopenia, granulocytopenia, thrombocytopenia, pancytopenia

>CV: Tachycardia, bradycardia, PVCs (rapid IV administration)

Administer oral drug with meals and at bedtime.

Instruct patient regarding the side effect of the drug: constipation or diarrhea; loss of libido or impotence (reversible); headache (adjust lights, temperature, noise levels).

Instruct patient to report sore throat, fever, unusual bruising or bleeding, severe headache, muscle or joint pain.

Name Action Contraindications Side effect Adverse reaction Nursing ResponsibilityGeneric Name: analgesic/ >Contraindicated >CNS:dizziness, , >Hematologic: > Correct hypovolemia before giving

Ketorolac

Brand Name:Toradol

anti-inflammatory

*Thought to inhibit prostaglandin synthesis, to produce anti-inflammatory, analgesic, and antipyretic effect.

as prophylactic analgesic before major surgery or intraoperatively when hemostasis is critical.

headache,sedation, drowsiness>CV: edema, hypertension, palpitations, arrhythmias>GI:nausea,vomiting, constipation, flatulenceSkin: rashes, pruritus, diaphoresis

Decreased platelet adhesion, purpura, increased bleeding time

ketorolac

> NSAIDs may mask the signs and symptoms of infection because of their antipyretic and anti-inflammatory actions.

Name Action Contraindications Side effect Adverse reaction Nursing ResponsibilityGeneric Name:Paracetamol

Brand Name:Biogesic

Drug classesAntipyreticAnalgesic (non-narcotic)

*Antipyretic: reduces fever by acting directly on the hypothalamic heat-regulating center to cause vasodilation and sweating, which helps

Contraindicated with allergy to acetaminophen.

Use cautiously with impaired hepatic function, chronic alcoholism, pregnancy, lactation.

>CNS: Headache>Hematologic: Anemia>Skin: rash

>CV: Chest pain, dyspnea, myocardial damage when doses of 5–8 g/day are ingested daily for several weeks or when doses of 4 g/day are ingested for 1 year >GI: Hepatic toxicity and failure, jaundice>GU: Acute kidney failure,

> Monitor for temperature regularly

and report to physician if hyperthermia

does not subside.

dissipate heat Analgesic: site and mechanism of action unclear

renal tubular necrosis

Name Action Contraindications Side effect Adverse reaction Nursing ResponsibilityGeneric Name: Mefenamic

Acid

Brand Name:Ponstan SF

o nonsteroi dal anti-inflammatory drugs (NSAIDs)

o Mefenamic acid works by reducing hormones that cause inflammation and pain in the body.

o Have an allergy to NSAIDs.

o Have an ulcer or bleeding in the stomach.

o Drink more than 3 alcoholic beverages a day.

o Have liver and kidney disease.

o Have bleeding disorder.

o Have fluid retention.

o Have heart disease.

o Have high blood pressure.

> dizziness, headache, insomnia , dyspepsia, diarrhea, flatulence, nausea, abdominal pain

> upper respiratory tract infection, hyper-chloremia

o Instruct patient to take Mefenamic acid exactly as directed by the physician.

o Instruct patient to take each dose with one full glass of water.

o Instruct patient to take Mefenamic acid with food or milk to lessen stomach upset.

o Instruct patient not to take Mefenamic acid for longer than 1 week with consultation.

o Instruct patient to avoid prolonged exposure in the sunlight because Mefenamic acid increases the sensitivity of the skin to the sunlight.

Name Action Contraindications Side effect Adverse reaction Nursing ResponsibilityGeneric Name: Metoclopram

ide

Brand Name:Plasil

Drug classesGI stimulantAntiemeticDopaminergic blocking agent

*Stimulates motility of upper GI tract without stimulating gastric, biliary, or pancreatic secretions

Contraindicated with allergy to metoclopramide; GI hemorrhage, mechanical obstruction or perforation; pheochromocytoma (may cause hypertensive crisis); epilepsy.

Use cautiously with previously detected breast cancer (one third of such tumors are prolactin dependent); lactation.

CNS: Restlessness, drowsiness, fatigue, lassitude, insomnia, akathisia, dystonia, myoclonus, dizziness, anxiety

CV: Transient hypertension

GI: Nausea, diarrhea

extrapyramidal reactions, parkinsonism-like reactions,

Monitor BP carefully during IV administration.

Monitor for extrapyramidal reactions, and consult physician if they occur.

Monitor diabetic patients, arrange for alteration in insulin dose or timing if diabetic control is compromised by alterations in timing of food absorption.

Provide diphenhydramine injection on standby in case extrapyramidal reactions occur (50 mg IM).

Provide phentolamine on standby in case of hypertensive crisis (most likely to occur with undiagnosed pheochromocytoma).

Name Action Contraindications Side effect Adverse reaction Nursing Responsibility

Generic Name:Magnesium Sulfate

Brand Name:

Anti-convulsant

Parenteral administration contraindicated in patients with heart block or myocardial damage

Contraindicated in patients with toxemia of pregnancy during 2 hours preceding delivery.

> drowsiness, hypothermia, depressed reflexes, hypotension, flushing, diplopia, diaphoresis

> Bradycardia, circulatory collapse, flaccid paralysis, respiratory paralysis

Watch our for respirator depression and sign and symptoms of heart block

Keep IV calcium gluconate available to reverse magnesium intoxication

Check Magnesium level after repeated doses. Disappearance of knee-jerk and patellar reflexes is sign of impending magnesium toxicity.

Monitor fluid intake and output. Make sure urine output is 100 ml more in 4-hour period before each dose.

c. Diet

Type of Diet Date ordered

Date started

Date change

General Description Indication(s) or Purposes(s) Client’s response &/ or reaction to the activity/

exercise

Nothing per orem

(NPO)

July 18, 2006 - also known

as nothing by mouth

diet

- the

- the patient is on NPO diet

status because of her

preoperative condition (CSIII

& BTL) on the date of July 18,

The NPO status was tolerated by the patient and was

compliant to the diet status prescribed/ordered by the

physician. There were no complication such as

aspiration and digestive tract upset because of the

restriction of oral

intake of foods,

liquids, or drugs.

2006. This diet is appropriate

for the patient because of the

presence of peristalsis and

bowel movement. It is also

indicated for the patient in

order to avoid aspiration or

worse, atelectasis. The patient

is at risk for aspiration because

of the absence of her gag and

coughing reflex secondary to

anesthesia induction.

patient’s proper compliance.

Nursing Responsibilities

1. Instruct patient to avoid eating/drinking any food, liquid/beverages, or even meds by mouth prior to surgery and after surgery as ordered.

2. Explain the importance of NPO status and its relation to the patient’s current condition.

3. Enumerate to patient and SO the complications that may arise if NPO status is not followed strictly.

4. Constantly/repeatedly reinforce to the patient her NPO status.

5. Educate patient that she could wet her lips using wet cotton but avoid excessive amount.

6. Observe for restoration of GI function such as passage of flatus and presence of bowel sounds then document findings.

Type of Diet Date ordered

Date started

Date change

General Description Indication(s) or Purposes(s) Client’s response &/ or reaction to the activity/

exercise

General Liquid diet

to soft diet

July 19, 2006 - A diet wherein the

client is allowed to

eat/take liquids, or

soft foods such as

gelatins,

noodles/pasta, mash

potatoes, and other

well-cooked soft

foods.

- On the date of July 19, 200 the

patient was placed on general

liquids to soft diet because of

the presence of bowel

movement/ peristalsis, and

passage of flatus and

restoration of gag reflex. It is

indicated after NPO in order to

allow the patient’s digestive

system to compensate for its

function depression caused by

the spinal anesthesia used

during her surgery (CSIII &

BTL).

The ordered diet was observed by the patient. She was

able to tolerate soft foods and general liquids such as

gelatin, noodles/pasta, and other noncarbonated

beverages and her oral meds as well. There were no

untoward signs of GI upset.

Nursing Responsibilities

1. Assess for signs of restored GI function such as passage of flatus, and presence of bowel sounds. If positive, document findings and notify physician.

2. Inform patient of her general liquid to soft diet status and evaluate the possible foods she could eat such as water, juices, gelatin, and pasta/noodles and

her prescribed oral meds. Instruct her to eat only in ample/moderate amounts.

3. Reinforce patient to comply to her general liquid to soft diet status and educate her about the possible complications she might experience if she could

be noncompliant.

4. Assess for signs of GI upset such as epigastric pain/abdominal pain, etc.

5. Assess for bowel movement by asking the client about the frequency of defecation, then document.

Type of Diet Date ordered

Date started

Date change

General Description Indication(s) or Purposes(s) Client’s response &/ or reaction to the activity/

exercise

Diet as Tolerated July 21, 2006 - Diet as tolerated by

its name indicates that

the patient could

eat/take all oral meds,

and any type of food

without restrictions.

It is ordered when all

normal digestive

functions are restored.

- The patient is placed on a

DAT status because of the

restoration of all her normal

digestive functions as

evidenced by normal BM (12-

20 bowel movement/min),

consecutive/ regular passage of

flatus, complete recovery of

the patient’s gag reflexes.

The patient was placed on DAT status upon restoring

proper/normal GI function. The diet was well tolerated

by the patient, and her GI function remain normal and

stable all throughout.

Nursing Responsibilities

1. Inform patient she could eat/drink the food and beverages she desires.

2. Instruct patient to eat only as tolerated and gradually increase intake as preferred.

3. Assess for GI upset symptoms.

4. Instruct patient to report signs of GI discomforts.

5. Regularly ask patient about frequency of bowel movement.

6. Document findings.

c. Activity/Exercise

Type of Exercise Date ordered

Date started

Date change

General Description Indication(s) or Purposes(s) Client’s response &/ or reaction to the activity/

exercise

Flat on Bed

July 18, 2006

July 18, 2006

July 19, 2006

- A non ambulatory status

commonly ordered for

postoperative patients.

Most commonly those

induced with spinal

anesthesia. This status,

the patient is placed 180o

or bed with no pillows.

- The FOB status is indicated for

the patient because of her post

operative status. She was induced

with spinal anesthesia because of

the surgical procedures CS & BTL

and was placed on FOB status to

avoid spinal headache. This is also

indicated to avoid incision bleeding

and other injuries.

> The patient was compliant with the FOB status there

was no onset of spinal headache postoperatively due to

proper compliance.

Nursing Responsibilities

1. Maintain airway, breathing and circulation

2. Raise side rails or place pillows or both sides of bed to avoid falls and injuries (maintain safety)

3. Monitor patients V/S every 15 min until stable (related to post-op status)

4. Place patient flat on bed, 180o on bed with no pillow to elevate the patient’s head

5. Assess for return of consciousness

6. Assess for surgical site and incision dressings- reinforce or change as necessary

7. Instruct patient to maintain 180o position on bed until the doctors order change the status of exercise

8. Document significant findings and intervention performed

9. Notify physician for significant deviations

*** All nursing responsibilities and interventions enumerated are performed in relation to the post operative condition and post op exercise status of the patient

Type of Exercise Date ordered

Date started

Date change

General Description Indication(s) or Purposes(s) Client’s response &/ or reaction to the activity/

exercise

Complete Bed Rest

July 19, 2006

July 19, 2006

July 20, 2006

- CBR is a non

ambulatory status also

ordered for post op

patients, patients with

pregnancy disorder such

as placenta previa,

preterm bleeding or

uterine contractions. In

this status the patient

could assume semifowlers

position or elevate her

head with the use of a

pillow. If tolerated, the

patient could also assume

a high fowlers position.

- Indicated for the patient due to

her post-op condition but with the

absence of the effect of spinal

anesthesia. This is also indicated

to the patient in order to avoid

post-op complications specially

dehiscence and evisceration.

> Patient complied with BCR status.

> Absence display of dehiscence and evisceration

> Absence of spinal headache onset

> Absence of postoperative complications

Nursing Responsibilities

1. Monitor V/S

2. Instruct patient about the activities she could perform like elevation of head, assuring a semi-fowlers position, or high fowlers position as tolerated

3. Instruct patient to comply with ambulatory status and explain the complications that could occur if CBR is not observed

4. Check surgical site for signs of dehiscence or evisceration, purulent exudates or bleeding

5. Reinforce or change wound dressings as needed/necessary

6. Record significant findings and intervention preformed

7. Inform physician for abnormalities or S/Sx of infection or would dehiscence/evisceration

8. Administer post-op meds as prescribed

*** All nursing responsibilities and interventions enumerated are performed in relation to the post operative condition and post op exercise status of the patient

Type of Exercise Date ordered

Date started

Date change

General Description Indication(s) or Purposes(s) Client’s response &/ or reaction to the activity/

exercise

Ambulate as

tolerated

July 20, 2006

July 20, 2006

Until discharged

- Full privileged to

ambulate as tolerated by

the patient may be started

form bedside exercises to

walking 1 yard, then

gradual increase in

activity until normal ADL

performance is restored.

- Indicated for the patient because

of the restoration of all the patients

system functions and consistent

stable vital signs.

> Ambulatory status was tolerated well

> The health teachings/education given to the client

were observed

> Manifested stable V/S

> Absence of wound dehiscence and evisceration

> Absence of post-op complications

Nursing Responsibilities

1. Monitor V/S

2. Instruct patient about ambulate as tolerated status

3. Instruct patient to avoid standing immediately. Instruct to first sit down at the edge of bed before standing up to avoid orthostatic hypotension

4. Instruct patient to start ambulating by performing bedside exercises then increase gradually

5. Monitor surgical incision site

6. Verify physician about significant findings

7. Administer medication as prescribed

8. Record/document all findings and intervention performed

*** All nursing responsibilities and interventions enumerated are performed in relation to the post operative condition and post op exercise status of the patient

Assessment Nursing Diagnosis

Scientific Explanation

Planning Nursing Intervention

Rationale Expected Outcome

Subjective

ObjectiveThe patient may manifest:increased urine output,decreased skin turgor, dry skin and mucous membrane, decreased hgb, hct count, altered serum sodium, decreased BP, increased PR and temperature

Fluid Volume Deficit R/T excessive blood loss during surgical procedure as manifested by a decreased in hgb & hct count.

As a result of post operative procedure of a cesarean birth blood loss occur at approximately 600 to 800 ml of blood leading to changes in hgb and hct ct. and cause a decreased in intravascular or intracellular fluid thus fluid volume deficient occur.

After 40 of Nursing Intervention the patient will be able to maintain fluid volume at a functional level as evidenced by individually active urinary output, stable vital signs, moist mucous membranes, and good skin turgor.

1. Establish rapport

2. Monitor and record vital signs

3. Note for the causative factors that contribute to fluid volume deficit

4. Assess for factor that could precipitate blood loss such as bleeding on incision site and excessive lochia

5. Note patients preferences regarding fluids and foods with high fluid content

6. Provide TSB if patient has fever

- to gain patients trust and establish good patient-nurse relationship

- to note for the alterations in V/S (decreased BP, Increased in PR and temp)

-to assess what factor contributes to fluid volume deficit that may be given prompt intervention.

- to evaluate degree of fluid deficit

- food rich with high fluid content replaces or contributes for the correction of fluid loss

- to decreased temperature and provide comfort

After 40 of Nursing Intervention the patient has able to maintain fluid volume at a functional level as evidenced by increase in urine output, with normal vital signs, moist mucous membrane, good skin turgor and normal hgb & hct count.

7. Keep fluids within client’s reach and encourage increased fluid intake

8. Provide oral care by moistening lips & skin care by encouraging daily bath

9. Change dressings frequently

10. Provide safety measures and assist patient when moving especially if patient has decreased BP

11. Administer IV fluid replacement as ordered

12. Administer blood products as ordered

13. Administer antipyretic drugs if patient has fever as ordered

- replaces fluid loss and provides hydration

- to prevent injury from dryness

- to protect skin and monitor losses

- to prevent injury related to hypotension

-replaces fluid losses

- replaces blood loss

- to reduce body temperature

ACTUAL SOAPIE

S - “Hindi ako nagpa-BT kase wala pang pera”- as verbalized by the patient

O - Received on bed on supine position conscious and coherent, with intact

and unsoaked incision dressing, (-) breast engorgement, urine (1), (-)BM,

unsoaked vagial/perineal pads with moderate amount of lochia serosa, (-)Homan’s

sign, ambulatory, pale buccal mucosa and conjunctiva, hgb count (77), hct (0.33),

with initial vital signs taken as follows: BP- 120/80 mmHg, PR-83 bpm, RR-26

bpm, Temp.-36.4 oC.

A - Altered Tissue Perfusion r/t decrease hgb(77), hct(0.33) counts

P - After 2o of nursing intervention, the patient will verbalize understanding

of the condition, treatment/therapy regimen, and will demonstrate behavioral

changes to improve circulation.

I - Assessed for physical manifestations of anemia

- Assessed for factors that could precipitate to anemia such as bleeding on

incision site, excessive lochia and diet.

- Assessed diet/food preference

- Encouraged to increase intake of food rich in iron such as animal liver &

green & leafy vegetables when in DAT status

- Instructed to watch for sign of bleeding on incision site (soaked dressing)

and increase in lochia

- Instructed compliance to oral iron supplement intake

- administered due medication

E - Patient verbalized understanding of condition and therapeutic regimen and

demonstrated behavioral changes to improve circulation

S - “Eku migalo masakit kasi, maghilab ya ing tiyan ku dati, tatakut naku”- as

verbalized by the patient

O - Received on bed on supine position conscious and coherent, with intact

and unsoaked incision dressing, (-) breast engorgement, urine (1), (-)BM,

unsoaked vagial/perineal pads with moderate amount of lochia serosa, (-)Homan’s

sign, ambulatory, pale buccal mucosa and conjunctiva, hgb count (77), hct (0.33),

with initial vital signs taken as follows: BP- 160/90 mmHg, PR-90 bpm, RR-23

bpm, Temp.-36.4oC.

A - Impaired Physical Mobility r/t pain and discomfort secondary to episodes

of uterine contractions: preterm labor

P - After 2 hours of nursing intervention, the patient will display increase in

activity level and will verbalize understanding to maintain safety.

I - Monitored V/S

- Assessed for episodes of preterm uterine contraction

- Assessed for degree of discomfort that limits patient’s movements

- Assisted in performing ADL

- Instructed to increase food rich in calorie sch as fruits, vegetables, rice,

bread, etc. to regain energy

- Instructed patient to perform ADL as tolerated

- Instructed adherence to presented meds

- administered due meds

E - After 2 hours of nursing intervention, the patient was able to display

increase in activity level and will verbalize understanding to maintain safety.

2. Surgical Management

Caesarean section

A caesarean section (cesarean section AE), or c-section, is a form of childbirth in which a surgical incision is made through a mother's abdomen (laparotomy) and uterus (hysterotomy) to deliver one or more babies. It is usually performed when a vaginal delivery would lead to medical complications, although it is increasingly common for otherwise normal births as well.

Etymology

There are several elements which contribute to a linguistic explanation of the word caesarean.

The term may be simply derived from the Latin verb caedere (supine stem caesum), "to cut." The term caesarean section then would be a tautology.

The caesarean is possibly named after Roman military and political leader Julius Caesar who allegedly was so delivered. Historically, this is unlikely as his mother was alive after he reached adulthood (extremely implausible if such a procedure was performed with the technology of the day), but the legend is at least as old as the 2nd century AD.

Roman law prescribed that the procedure was to be performed at the end of a pregnancy on a dying woman in order to save the life of the baby. This was called the lex caesarea. Thus the Roman law may be the origin of the term.

Most likely the term is the product of a combination of these. The beginning of the story is certainly the verb caedo: the phrase a matre caesus ("cut out of his mother") was used in Roman times to describe the operation. The real etymology of the name Caesar (a much older family name) is completely unrelated, but a very early folk etymology invented the story of Julius Caesar's birth by section in order to suggest that his name is derived from this verb. The title of the Roman law must be influenced by this legend, since the form caesareus cannot be derived directly from caesus without some interference of Caesar. The form of the modern English word caesarean may come either from the law or from the name Caesar, but the modern German Kaiserschnitt (literally: "Emperor's section") obviously comes directly from the legend of Julius Caesar's birth.

Types

A caesarean section in progress. This is the view that the father can expect of their newborn child. The mother's view is similar but from a lower angle.

There are several types of caesarean sections (CS):

The classical caesarean section involves a midline longitudinal incision which allows a larger space to deliver the baby. However, it is rarely performed today as it more prone to complications.

The lower uterine segment section is the procedure most commonly used today; it involves a transverse cut just above the edge of the bladder and results in less blood loss and is easier to repair.

A crash caesarean section or emergency caesarean section is a CS performed in an obstetrical emergency and is usually initiated within 30 minutes after making the decision.

A caesarean hysterectomy consists of a caesarean section followed by the removal of the uterus. This may be done in cases of intractable bleeding or when the placenta cannot be separated from the uterus.

Traditionally other forms of CS have been used, such as extraperitoneal CS or Porro CS.

a repeat cesarean section is done when a patient had a previous section. Typically it is perfomed through the old scar.

In many hospitals, especially in the United States, United Kingdom, Australia and New Zealand the mother's partner is encouraged to attend the surgery to support the mother and share the experience. The anesthesiologist will usually lower the drape temporarily as the child is delivered so the parents can see their newborn.

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Indications

Obstetricians or other care providers recommend caesarean section when vaginal delivery might pose a risk to the mother or baby. Possible reasons for caesarean delivery include:

prolonged labor or a failure to progress (dystocia) apparent fetal distress apparent maternal distress complications (pre-eclampsia, active herpes) catastrophes such as cord prolapse or uterine rupture multiple births (though this is controversial) abnormal presentation, (breech or transverse positions) failed induction of labour failed instrumental delivery (by forceps or ventouse) the baby is too large (macrosomia) placental problems (placenta praevia, placental abruption or placenta

accreta) contracted pelvis previous caesarean section (though this is controversial – see discussion below)

prior problems with the healing of the perineum (from previous childbirth or Crohn's Disease)

Note, however, that different providers may disagree about when a caesarean is required. For example, one obstetrician may feel that a woman is too small to deliver her baby, another might well disagree. Similarly, some care providers may be much quicker to cite "failure to progress" than others. Disagreements like this help to explain why caesarean rates for some physicians and hospitals are much higher than are those for others. The medico-legal restrictions on VBAC, vaginal birth after caesarean, have also increased the caesarean rate.

For religious, personal or other reasons, a mother may refuse to undergo caesarean section. In the United Kingdom, the law states that a labouring woman has the absolute right to refuse any medical treatment including caesarean section "for any reason or none", even if that decision may cause her own death, or that of her baby. Other countries have different laws.

As scheduled caesarean sections have become a rather safe operation, there has been a movement to perform caesarean delivery on maternal request (CDMR). There is also a consumer-driven movement to support VBAC as an alternative for repeat caesareans in the face of increased medico-legal restrictions on vaginal birth.

Risks

Statistics from the 1990s suggest that less than one woman in 2,500 who has a caesarean section will die, compared to a rate of one in 10,000 for a vaginal delivery. [1] However the mortality rate for both continues to drop steadily. The UK National Health Service gives the risk of death for the mother as three times that of a vaginal birth. [2] However, it is not possible to directly compare the mortality rates of vaginal and caesarean deliveries as women having the surgery are often those who were at a higher risk anyway.

Babies born by caesarean sometimes have some initial trouble breathing. In addition, because the baby may be drowsy from the pain medication administered to the mother, and because the mother's mobility is reduced, breastfeeding may be difficult.

A caesarean section is a major operation, with all that it entails. Pain at the incision can be intense, and full recovery of mobility can take several weeks or more. A prior caesarean section increases the risk of uterine rupture during subsequent labour.

If a CS is performed under emergency situations, the risk of the surgery may be increased due to a number of factors. The patient's stomach may not be empty, increasing the anesthesia risk.[3] Obstetrical hemorrhage may lead to anemia or to a clotting disorder.

Anaesthesia

The mother usually receives regional anaesthesia (spinal or epidural), allowing her to remain awake for the delivery and avoiding sedation of the infant.

In current practice, general anaesthesia for caesarean section is becoming less common as scientific research has now clearly established the benefits of regional anaesthesia for both the mother and baby. General anaesthesia tends to be reserved for high-risk cases or emergencies. The risks of general anaesthesia for mother and baby are still extremely small overall.

Anaesthetic care is not limited to the operation itself. Anaesthetic teams in the United Kingdom and New Zealand are responsible for post-operative pain relief.

There seems to be a link between the use of anaesthesia during labour and birth, as a form of pain relief for women planning a vaginal birth, and caesareans. Recent medical research concluded that epidural anaesthesia did not lead to labour failure leading to a caesarean, but medical practice is to use labour induction drugs after anaesthesia is applied to counteract the obvious sedative effect that causes labours to slow down or often stop.

Vaginal births after caesarean

Vaginal birth after caesarean (VBAC) is not uncommon today. The medical practice until the late 1970s was "once a caesarean, always a caesarean" but a consumer-driven movement supporting VBAC changed the medical practice. Rates of VBAC in the 80s and early 90s soared, but more recently the rates of VBAC have dramatically dropped due to medico-legal restrictions.

In the past, caesarean sections used a vertical incision which cut the uterine muscle fibers. Modern caesareans typically involve a horizontal incision along the muscle fibers. The uterus then better maintains its integrity and can tolerate the strong contractions of future childbirth. Cosmetically the scar for modern caesareans is below the "bikini line."

Obstetricians and other caregivers differ on the relative merits of vaginal and caesarean birth following a caesarean birth. Some still recommend a caesarean routinely, others do not; still others respect the wishes of the expectant mother.

Twenty years of medical research on VBAC, support a woman's choice to have a vaginal birth after caesarean. Because the consequences of cesareans include a higher chance of re-hospitalization after birth, infertility, and uterine rupture in the next birth, preventing the first caesarean remains the priority. For women with one or more previous caesareans, as an alternative to major abdominal surgery, VBAC remains a safer option.[6]

Tubal Sterilization Overview

Tubal sterilization is surgery to block a woman’s fallopian tubes. Tubal sterilization is a permanent form of birth control. After this procedure, eggs cannot move from the ovary through the tubes (a woman has two fallopian tubes), and eventually to the uterus. Also, sperm cannot reach the egg in the fallopian tube after it is released by the ovary. Thus, pregnancy is prevented.

This procedure is also called tubal ligation or you are said to have your “tubes tied.” More formally, it is known as bilateral tubal ligation (BTL).

Currently, about 700,000 of these procedures are performed each year in the United States. Half are performed right after a woman gives birth. The rest are elective procedures performed as a one-day operation in an outpatient clinic. Eleven million US women aged 15-44 years rely on sterilization as a means of birth control to prevent pregnancy. More than 190 million couples worldwide use surgical sterilization as a safe and reliable method of permanent birth control.

Prior to the 1960s, female sterilization in the United States was generally performed only for medical problems or when a woman was considered “too old” to have children or at risk. The changing cultural climate in the 1960s resulted in safe, minimally invasive female sterilization procedures.

During the Procedure

While you are under anesthesia, one or two small incisions (cuts) are made in the abdomen (usually near the navel), and a device similar to a small telescope on a flexible tube (called a laparoscope) is inserted.

Using instruments that are inserted through the laparoscope, the tubes (fallopian tubes) are coagulated (burned), sealed shut with cautery, or a small clip is placed on the tube. The skin incision is then closed with a few stitches. You are usually feeling well enough to go home from the outpatient surgery center in a few hours. 

Your health care provider may prescribe pain medications to help you manage the pain, if any.   Most women return to normal activities, including work, in a few days, although you may be advised not to exercise for several days. You may resume sexual intercourse when you feel ready.

Tubal ligation can also be performed immediately after childbirth through a small incision near the navel or during a Cesarean delivery.

Currently, laparoscopy (bipolar laparoscopy, Falope ring, Filshie clip) is the most popular method of female sterilization in nonpregnant women. Periumbilical

minilaparotomy (Pomeroy, Parkland) is the most common procedure right after childbirth.

A new device acts much like tubal sterilization by blocking the fallopian tubes. The Food and Drug Administration has approved a small metallic implant (called the Essure System) that is placed into the fallopian tubes of women who wish to be permanently sterilized. Unlike other currently available tubal sterilization procedures for women, placement of the device does not require an incision or general anesthesia.

During the Essure procedure, your health care provider inserts an obstructive device into each of the 2 fallopian tubes at the time of hysteroscopy. This is done with a special catheter that is inserted through the vagina into the uterus and then into the fallopian tube. The device works by inducing scar tissue to form over the implant, blocking the fallopian tube and preventing fertilization of the egg by the sperm.

Risks

As with any surgery, there is always a risk when you are given general anesthesia. You may have a bad reaction to the medication used. Surgery itself may present problems with bleeding or infection.   There is still a chance you may become pregnant after tubal sterilization. About 1 in 200 women become pregnant who have their tubes tied. This may be caused by an incomplete closure of the tubes. If pregnancy occurs after the procedure, you are at increased risk for an ectopic pregnancy in which the pregnancy develops in the fallopian tubes. This is a dangerous situation. Because the procedure is performed by tiny instruments inserted into your abdomen, you may have injury to other organs in your body.

Results

Most women recover from the laparoscopic procedure with no problems. There are no tests required to confirm that you are now sterile (that is, unable to become pregnant) after a laparoscopic procedure. 

During the first 3 months after the Essure procedure, you must use another form of birth control. At the 3-month point, you must undergo a final x-ray procedure in which dye is placed in your uterus and an x-ray is taken to confirm that the device is in place. 

This procedure cannot be reversed.

Alternatives

If you feel you want a permanent solution to birth control, discuss your options with your health care provider. Many younger women who choose this procedure regret their decisions later. The younger the woman, the more likely she will regret choosing this permanent form of birth control. 

Your doctor will discuss your current number of children, your plans for your future and family, and will want to talk with your spouse. This is an important decision. Women with certain medical conditions may not be suited for this procedure.

Tubal sterilization is surgery. Many couples, in looking at their birth control options, especially when they are ready to stop having children, weigh the benefits and risks of whether the woman would undergo tubal sterilization or the man a vasectomy.  

Tubal ligation is not temporary. Do not think of it as a procedure to be reversed. When reversal is attempted, the operation becomes major surgery and is only successful about 50-80% of the time (meaning the woman is able to become pregnant after reversal).

Surgical removal of genital warts by excision

Surgery Overview

Visible genital warts on the penis or vagina or around the anus are removed by cutting them off with a surgical knife (scalpel). Warts on the cervix may be removed by laser or loop electrosurgical excision (LEEP).

The procedure is usually done in a health professional's office or clinic. You receive medication that numbs the area around the warts (local anesthetic). Stitches (sutures) usually close the incisions.

What To Expect After Surgery

Recovery time depends on the location and number of warts removed.

Most people will be able to return to normal activities within 1 to 3 days. Healing takes 2 to 4 weeks. Scarring may occur.

For men and women who have had genital warts removed, call your health professional for any of the following:

Bleeding that lasts longer than 1 week A fever Severe pain Bad-smelling or yellowish discharge, which may indicate an infection

Avoid sexual intercourse until the treated area heals and soreness is gone (usually 1 to 3 weeks, depending on the size of the area treated).

Why It Is Done

Surgery is used to removal warts that continually return. It also may be used when warts are widespread. A single treatment may be all that is needed.

How Well It Works

Surgery is effective in up to 72% of cases. Warts come back in 19% to 29% of people.1, 2

Risks

Risks of surgery are:

Bleeding. Infection. You may receive antibiotics at the time of the procedure to reduce the

risk of infection. Pain. You may need medication for several days after the procedure.

What To Think About

Treating genital warts does not cure a human papillomavirus (HPV) infection. The virus remains in the body in an inactive state after warts are removed. A person treated for genital warts may still be able to spread the infection. Condoms may help reduce the risk of HPV infection, but it is not known how much protection they provide.

The benefits and effectiveness of each type of treatment need to be compared with the side effects and cost. Discuss this with your health professional.

CLIENTS RESPONSE TO TREATMENT

CS & BTL

- The dead baby and the retained placenta were successfully evacuated via

transumbilical/lower abdominal midline incisions.

- Vaginal bleeding caused by the retained products of conception was stopped

- Bilateral fallopian tubes were ligated

- Complications that could be brought about the retained products of conception

such as hemorrhage, or worst shock were prevented

- Postoperatively, the client manifested fast recovery from the effects of the

anesthesia

- Physical mobility was impaired due to the pain caused by the surgical incision

- Tissue perfusion was impaired as a result of blood loss of the retained dead baby

boy and placenta and minimal blood loss during the surgical procedure

- Low count of hgb & hct were obtained form the blood sample postoperatively.

- Presence of manifestations of anemia such as pale conjunctiva, pale buccal

mucosa, and cold clammy peripheries.

GENITAL WARTS EXCISION BIOPSY

1. Genital warts in the vulvar, vaginal and perianal area were removed via vaginal

incision

2. Absence of bleeding on the excision sites

3. Absence of outward manifestations of would infections such as presence of

purulent exudates and hyperthermia

4. Therapeutic and palliative goals of excision biopsy were obtain

PROCEDURES FOR MONITORING AN IV SITE AND INFUSION

Nursing Actions

1. Monitor IV infusion at least once every hour. More frequent checks may be

necessary if medication is being infused.

a. Check physician’s order for IV solution

b. Check drip chamber and time drops

c. Check tubing for anything that might interfere with flow. Be sure that clamp is in

the open position. Observe dressings for leakage of IV solution

2. Inspect site for swelling, pain, coolness or pallor at site of insertion, which may

indicate infiltration of IV. This necessitates removing IV and restarting at

another site

3. Check for local or systemic manifestations that indicate and infection present at

the site

VIII. DISCHARGE PLANNING

1. General Condition of Client upon Discharge

Days prior to the patients discharge, she had stable and normal vital signs in the

continuity of consecutive shifts. There were no signs of would dehiscence and

evisceration, outward manifestation of infection such as purulent exudates, hyperthermia,

and inflammation. Her breasts are engorged, firm and globular uterus, regular/normal

urination and intake and output, and regular bowel movement. The patient also had

minimal to moderate production of lochia alba. No sign of dehydration were also

evident, the patient displayed good skin turgor. She is negative of signs of embolism, and

is on an ambulatory status.

The patient was incompliant to undergo the requested follow-up blood

examinations, urinalysis, chest examination and the procedures for several reasons.

Because of these there were no basis for evaluation of the treatment regimens for the

physician such as if the patient’s anemia and infection was treated.

On the other hand, the patient is very compliant/adherent in taking all her

prescribed medications and was placed on a “May Go Home” status by her attending

physician on the date of July 23, 2006.

2. METHOD

M - Mefenamic Acid 500 mg cap 3 x a day (8am-1pm-6pm)

- Ferrous Sulfate, cap OD (8am)

- Methyldopa 250 mg, tab 4 x a day (8am- 2 pm- 8am- 2am)

- Cefuroxime 500 mg cap 2 x a day (8am- 8pm)

E - Mefenamic acid

* There was a decrease in pain level on the incision site and excision site.

* Decrease in the mild inflammation

* Patient increased activity level as a result of decrease pain discomfort

- Ferrous Sulfate

* There was elimination of physical/outward manifestations of anemia

such as pale conjuctiva and buccal mucosa

* improve general well-being as a result of increased/improved RBC

content in the blood which resulted to proper perfusion and gas exchange.

- Methyldopa

* Blood pressure was restored to normal range

* Episodes of acute hypertension were managed

- Cefuroxime

* There were no outward manifestations of infections such as increase

temperature and purulent discharges from incision and excision sites

* The pain and mild redness on incision and excision sites subsided

T - Continue due meds

H - 1. Advised patient to increase fluid intake

2. Advised patient to eat foods rich in vitamin C such as oranges or

guavas.

3. Advised patient to rest

4. Advised patient to exercise

5. Maintain proper hygiene

6. Do perineal wash using “tawas”

O - Advised patient to come for follow-up check-up on July 31, 2006

(Monday)

D - Diet as Tolerated

IX. Conclusion

In our practice of nursing, we have been made aware that sexually transmitted

diseases cases continue to increase. On the other hand, not all of these diseases or

cases are reported to health care provider because of the common misconception that

they may be looked upon as immoral, and/or unclean. For this reason, numerous

cases of STD’s are left untreated, and worst, there is already a poor prognosis of the

ailment due to secondary complications that arise.

Conducting a case study about a sexually transmitted disease (condyloma

acuminata) is a very challenging task for us as student nurses. It was our first time to

deal with a sexually transmitted disorder. Unlike in our previous case studies which

dealt with pathological deranges wherein we have knowledge about, condyloma

acuminata, encouraged us to strive and exert extra effort in order for us to accomplish

this case study. Accomplishing this case study really helped us enhance the

resourcefulness, critical thinking, and knowledge that we possess especially in cases

where limited facts and information’s are available. It also enabled us to be tactful in

dealing with a patient with such disease because of the fact that they get easily

offended and they will not present all the essential information that we need. We

were able to develop and apply the principles of therapeutic communications during

our nurse-patient interaction and history taking, making it easier for us to

extract/obtain information from the patient without causing negative feelings. We

learned how to be efficient and consistent in prioritizing nursing interventions

through proper history taking and accurate physical assessment. We were also able to

improve our skills in building links and relationship between cause and effect

relationship between the information obtained in the physical assessment and the

disease condition in a highbrow and intellectual manner. Because of this, we were

able to establish strong factual relationship of the factors contributing to the disease,

the synthesis of the disease condition, and its effects on the laboratory and diagnostic

procedures.

Most importantly, with all the new knowledge we have acquired as we conducted

and accomplished or case study about condyloma acuminata, we were able to

ameliorate our nursing skills, hence, enabling us to be efficient and effective in

performing and delivering nursing care and interventions appropriate for the client

with condyloma acuminate and other related sexually transmitted disease. All the

nursing objective of this case study as enumerated in the introduction were met and

attained

X. Recommendations

We, as student nurses, should be proficient in performing our tasks and

responsibilities. We should never take for granted even the simplest tasks that we are

to perform when handling patients. Learning how to adjust in circumstances that are

unexpected should be learned by every nursing student. This could be developed by

reading books and being assertive in learning new things. Each clinical exposure and

lecture that we have should be considered a new learning experience because through

this, we would improve not only our academic and clinical competency but also our

values and attributes as well.

A broad continuum of skills and knowledge is needed in order to be flexible,

efficient and effective in performing nursing interventions and health teachings nor

only in patients with condyloma acuminate but also with patients having other

ailments as well. The knowledge of a nurse should not only be limited to what is

currently existing, but to what is important in the nursing practice. As nurses, we

should be concerned of the importance of preventive, curative, and rehabilitative

treatment approaches. More importantly, we should show more importance in

promoting preventive measures because, as factually known by the many,

“Prevention is better than cure”. We should also be able to learn the art of

consolidating the 3 H’s of nursing, the head, the hands, and the heart. If this art is

developed by all nursing students, nurses, and other medical-related professionals,

there will be a remarkable change in the medical field service.

VII. CLIENT'S DAILY PROGRESS

DAYS ADMISSION DAY 1 DAY 2 DAY 3 DAY 4 DISCHARGE  7/18/2006 7/19/2006 7/20/2006 7/21/2006 7/22/2006 7/23/2006Nursing Problems            1            2            3            4            5            6            Vital Signs            

PR 92 bpm 90 bpm 85bpm 73 bpm 84 bpm 83 bpmRR 24 bpm 23 bpm 20 bpm 23 bpm 22 bpm 21 bpm

BP 180/100 mmHg160/90 mmHg

160/90 mmHg

120/80 mmHg

120/80 mmHg 120/60 mmHg

Temp 36.0oC 36.4 oC 38.5oC 36.4 oC 36.0oC 36.3oCDiagnostic & Laboratory Procedure            

CBC * *   *    U/A * *        

HbSAg *          CXR *          ECG *          

Platelet ct. * *        Medical Management            

O2 Inhalation *          Folley Catheter *          

D5LRS * *        I&O *          CS *          BTL *          

BT-PRBC *     *    Excision biopsy *          

Drugs            MgSO4 * *        

Cefuroxime * * * * * *Metronidazole * * *      

DAYS ADMISSION DAY 1 DAY 2 DAY 3 DAY 4 DISCHARGE  7/18/2006 7/19/2006 7/20/2006 7/21/2006 7/22/2006 7/23/2006Drugs            

Ketorolac *          Famotidine * *        

Tranexamic Acid * *        Tramadol * *        

Paracetamol * * *      Ranitidine * *        

Metochlopramide *          Nifedipine * *        

Mefenamic Acid   * * * * *FeSO4     * * * *

Methyldopa     * * * *Diet            

NPO *          Gen Liquid to Soft diet   *        

Soft diet     *      DAT       * * *

Activity/Exercise            FOB *          CBR   *        

ambulatory     * * * *

XI. BIBLIOGRAPHY

1981. The American Heritage Desk Dictionary. Hughton Mifflin Company

1991. Essentials of Maternity Nursing. 3rd edition. Bobak & Jensen

1993. Nursing 93 Drug Handbook. C & E Publishing Co.

1994. Pathologic Basis of Disease. 5th edition. Cotran, Kumar & Robbins

1996. Handbook of Drugs for Nursing Practice. 2nd edition. Karb, Queener &

Freeman.

2002. Mosby’s Pocket Dictionary of Medicine, Nursing, and Allied Health Sciences.

4th edition. El Sevier (Singapore) PTE LTD, Mary A. Allen et. Al.

2003. Maternal and Child Health Nursing. 4th edition Vol 1 & 2. Lipincott, Williams

& Adele Pillitteri.

2004. Nurses Pocket Guide. 9th edition. F.A. Davis Company, Marlyn E Doenges et

al.

2005. Essentials of Anatomy and Physiology. 6th edition. McGrawhill Companies

INC., Rod R. Seeley et al.

2005. Medical-Surgical Nursing. 7th edition Vol 1 & 2. El Sevier (Singapore) PTE

LTD, Joyce M. Black et. Al.

2005. Bansal’s New Medical Dictionary. A.I.T.B.S Publisher & Distributors (Regd;

Dr. Shiramandau Bansal)

URL’s

http://www.niaid.nih.gov/factsheets/stdhpv.htm

http://www.medicalgeo.com/Med-Diseases-Ci---Cy/Condyloma.html

http://www.5mcc.com/Assets/SUMMARY/TP0222.html

http://www.indiana.edu/~health/hw/hpv.shtml

http://www.total-health-care.com/family-health/condyloma-acuminata.html

http://www.webmd.com/hw/std/tw3555.asp