Acknowledgement

This case study would not have been possible without the support of many people. Frist of all, I
would like to thank Purbanchal University (PU) for coming up with a great scheme (included in
the PBBN 1st year syllabus practicum) by letting us, the student, practice our already-acquired
professional nursing skill further in Child Health Nursing area. These clinical posting did and
will definitely help us gain abundant proficiency.

I would also like to express my thanks to the entire management committee of our college,
Kantipur Academy of Health Sciences, Tinkune, for letting us practice and enhance our nursing
skills further for one whole month at Kantipur Hospital.

At the same time, I extend my humble and respectful gratitude to our PBBN 1st year coordinator
and instructors, Mrs. Jharana Shah, Mrs. Ambika wagle, Mrs. Ishu Giri as their guidance and
suggestions throughout our clinical posting. I also would like to thank the hospital Matron and all
the working staffs of every unit, department, and ward including the hospitals administration and
its management committee for being such an excellent team during our clinical posting.

Distinctively, I would like to acknowledge with many thanks the entire working staffs of cabin,
who were very warm and cordial at all times. They also gave me the permission to use every
required article and equipment to complete my tasks.

Finally, last, but definitely not the least, I give my special gratitude to my patient and his family
members for being active participants and cooperating well all through the very end. I pray for
his better health in the near future.
 BACKGROUND
According to the requirement for the degree of post basic bachelor in nursing curriculum of
Purbanchal University under Medical Surgical nursing practicum we were taken to Kantipur
Hospital Pvt. Ltd. for our advance nursing practicum for 4 weeks. At this hospital, we were
exposed to different wards like Medical ward, Surgical ward, Emergency ward ICU, High care
unit, OT, Post-operative ward etc.

We got chance to provide care to different kinds of patient in each ward. We have to perform one
case study during this period therefore I have chosen a case of fibroid uterus. This case was
designed so as to gain comprehensive knowledge of fibroid uterus and its pre-op, surgical and
post-op management which aids to provide total care to the patient. It aims to enable the PBBN
student to get knowledge about condition and providing quality nursing care to the client by
applying knowledge of pathophysiology, basic science, nursing theories and nursing process. Its
management in hospital setting as well as in any situation.
 Objectives of the case study

General objective

 To gain comprehensive knowledge about disease condition and use appropriate nursing
measures to provide care to patient.

Specific objective

1. To identify Physical and psychological problems of the patient.

2. To provide care to the patient in critical conditions during hospitalization.
3. Formulate appropriate nursing treatment and care plan according to nursing theory and
prioritizing patients need.
4. Take history and record of finding and perform physical examination.
5. To provide holistic nursing care to the patient with physical and psychological problems
with application of nursing process.
6. To identify ethical problems which affect the nursing practice.
7. To use knowledge, skills and attitude while providing care to the client.
8. To demonstrate skill in counseling the patients and the families.
9. To conduct the case study.
Table of Contents
PATIENT PROFILE.................................................................................................................................1
PHYSICAL EXAMINATION..................................................................................................................5
DEVELOPMENTAL TASK.....................................................................................................................9
ANATOMY..............................................................................................................................................11
DISEASE PROFILE...............................................................................................................................13
Introduction...........................................................................................................................................14
Incidence..............................................................................................................................................14
Types.....................................................................................................................................................14
Causes...................................................................................................................................................15
Pathophysiology...................................................................................................................................16
Risk Factors.........................................................................................................................................17
Symptoms.............................................................................................................................................17
Diagnostic Investigation......................................................................................................................18
Complication........................................................................................................................................21
Management.........................................................................................................................................22
Medical Management..........................................................................................................................22
Surgical Management..........................................................................................................................23
Nursing Management..........................................................................................................................24
DRUG PROFILE....................................................................................................................................26
APPLICATION OF NURSING THEORY...........................................................................................45
NURSING CARE PLAN.........................................................................................................................49
DAILY PROGRESS NOTE....................................................................................................................54
DIVERSIONAL THREAPY...................................................................................................................56
DISCHARGE TEACHING AND HEALTH TEACHING...................................................................57
LEARNING FROM CASE STUDY.......................................................................................................59
CONCLUSION........................................................................................................................................61
References................................................................................................................................................62
 PATIENT PROFILE
BIO-DEMOGRAPHIC DATA
Name of the patient - Usha Shrestha

Age/sex - 39yrs

IP No. -933

Ward -Cabin

Bed No. -309

Marital Status -Married

Address -Naya bazar, Kathmandu

The Nationality - Nepali

Religion - Hindu

Education - Bachelor passed

Date of admission - 2076-11-12

Diagnosis -Fibroid Uterus

Consultant -Dr. Rosy Malla

Date of discharge - 2076-10-15

Language known -Nepali

Weight on Admission -68kg

Date of assessment -2076-11-12

Time of case study -2076-11-12 to 2076-11-15

Information obtained from:

 Patient

 Patient’s family members and visitors

 History taking

 Physical examination
1
  Patient’s chart and Laboratory investigations

CHIEF COMPLAIN
Pain in lower abdomen since 1 year. Case referred from Bharosha Hospital. She was in regular
check up with Dr. Rosy Malla.

HISTORY OF PRESENT ILLNESS

Pain in lower abdomen since 1 week.

HISTORY OF PREVIOUS ILLNESS

Hypertension since 7 month and under medication Tab. Telmisartan 40mg OD.

Severe dysmenorrhea and menorrhagia.

PERSONAL HISTORY
 Non-smoker

 Non-alcoholic

 Normal diet habit

 Normal bowel and bladder habit

HISTORY OF PAST ILLNESS

History of any drug allergy: No any history of drug allergy.

Previous hospitalization: No history of hospitalization

History of any operation: No any history of surgical procedure

History of any chronic illness e.g. (HTN, heart disease, asthma, diabetic, tuberculosis,
measles etc.): Hypertension

Personal Habit: No history of alcohol intake.

Dietary Habit:

 Number of meals taken in a day: 3

 Meal timing: Morning, evening and night.

2
  Food dislikes: Brinjal, Bitterguard
 Food allergies: No any food allergy

Elimination Habit: She had regular bowel & bladder habit.

Personal care Habit: She had good personal care habits.eg- brush & comb hair herself daily

Rest and sleep: 6-8 hours per day.

Recreational Habit: Watching television, listening to songs etc.

Environmental history: They have separate kitchen, used LP gas for cooking, no animal kept at
home.

Socio-economic history: Middle class family

Health seeking behavior: First visit to Hospital

GYANECOLOGICAL/ OBSTETRIC HISTORY

Gravida: 2

Para: 2

Abortion: 0

Still Birth: 0

Types of delivery: Normal

Contraceptive History: Depo-provera before 1 year and her husband did vasectomy

MENSTRUAL HISTORY
Age of menarche: 12years

Frequency and duration: irregular, 1-2 times in a month

FAMILY HISTORY
Type of Family: Nuclear

3
Total No. Of Family: 5

Patient’s mother had died due to pancreas cancer at the age of 55years. She is married and has 2
children.

FAMILY TREE

69 yrs 55yrs

39yrs
43yrs 41yrs 42yrs 30yrs

10yrs 5yrs

Index
Male

Female

Patient

Deceased
PHYSICAL EXAMINATION

4
I performed the physical examination of my patient on 2076-11-12 as systematically and using
the steps of physical examination like measurement, inspection, percussion, palpation and
auscultation method during head to toe examination. The findings are listed below:

1. Measurements:
 Height 5 feet 4 inch
 Weight 68kg
 Temperature 98℉
 Pulse 90 beats/min
 Respiration 22 breaths/min
 Blood pressure on lying position 150/90 mm of Hg
 Blood pressure on sitting position 140/90mm of Hg
 Oxygen saturation 95% in room atmosphere

2. General Appearance:
 Consciousness: Conscious
 Nutritional status: Good.
 Gait: Balanced
 Hygiene and grooming : Well groomed

3. Systemic data:

a) Integumentry:
 Color of skin : Slightly pinkish
 Texture: Smooth and soft
 Edema: Absent
 Cyanosis : Not present
 Turgor: Skin returns to previous status more than 2 seconds.
 Pigmentation : Not present
 Hair: Equally distributed over the scalp, thin black color.
 Nails: Normal shape, short, pinkish in color and no any cyanosis and clubbing
present

b) Head:
 Normal in size and shape
 No any masses, nodules or scar
 No depressed swelling or injury

c) Eyes:
 Eye brows: Equally distributed hair, asymmetrical, equal movement of eyebrows.
 Eyelid : Normal
 Bulbar conjunctiva: Transparent with white in color
 Colour of conjunctiva/sclera: Slightly pinkish, no discharge, no anemia

5
 Cornea: No opacity is present, smoothly rounded, No abrasions, transparent
cornea.
 Lens: Equal, light reflex is equal, clear, no opacities.
 Pupils: Reactive to light
 Discharge: No any discharge from eyes.
 Visual acuity; Normal

d) Ears:
 Location: B/L equally located, Top of the pinna meets with outer canthus of eye.
 Pinna: No lesion, lump, smooth rounded contour and B/L symmetrical.
 External Ear Canal: No redness, discharge, mass or foreign body
 Lymph nodes and mastoid area: Not palpable, no swelling and tenderness
 Hearing problem: No any detected

e) Nose:
 Location: Centrally located on face
 Nostril: Nostrils are uniform flaring while respiration, no nasal discharge.
 Nasal septum: Symmetrical nasal septum, no extra growth or polyps.
 Nasal canal: Pinkish mucosa, no extra growth
 Smelling: Good (Identified the smell of spirit swab).
 Sinuses: When pressure is applied with fingers and while palpating maxillary and
frontal sinuses no tenderness and no pain

f) Mouth and Throat:

 Lips: Brown, no cyanosis, no pallor smooth but slightly dry, symmetrical, no
cracks and injury.
 Teeth: White in color no dental caries and cavities
 Mucosa: Smooth and moist
 Gums: Tight margins at teeth, no ulcer or inflammation/gingivitis or swelling and
no bleeding.
 Tongue: Pink
 Palate: Soft palate-pink; hard palate-whiter in color

 Pharynx: Pink, smooth oropharynx

 Tonsil: Present, no swelling
 Oral hygiene: Maintained

g) Neck:
 Range of motion:
 Flexed : 45 degree, able to touch chin to sternum ( No stiffness)
 Extension: Full movement
 Thyroid Gland: No enlargement, not visible, no any swelling lump on the neck.
 Jugular vein: Not distended
 Lymph Nodes: No tenderness, palpable, any swelling

6
  Tracheal position: Mid- line

h) Chest (Thorax and Lungs)

 Size, shape and symmetry: Normal size and shape
 Location of sternum: Symmetrical, located in mid-sternum
 Respiration excursion: Symmetrical range of movement on inspiration and
expiration.
 Breast: Equal size of breast and nipples black in colour. No any mass and
tenderness found on palpation.
 Percussion of lung fields:
Resonant throughout lungs fields and dull sound heard on solid part.
 On Auscultation:
Breath sound: Normal breathe sound heard
 Axilla: No enlarged lymph-nodes or massed on right and left. Hair distribution
present. Skin intact. No lesion.

i) Heart:
 Heart sound: In Aortic, pulmonic, tricuspid and mitral region, normal lub dub
sound heard. No added sound heard.

j) Abdomen:

 Inspection:
Skin: Not tight or shiny, no discoloration, moles present, straie, lesion on the
abdomen, abdomen looked distended.
 Auscultation
Peristaltic sound: Gurgling sound heard at every 3-5 seconds.
 Palpation:
Tenderness in hypogastric region.

k) Genitals:
-According to patient, she do not have vaginal discharge, but sometimes it itches
in the genital area
- No burning sensation during micturition
 Rectum: No history of difficulty in defecation. No hemorrhoids in anus, stool
pattern is solid. No complain of itching and pain in anal region.

l) Extremities:
Upper Extremities/Arms
 Skin: Slightly dark, dry ecchymosed on the injected site.
 Nails: Hard, pink colored, no clubbing or thickening
 Symmetry: Symmetrical shape and size
 Range of motion: Bilaterally equal.

7
  Joints: No tenderness, no swelling
 Hands: No tenderness
 Temperature: Normal

Lower extremities/Legs:
 Skin: Slightly gray hair distribution present. No pallor and cyanosis.
 Temperature: Normal
 Nails: Hard, pink colored
 Range of motion: Bilaterally equal.
 Joints: No tenderness, no swelling
 Pulse: Dorsalispedis, posterior tibials and popliteal pulses are present

m) Back:

 Continuation and curvature of spine present, spine medially located.

 No scars and injuries.

Major Findings:

 Tenderness in hypogastric region

 Itching around the genital area

8
 DEVELOPMENTAL TASK
Erikson’s psychosocial stages of development focus on the resolution of different crises to
become a successful, complete person.

 Erik Erikson (1902–1994) was a stage theorist who took Freud’s

controversial psychosexual theory and modified it into an eight-stage psychosocial theory
of development.

 During each of Erikson’s eight development stages, two conflicting ideas must be resolved
successfully in order for a person to become a confident, contributing member of society.
Failure to master these tasks leads to feelings of inadequacy.

 Erikson’s eight stages of psychosocial development include trust vs.

mistrust, autonomy vs. shame/doubt, initiative vs. guilt, industry vs. inferiority, identity vs.
role confusion, intimacy vs. isolation, generativity vs. stagnation, and integrity vs. despair.

 Erikson also expanded upon Freud’s stages by discussing the cultural implications of
development; certain cultures may need to resolve the stages in different ways based upon
their cultural and survival needs.

According to Erik Erikson’s Theory my patient is a young adult and is concerned with intimacy
vs. isolation. After we have developed a sense of self in adolescence, we are ready to share our
life with others. However, if other stages have not been successfully resolved, young adults may
have trouble developing and maintaining successful relationships with others. Erikson said that
we must have a strong sense of self before we can develop successful intimate relationships.
Adults who do not develop a positive self-concept in adolescence may experience feelings of
loneliness and emotional isolation.

Young adult is age group between 21 to 39 years Developmental task is a growth responsibility
that arises at a certain time in the course of development, successful achievement of which leads
to satisfaction and success with later task. Failure leads to unhappiness, disapproved by society
and difficulty with later development tasks and functions.

9
 Comparison of developmental task:

Developmental task of Young Adult Developmental task in my patient

1. Accepting self and stabilizing self-concept and 1. Patient has positive attitude towards self and her
body image. body image but little anxious about the surgery.
2. Establishing independence from parenteral 2. Patient is able to establish independence from
home and financial aid. parenteral and financial aid as she owns her own
grocery store.
3. Becoming established in a vocation or 3. Patient is established as a shopkeeper and is
profession that provides personal satisfaction, economically supporting her family and
economic independence and feeling of making personally satisfied.
a worthwhile contributing to society.
4. Establishing an intimate bond with another, 4. Patient is able to express love and care to her
either through marriage or with a close friend. children and husband and has a good relationship.
5. Finding a congenital social and friendship 5. Patient has group of friends and has a good
group. friendship circle who visited during
6. Establishing and managing a home and hospitalization
managing a time schedule and life stresses. 6. She has managed her all personal, professional
life and as a parent given adequate time to her
7. Deciding whether or not to have a family and children.
carried out tasks of parenting.

7. She is able to decide the number of family

8. Formulating a meaningful philosophy of life member in her family and as a parent she is able
to give her children proper care and support.
and reassessing priorities and values.

9. Becoming involved as a citizen in the 8. She is well capable to prioritize the values and
community and beginning leadership norms.
responsibilities in the community

9. She is involved in the community as a citizen and

is also a member of a small co-operative business
organization in the community.

10
 ANATOMY

The uterus is a pear-shaped organ located in the female pelvis between the urinary
bladder anteriorly and the rectum posteriorly. The average dimensions are approximately 8 cm
long, 5 cm across, and 4 cm thick, with an average volume between 80 and 200 ml. The uterus is
divided into 3 main parts: the fundus, body, and cervix.

The uterus consists of the following 3 tissue layers:

 Perimetrium: This is an outer coat of peritoneum, which covers the fundus and the
anterior surface on the level of the internal os, and form small pouch. This pouch is termed
the utero-vesical pouch.
 Myometrium: This is a thick middle coat of smooth muscle fibers arranged in three layers.
The inner layer of fibers run in a circular fashion, the middle layer of fibers runs obliquely,

11
 the outer layer of fibers runs in a longitudinal fashion. During third stage of labour, the
myometrium acts as a “living ligature” by contracting its fibers.
 Endometrium: This is inner lining of the uterus and consists of columnar epithelium and
glands. It is a highly specialized active membrane. The endometrium is shed every month
during menstruation.

The uterus is supported by number of structures:

1) The surrounding organs
2) The muscles of the pelvic floor
3) Four pairs of ligaments derived from folds of peritoneum and connective tissue
which are: The broad ligaments, The round ligaments, The transverse cervical
ligaments and The uterosacral ligaments

Its functions are:

1) Menstruation: To be involved in menstrual cycle from puberty to menopause.
2) Canal for transmission of sperm to fallopian tube for fertilization.
3) Embedding of fertilized egg on endometrium to bear pregnancy and stoppage
of menstruation.
4) Uterine wall forms a sac for growing fetus inside uterus up to term.
5) Expel fetus from uterine cavity to exterior through cervical and vaginal canal.

12
 DISEASE PROFILE
Uterine Fibroids

13
Introduction
Uterine fibroids are benign (non-cancerous) growths that develop from the muscle tissue of the uterus
clinically apparent in a large part of reproductive age women. They are also called leiomyomas or
myomas. It is common in nullipara women. The prevalence in highest between 35 to 45 years. The
fibroid may affect the reproductive outcome adversely by enlargement and distortion of the uterus or
poor endometrial vascularity. The tumors usually grow very slowly, about 1-2 cm per year.

Incidence
 20% of women> 35 years
 Fibroids occur more often in nulliparous women or those women who have secondary infertility
problems.
 Higher incidence is seen in obese women or women with the history of long term use of oral
contraceptive pills.

Types
There are three common types of fibroids.

1. Interstitial or intramural fibroids (75%): In this type, fibroids grow

within the myometrium. (Muscle layer of the uterus)
2. Sub peritoneal or subserous fibroids (15%): These are Intramural
fibroids that are pushed outwards towards the peritoneal cavity. They are
partially or completely covered by the peritoneum. If the fibroid has a
pedicle, it is called pedunculated submucosa fibroid.
3. Submucous fibroid (5%): The intramural fibroid when pushed towards
the uterine cavity, and is lying underneath the endometrium, it is called
submucous fibroid. Submucous fibroid can make the uterine cavity
irregular and distorted.

14
Causes
According to book According to my patient

1.Hormones The cause is unknown in my patient.

2. Family history

3.Pregnancy

15
Pathophysiology

16
Risk Factors

 Nulliparous women
 Obesity
 Black women
 Multiparity
 Eating Habits (red meat)

Symptoms

According to book According to my patient

1. Asymptomatic- majority (75%) 1. symptomatic

2. Menstrual abnormality: Menorrhagia, 2. She complains of menorrhagia and

metrorrhagia metorrhagia since 2 years.

3.Dysmenorrhoea 3. She complains of severe abdominal during

each menstruation.

4.Infertility 4.Absent

5.Pressure Symptoms (difficulty urination, 5. Present

constipation)

6.Recurrent Pregnancy loss 6. Absent

(miscarriage ,preterm labour)

7.Lower abdominal or pelvic pain 7. Present

8.Abdominal enlargement 8. Absent

17
Diagnostic Investigation

In my book In my patient

History Taking Done

Physical examination Done

Hematological studies CBC, RBS,RFT,LFT, Serology(HIV,

HBsAg) ,Urine R/E, Blood Grouping

Ultrasound It reveals Fibroid Uterus (Multiple,

Intramural)

Hysteroscopy Not done

Hysterosalphingography Not done

Magnetic Resonance Imaging (MRI) Not done

Laparoscopy Not done

18
S.N Test Name Result Normal Range

CBC (Complete Blood Count)

1. Hb 13.3 11-14 (g/dl)

2. WBC/TLC 7,700 5000-15000 (cu mm)

3. RBC 4.6 4-5.1 (mill/cu mm)

4. Platelets 2,88,000 200000-450000 (cu

mm)

5. PCV 37.4 34-40 (%)

6. MCV 81 75-87 (fl)

7. MCH 28.7 24-30 ( pg)

8. MCHC 35.4 31-37 (gm/dl)

Differential Count

9. Neutrophils 76 30-80 (%)

10. Lymphocytes 21 50-90 (%)

11. Monocytes 3 0-10 (%)

12. Eosinophils 00 0-8 (%)

13. Basophils 00 0-1 (%)

14. Bands 00

Haematology

15. Blood “ B” Positive

Grouping
&rh typing

16. BT 3 (2.0-6.0)min

17. CT 9 (5.0-11.0)min

18. Prothrombin 13 (10-13)sec

Time: (T)

19
19. (C ) 13

20. INR 1 (ISI-1.0)

S.N Test Name Resu Normal Range

lt

Biochemistry Test

1. Blood glucose(F) 75.7 70-110(mg/dl)

Renal Function Test

2. Blood urea 19.2 10-50(mg/dl)

3. S. Creatinine 0.9 0.4-1.5(mg/dl)

4. Sodium (NA+) 142 135-145(mmol/l)

5. Potassium (K+) 4.0 3.5-5.5(mmol/l)

Liver Function Test

6. S.Billirubin(Total) 0.6 0.4-1.5(mg/dl)

7. S.Billirubin(Direct) 0.3 0.1-0.5(mg/dl)

8. Alk. Phosphatase 101.06 <271 (U/I)

9. SGOT(AST) 13.7 05-40 (U/I)

10. SGPT(ALT) 14.3 05-40(U/I)

Serology Test

11. HIV 1&2 Non-Reactive

12. HBsAg Non-Reactive

13. VDRL Non-Reactive

Urine Examination

20
14. Colour Light Yellow RBC: NIL

15. Transparency Clear WBC: 0-2/HPF

16. Reaction Acidic Epithelial cells:0-2/hpf

17. Albumin Nil

18. Sugar Nil

Complication

1. Degenerations
2. Hemorrhage
3. Infection
4. Necrosis
5. Polycythemia due to erythropoietic function by the tumor
6. Infertily is seen about 30% of the women
7. Recurrent pregnancy loss (miscarriage) or preterm labour.

21
Management

According to Book treatment of uterine fibroids may include medical or surgical intervention
and depends to a large extent on the size, symptoms and locations as well as women’s age and
her reproductive plans. Fibroids usually shrink and disappear during menopause, when estrogen
is no longer produced. Simple observation and follow up may be all the management that is
necessary. The patient with minor symptoms is closely monitored. If she plans to have children,
treatment is as conservative as possible. As a rule, large tumors that produce pressure symptoms
must be removed (myomectomy)

Medical Management
In my book

 Gonadotropin-releasing hormone (GnRH) agonists. Medications called GnRH agonists

treat fibroids by blocking the production of estrogen and progesterone, putting you into a
temporary menopause-like state. As a result, menstruation stops, fibroids shrink and
anemia often improves.

GnRH agonists include leuprolide (Lupron, Eligard, others), goserelin (Zoladex) and
triptorelin (Trelstar, Triptodur Kit).

Many women have significant hot flashes while using GnRH agonists. GnRH agonists
typically are used for no more than three to six months because symptoms return when the
medication is stopped and long-term use can cause loss of bo

 Progestin-releasing intrauterine device (IUD). A progestin-releasing IUD can relieve

heavy bleeding caused by fibroids. A progestin-releasing IUD provides symptom relief
only and doesn't shrink fibroids or make them disappear. It also prevents pregnancy.

 Tranexamic acid (Lysteda, Cyklokapron). This nonhormonal medication is taken to ease

heavy menstrual periods. It's taken only on heavy bleeding days.

 Other medications. Other medications for example, oral contraceptives can help control
menstrual bleeding, but don't reduce fibroid size.

22
 Nonsteroidal anti-inflammatory drugs (NSAIDs), which are not hormonal medications,
may be effective in relieving pain related to fibroids, but they don't reduce bleeding caused
by fibroids. Vitamins and iron can be taken in case of heavy menstrual bleeding and
anemia.

In my patient during hospitalization

 Inj. Pethidine 50mg I/M SOS

 Inj. Ketorolol 30mg IV TDS
 Inj. PCM 1gm IV SOS
 Inj Pantop 40mg IV BD
 Tab. Cefixime 200mg PO BD
 Tab Metron 400mg PO TDS
 Tab Telmisartan 40mg PO HS

Surgical Management
In my book

Surgical treatment may involve cutting off the blood supply to the fibroid with

1. Uterine artery embolization: In this procedure, tiny particles of polyvinyl

alcohol or gelatin are injected to the blood vessels that supply the fibroid via
femoral artery resulting in infraction and resulting shrinkage. It can be
performed as an outpatient procedure.
2. Magnetic resonance imaging-guided ultrasound surgery: Ultrasound
waves are used to destroy the fibroids. The waves are directed at the fibroids
through the skin with the help of magnetic resonance imaging.
3. Hysterectomy:

Large leiomyoma may require hysterectomy. Three types of hysterectomy can be

performed:

 Total hysterectomy: It is a removal of the uterus and cervix, and can be

performed either abdominally or vaginally.

23
  Total hysterectomy with bilateral salpingoophorectomy ( TAH-BSO):
It is the removal of the uterus, cervix, fallopian tubes and ovaries. It can be
performed abdominally or vaginally.
 Radical hysterectomy : It is same as a TAH-BSO plus removal of the
lymph nodes , upper third of the vagina and parametrium.
Usuallypeformed if a malignant tumor is found.

In my patient

The operative procedure done in my patient was Total Abdominal Hysterectomy with
Bilateral Salpingoophorectomy (TAH-BSO). Low transverse incision was made.

Nursing Management

 Pre-operative Nursing Management:

A. Assessment:

1. Assess vital sign.

2. Assess for pain discomfort, severity and location.

3. Assess for anxiety level of the patient.

4. Assess intake and output for sign of dehydration.

B. Nursing Diagnosis:

1. Acute Pain related to disease condition.

2. Anxiety related to surgery.

3. Fluid Volume deficit related to NPO.

C. Nursing Intervention:

1. Relieving Pain.

2. Reducing anxiety

24
3. Prevent fluid volume deficit.

 Post-Operative Nursing Management

 Assessment:
1.Assess for pain and bleeding at the surgery site.

2. Assess for associated symptoms fever, tachycardia.

3.Assess for nutritional status and dehydration.

4. Assess for bowel and bladder.

 Nursing Diagnosis:
1. Pain related to surgery.

2. Hyperthermia related to infection.

3. Anorexia related to hospitalization.

 Nursing Intervention
A. Relieving Pain

 Place Patient in semi-fowler’s position.

 Give prescribed analgesic as ordered.
 Give sedative and analgesic for pain, rest and sleep.
B. Prevent Infection

 Maintain personal hygiene.

 Dressing of wound, note colour and for soakage.
 Give antibiotic as ordered.
 Record vital signs.
C. Maintain nutritional status:

 Encourage fluid intake.

 Give food as desired gradually.
 If dehydration after surgery administer IV fluid.

25
 DRUG PROFILE

1.CEFOTAXIME

ANTIBIOTIC CLASS:

Third-Generation Cephalosporin

MECHANISM OF ACTION:

Cephalosporins exert bactericidal activity by interfering with bacterial cell wall synthesis and
inhibiting cross-linking of the peptidoglycan. The cephalosporins are also thought to play a role
in the activation of bacterial cell autolysins which may contribute to bacterial cell lysis.

PHARMACOKINECTS:

Dose of 1g Cmax: 102 mcg/L Half-life: 1.1 hours Volume of distribution: 14L

INDICATIONS:

Lower respiratory tract infections, genitourinary infections, sepsis, Intra-abdominal infections,

Joint and bone infections, CNS infections

ADVERSE EFFECTS:

Hypersensitivity: Maculopapular rash, Urticaria, Pruritis, Anaphylaxis/angioedema, eosinophilia

Hematologic: Hypoprothrombinemia, Neutropenia, Leukopenia, Thrombocytopenia GI:
Diarrhea, C. difficile disease Renal: Interstitial nephritis

DOSAGE:

IV: Powder for reconstitution: 500mg, 1g, 2g, 10g, 20g

Intravenous Solution: 1g/50mL, 2 g/50mL

26
Dosing in adults: Meningitis: 1-2 g IV/IM q8h Bone and/or joint infection: 1-2g IV/IM q8h
Gonococcal urethritis: 0.5g IM x 1 dose Lower respiratory tract infection: 1-2 g IV/IM q8h
Bacterial peritonitis: 1-2g q8-12h

Dosing in pediatrics: 100-150mg/kd/day divided q4-6h

CONTRAINDICATIONS/WARNINGS/PRECAUTIONS

Precautions: hypersensitivity to penicillin, history of gastrointestinal disease, particularly colitis,

renal impairment

DRUG INTERACTIONS: Live Typhoid Vaccine: decreased immunological response to

the typhoid vaccine

PREGNANCY FACTOR: B

2. PETHIDINE

Group: opioid analgesic

Injection: 50 mg (hydrochloride) in 1-ml ampoule
Tablet: 50 mg (hydrochloride)

GENERAL INFORMATION
Pethidine is a synthetic narcotic analgesic that competes for the same receptors as morphine in
the central nervous system. It is a dangerous drug of addiction. Its supply is controlled under
Schedule I of the Single Convention on Narcotic Drugs, 1961.

Pethidine is comparable to morphine in its sedative and tranquillizing effects, but the analgesia
and respiratory depression it produces are of shorter duration, and it induces less smooth muscle
spasm. Pethidine is preferred to morphine in the preoperative management of biliary colic and in
the management of acute diverticulitis.

INDICATION
 Preoperative management of musculoskeletal and visceral pain.

27
  Premedication prior to general anesthesia.
 An adjunct to inhalational and other anesthetic agents during major surgical
interventions.
 To prevent tachypnea induced by trichloroethylene.
 Postoperative and obstetric analgesia.
 In combination with diazepam, and in the absence of other agents, for reduction of
fractures and other minor interventions.

DOSAGE AND ADMINISTRATION

Premedication

Adults: 50-100 mg I.M or subcutaneously 1 hour before induction.

Children: 1 mg/kg I.M or subcutaneously 1 hour before induction.

CONTRAINDICATION
• Bronchial asthma, emphysema or heart failure secondary to chronic lung disease.
• Increased intracranial pressure, head injury or brain tumor.
• Severe hepatic impairment, adrenocortical insufficiency, hypothyroidism.
• Convulsive disorders, acute alcoholism, delirium tremens.
• Use of monoamine oxidase inhibitors within the previous 14 days.

PRECAUTION
Vital signs must be monitored regularly in the immediate postoperative period when pethidine
has been administered during anesthesia since respiratory depression may persist for several
hours.

Facilities for intermittent positive pressure ventilation must be immediately available.

To reduce risk of dependence, opioids should not normally be used for postoperative analgesia
for longer than 7 days.

28
USE IN PREGNANCY
Pethidine should be used during pregnancy only when the need outweighs any possible risk to
the fetus. Its use during labour may produce respiratory depression in the infant, who may
require administration of naloxone 10 micrograms/kg i.m. immediately after birth.

ADVERSE EFFECTS
Adverse effects include respiratory depression, nausea and vomiting, dizziness, drowsiness and
confusion, hypotension, bradycardia and palpitations.

Allergic phenomena are uncommon but anaphylactoid reactions have been reported.

Physical dependence may occur with prolonged administration.

DRUG INTERACTION
Pethidine potentiates the effects of other cerebral depressants. Its effect is counteracted by
naloxone within 2 minutes.

Sedatives should be withheld if a patient has been given pethidine since they may cause
restlessness or confusion.

OVERDOSE
Serious over dosage is characterized by respiratory depression, extreme somnolence progressing
to stupor or coma, and pin-point pupils. Cardiovascular collapse and cardiac arrest are terminal
events. Supportive therapy includes mechanically assisted ventilation and administration of
pressor drugs and fluids to maintain the circulating blood volume. Except in dependent
individuals, in whom specific opioid antagonists induce an intense acute withdrawal reaction,
naloxone (200 micrograms i.v) should be administered, as necessary, at 2-minute intervals.

29
Storage
Pethidine tablets and injection should be kept in tightly closed containers protected from light,
and should not be allowed to freeze.

The requirements relating to drugs controlled under Schedule 1 of the Single Convention on
Narcotic Drugs should be observed

3. KETOROLAC

Trade Name: Acular, Acular LS, Acular PF, Toradol, Acuvail, Sprix

CLASSIFICATION
Therapeutic: Non-steroidal antiinflammatory agents, nonopioid analgesics
Pharmacologic: Pyrroziline carboxylic acid
Pregnancy Category

MECHANISM OF ACTION
Inhibits miosis by inhibiting the biosynthesis of ocular prostaglandins; prostaglandins play role
in the miotic response produced during ocular surgery by constricting the iris sphincter
independently of cholinergic mechanisms.

INDICATION
 Pain and inflammation after cataract surgery
 Refractive surgery
 Seasonal allergic conjunctivitis
 Pain , short term
 Regional anesthesia

PREPARATION
Tablets: 10 mg

30
Injection: 15 mg/ml, 30 mg/ml

DOSE
Extraction of cataract (0.45% ophthalmic solution): 1 drop in affected eyes twice a day starting
1 day before surgery, continue on day of surgery, and for 2 weeks after surgery

Pain, short-term (intravenous; younger than 65 years of age) 30 mg IV as a single dose or 30

mg IV every 6 hours

Pain, short-term (intravenous; 65 years of age and older or weight less than 50 kg):15mg IV as
a single dose or 15 IV every 6 hours

Pain, short-term (intramuscular; younger than 65 years of age):60mg IM as a single dose or 30

mg IM every 6 hours

Pain, short-term (intramuscular; 65 years of age and older or weight less than 50 kg):30 mg IM
as a single dose or 15 mg IM every 6 hours

CONTRAINDICATION
 Bleeding risk, suspected or confirmed
 Cerebrovascular bleeding
 Gastrointestinal bleeding
 Hemorrhagic diathesis
 Hypersensitivity to aspirin or to other NSAIDs
 Peptic ulcer disease, active or history
 Renal impairment, advanced, or risk of renal failure due to volume depletion

PRECAUTION
 Cardiovascular disease, known or risk factors for; increased thrombotic risk, particularly
with increased duration of use

31
  Creatinine, moderately elevated; dosages adjustment recommended
 High dose; increased risk of serious or fatal adverse events
 Anemia has been reported; monitoring recommended
 Aspirin, triad, history of; increased risk of anaphylactic reactions
 Pregnancy, third-trimester, may cause premature closure of the ductus arteriosus

ADVERSE EFFECT
CNS: Drowsiness, abnormal thinking, dizziness, headache, euphoria
RESP: Asthma, dyspnea
CV: Edema, pallor, vasodilation
GI: GI bleeding, abnormal taste, diarrhea, dry mouth, nausea
GU: Oliguria, renal toxicity, urinary frequency
DERM: Exfoliated dermatitis, Stevens-Johnson syndrome, Toxic epidermal, sweating, urticaria,
purpura, pruritus
MISC: Allergic reactions including, anaphylaxis

PHARMACOKINETICS
Absorption: Rapidly and completely absorbed following all routes of administration.
Distribution: Enters breast milk in low concentrations
Metabolism and excretion: >50% metabolized by the liver. Ketorolac and its metabolites are
excreted primarily by the kidneys
Half-life: 4.5 hrs.

MONITORING
 Relief of moderate to moderately severe pain is indicative of efficacy
 Relief of ophthalmic inflammation, ocular pain, and temporary relief of ocular itching
may be indicative of efficacy
 Renal function in patients with renal impairment, heart failure, liver dysfunction
 Blood pressure at baseline and throughout the course of therapy
 Signs and symptoms of gastrointestinal bleeding

32
CLINICAL TEACHING
 Advice patient to avoid use in late pregnancy as drug may cause premature closure of
ductus arteriosus.
 Advise patient to report signs and symptoms of myocardial infraction or stroke,
especially with long term use.
 Instruct patient to report signs and symptoms of serious gastrointestinal events, such as
bleeding, ulceration or perforation.
 Patient should promptly report serious skin reactions such as blistering, peeling or
redness.
 Instruct patients using the ophthalmic formulation on proper instillation technique.
 Patient should not administer drug while wearing contact lenses.
 Patients should allow at least 5 minutes between instillation of the ophthalmic
formulation and other ophthalmic products.
 Advise patient to avoid use of additional NSAIDs or aspirin during therapy, unless
approved by doctors

4. PANTOP
Pantoprazole sodium
Trade Name: Protonix, Pantop
CLASSIFICATION
Therapeutic class: Antiulcer agents
Pharmacologic: Proton-pump inhibitors
Pregnancy Category B

MECHANISM OF ACTION
Suppresses gastric secretion by inhibiting hydrogen/potassium Atpase enzyme system in gastric
parietal cell; characterized as gastric acid pump inhibitor, since it blocks final step of acid
production.

33
INDICATION
 Gastro esophageal reflux disease (GERD)
 Severe erosive esophagitis
 Maintenance of long-term pathologic hypersecretory conditions including zollinger –
Ellison syndrome.

PREPARATION
Delay tabs 20, 40mg; powder for Inj; freeze-dried 40mg/vial

DOSE

GERD: PO 40mg daily x 8wks, may repeat course(adult)

Erosive esophagitis:
Adult: IV 40mg daily x 7-10day PO 40mg daily x 8wks; may repeat PO course.

Pathologic hypersecretory conditions:

Adult: IV 80mg QID; max 240mg/day

CONTRAINDICATION
Hypersensitivity

PRECAUTION
Pregnancy, lactation, children

ADVERSE EFFECTS
CNS: Headache, insomnia
GI: Diarrhea, abdominal pain flatulence
INTEG: Rash
META: Hyperglycemia

34
PHARMACOKINETICS
Peak 2-4hr, duration > 24hr, half-life 1.5hr, protein binding 97%, eliminated in urine as
metabolites and in feces, ingeriating elimination rate decreased.

INTERACTIONS:
 Increase: Pantoprazole serum levels- diazepam, phenytoin, flurazepam, triazolam,
clarithromycin
 Increase: bleeding- warfarin
 Decrease: absorption- sucralfate, calcium carbonate, vitB12

NURSING CONSIDERATIONS
A. Assess
 GI system: bowel sounds q8h, abdomen for pain swelling anorexia.
 Hepatic studies: AST, ALT, alk phos during treatment
B. Administer: PO route
 Swallow Del rel tabs whole, do not break, crush, or chew.
 Take Del rel tabs at same time of day.
 May take with or without food
IV route: Reconstitute with 10ml 0.9% NaCl, further dilute with 80ml RL, d5, 0.9% NaCl
(0.8mg/ml), giver over 15min (< 6mg/min) using in- line filter provided.
C. Evaluate
 Therapeutic response: absence of epigastric pain, swelling, fullness.

PATIENT/FAMILY TEACHING
 To report severe diarrhea, drug may have to be discontinued.
 That diabetic patient should know hypoglycemia may occur.
 To avoid hazardous activities, dizziness may occur.
 To avoid alcohol, salicylates, and ibuprofen; may cause GI irritation.
 To notify prescriber if pregnant or plan to become pregnant, do not breastfeed.

35
 5. TABLET PARACETAMOL
Paracetamol
Trade Name: Abenol, Aceta, Tapanol

CLASSIFICATION
Therapeutic: Antipyretics, non-opioid analgesics
Pregnancy Category B

MECHANISM OF ACTION
Inhibits the synthesis of prostaglandins that may serve as mediators of pain and fever, primarily
in the CNS. Has no significant anti-inflammatory properties or GI toxicity.

INDICATION
 Mild to moderate pain examples: headache, bodyache, toothache, backache, joint pain.
 Fever
 Dysmennorhoea
 After minor surgery

PREPARATION
Oral: 500 mg
Suspension: 100 mg/ml

DOSE
Adult: 250 mg-1g QID or SOS(Maximum 4 gm/day).
Child(less than 3 months): 10 mg/kg
Child(more than 3 months):10-15 mg/kg

ADVERSE EFFECT
GI: nausea, vomiting, epigastric distress

36
DERM: skin rashes, urticaria
UT: renal failure

CONTRAINDICATION
 Liver disease eg. Hepatitis

MONITORING
 Fever reduction is indicative of efficacy
 Pain relief is indicative of efficacy

NURSING CONSIDERATIONS
 Advise patient it is unsafe to take moer than 4 grams in a 24 hour period.
 Instruct patient to report signs and symptoms of gastrointestinal hemorrhage,
hepatotoxicity, or nephrotoxicity.
 Patient should take with a full glass of water.
 Patient should not drink alcohol while taking this drug.
 Advise patients who drink more than 3 alcoholic drinks a day to consult a healthcare
professional prior to taking this drug.

6. INJECTION ONDEM
Ondansetron

Trade Name: Zofran, zuplenz

CLASSIFICATION
Therapeutic: Antiemetics
Pharmacologic: 5-HT3 antagonists
Pregnancy Category B

MECHANISM OF ACTION

37
Blocks the effects of serotonin at 5-HT3 – receptor site (selective antagonist) located in vagal
nerve terminals and the chemoreceptor trigger zone in the CNS.

INDICATION
 Prevention of nausea, vomiting associated with cancer chemotherapy, radiotherapy
 Prevention of post-operative nausea, vomiting

PREPARATION
Injection 2 mg/ml, 32 mg/50ml
Tablets 4 mg, 8 mg

CONTRAINDICATION
 Hypersensitivity
 Phenylketonuric hypersensitivity

PRECAUTION
ADVERSE EFFECT
CN: Headache, dizziness, drowsiness, fatigue
GI: Diarrhea, constipation, abdominal pain, dry mouth
MISC: Rash, bronchospasm (rare), musculoskeletal pain, shivering, fever, urinary retension

PHARMACOKINETICS
IV: Mean elimination half-life 3.5-4.7 hr, plasma protein binding 70-76%, extensively
metabolized in the liver, excreted 45%-60% in urine.

INTERACTIONS
Drug-Drug: May be affected by drugs altering the activity of liver enzymes.

NURSING CONSIDERATIONS
Assess:

38
  Absence of nausea, vomiting during chemotherapy
 Hypersensitivity reaction: rash, bronchospasm

Perform/provide:
 Storage at room temperature for 48 hours after dilution

Evaluate:
 Therapeutic response: absence of nausea, vomiting during cancer chemotherapy

Teach patient/family
 To report diarrhea, constipation, rash, changes in respirations or discomfort at insertion
site
 Headache requiring analgesic is common.

7. PHENARGAN (PROMETHAZINE HYDROCHLORIDE)

Category: Anti-emetic, Anti-histamine & sedative- hypnotic

Mechanism of action:

A promethazine, that acts as an anti-emetic, anti-histamine, and sedative-hypnotic. As

anti-emetic, diminishes vestibular stimulation, depresses labyrinthine function, and act on the
chemoreceptor trigger zone (CTZ) by blocking dopamine receptors in the CTZ.. As a
sedative-hypnotic, produces CNS depression by decreasing stimulation to brain stem reticular
formation.

Indication and Dosage:

 Allergic symptoms
PO
Adults, Elderly: 6.25-12.5mg, three times a day plus 25 mg at bed time.
Children: 0.1mg/kg/dose (maximum: 12.5mg), 3 times a day plus 0.5 mg/kg/dose
(maximum: 25mg) at bed time.

39
 IM, IV
Adults, Elderly: 25mg. May repeat in 2hr.

 Motion sickness
PO
Adults, Elderly: 25mg 30-60 min before departure; may repeat in 8-12 hr, then every
morning on rising and before evening meal.
Children: 0.5 mg/kg 30-60min before departure; may repeat in 8-12 hr, then every
morning on rising and before evening meal.

 Prevention of nausea and vomiting

PO, IV, IM, Rectal
Adults, Elderly: 12.5-25mg q4-6h as needed.
Children: 0.25-1mg/kg q4-6h as needed.
 Pre-operative and post-operative sedation; adjunct to analgesics
IV, IM
Adults, Elderly: 25-50mg/dose
Children: 12.5-25mg/dose.

 Sedative
PO, IV, IM, Rectal
Adults, Elderly: 25-50mg/dose.
May repeat q4-6h as needed.
Children: 0.5-1mg/kg/dose q6h as needed. Maximum: 50mg/dose.

Contraindication:
 Angle-closure Glaucoma

 GI or GU obstruction

 Severe CNS depression or coma.

Side Effects:
40
  Expected: Somnolence, Disorientation; in elderly, hypotension, confusion, syncope.
 Frequent: Dry mouth, nose, or throat,; urine retention,; thickening of bronchial
secretions.
 Occasional: Epigastric distress, flushing, visual disturbances, hearing disturbances,
wheezing, paresthesia, diaphoresis, chills.
 Rare: Dizziness, urticaria, photosensitivity, nightmares.

Nursing Consideration:
1. Baseline assessment:
 Assess the patient for dehydration, including dry mucous membranes,
longitudinal furrows in the tongue, and poor skin turger, before and regularly
during therapy when promethazine is used as an antiemetic.

 Expect to discontinue the drug 4 days before antigen skin testing.

2. Precautions:
 Use promethazine cautiously in patients with asthma, history of seizures,
cardiovascular disease, hepatic impairment, peptic ulcer disease, sleep apnea,
possible Reye’s syndrome, BPH, pregnancy & lactation.

3. Intervention and evaluation:

 Give promethazine without regard to food.
 Assess the blood pressure and pulse rate if the patients receives the parenteral
form of promethazine.
 Avoid giving subcutaneously or give deep I/M because significant tissue
necrosis may occur.
 Assist the patient with ambulation if he or she experiences drowsiness or light-
headedness.

4. Patient Teaching:

41
  Inform the patient that drowsiness and dry mouth are expected side effects of
drug. Tell the patient that drinking coffee or tea may help reduce drowsiness
and sipping tepid water and chewing sugarless gum may relieve dry mouth.
 Warn the patient to avoid performing tasks that require mental alertness or
motor skills until his or her response to the drug has been established.
 Instruct the patient to notify the physician if he or she experience visual
disturbance.
 Urge the patient to avoid alcohol and other CNS depressants during
promethazine therapy.
 Extra pyramidal reaction may appear early in drug therapy so should be
observed the symptoms carefully and inform to doctor.

8. METRONIDAZOLE

Category: - 5-nitromidazole / antiprotozoal- antibacterial

It is the prototype nitromidazole which is highly active amoebicide. It has

bread spectrum activity against protozoa including Giardia lamblia. It is effective
against a wide range of organisms including E. histolytica, T. vaginalis, Giardia,
anaerobes.

Mechanism of Action:-

Not known, but nitrogroup is reduced to intermediate compounds which cause

cytotoxicity, probably by damaging DNA.

Indications:-

42
 Amoebiasis, Giardiasis, Trichomonas vaginitis, anaerobic infections,
Ulcerative gingivitis, Pseudo-membtanous enterocolitis, Gastritis / Peptic
ulcer, Guinea worm infestation. Prophylaxis against post-operative infections.

Dosages and Routes:-

 Oral :
Adult :

 Amoebiasis : 400-800 mg orally after food 3 times a day for 5-10 days.
 Giardiasis : 200 mg orally 3 times a day for 5-7 days.
 Trichomoniasis : 250 mg TID for 7 days. Treat sexual partner at same
time.
Child :

 Amoebiasis : 35-50 mg/kg/day orally in 3 divided dose.

 Giardiasis : 15 mg/kg/day in 3 divided doses for 5-7 days.

 I/V :
 Anaerobic infections : Adults – 15 mg/kg infused over 1 hour followed
by 7.5 mg/kg infused over 1 hour every 6 hours. Maximum daily dose
is 4 gm.
 Prophylaxis against post-operative infections : 15 mg/kg infused over
30-60 minutes, 1 our before surgery. 7.5 mg/kg infused over 30-60
minutes 6 and 12 hours after initial dose.

Contraindications :-

 Pregnancy

43
  Lactation
 CNS disorders
 Hepatic failure
 Blood dyscrasias
 Hypersensitivity
 Serious neurological diseases
 Seizures
 Alcoholism

Side Effects:-

 Nausea, vomiting, diarrhea, metallic taste, abdominal pain, headache,

dizziness, vertigo, ataxia, urticaria, pruritus, flushing, seizure, peripheral
neuropathies, candida, furred tongue, glossitis, dark urine, reduced serum level
of cholesterol and triglycerides.

Nursing consideration:-

 Give after meals, on a full stomach. If a single daily dose is used, give at bed
time so the worst side effects happen while the patient is sleeping.
 Encourage patient to finish full course of medicine even though side effects
may be unpleasant.
 The drug may change the urine color into reddish brown so inform patient
about this.
 I/V form should be administer by slow infusion, don’t give by I/V push.
 Inform patient that drug may cause metallic taste.

44
 APPLICATION OF NURSING THEORY

Theory is a set of definition, concepts that projects a systematic view of phenomena. The
purpose of the theory is to describe, predict, and explain the phenomena by designating
specific inter relationship among concepts. It helps in teaching practice by providing
guideline, rationales and goals of the practice.

The nursing theory that was adopted while providing nursing care to my patient Mrs. Usha
Shrestha 39 years female, diagnosed as Fibroid uterus in cabin of Kantipur hospital is as
following:

Orem’s Self Care Theory

Orem’s Nursing Theory as self-care published in 1971 with nursing concepts of practice.
Application of nursing theory starts from assessment and continue throughout planning,
implementation, evaluation and reassessment/replan.
According to Orem, "nursing is the provision and management of self care action on a
continuous basis in order to sustain life and health, recover from disease or injury, and cope
with their effect. She also states that "nursing is a way of overcoming human limitations and
it is a service to people, not a derivative of medicine.'' Orem's theory consists of following
three related theories collectively referred to as "Orem's General Theory of Nursing":
1. Theory of self care
2. Theory of Self care deficit
3. Theory of nursing system

1. Theory of Self care:

Self care is defined as those health generating activities that are undertaken by the persons
themselves.

45
A self-care activity comprises observance of simple rules of behaviors relating to diet, sleep,
exercise, alcohol, smoking and drugs. Other includes attention to personal hygiene, cultivation
of healthful habits and lifestyle, maintenance of balance between solitude and social
interaction, submitting oneself to selective medical examinations and screening, accepting and
carrying out the specific disease preventive measures.
According to Orem's theory self care is the practice of activities that individuals personally
initiate and perform on their own behalf to maintain life, health and wellbeing. It is related to
man, environment, culture and values of daily living.

In my patient I encouraged my patient for self care during admission and pre operative
period because she was able to perform most of her daily activities herself. I advised her to
participate actively in performing her daily and routine activities like cleaning, brushing
teeth, wearing clothes, eating etc. I also encouraged her to maintain proper body mechanics
and to have adequate diet & rest.

2. Theory of Self care deficit:

The self-care deficit is the care of Orem's general theory of nursing because it delineates when
nursing is needed. Nursing is required when an individual is incapable or limited in the
provision of continuous effective self-care. Nursing may be provided if the care abilities are
less than those required for meeting a known self- care demand. Three categories of health
care requisite are universal self care, developmental self care and health deviation self care.
Health deviation self care is required in condition of illness, injury or disease; or may result
from medical measures required for the diagnosis and correction of the condition. I focused on
this aspect because patient was suffering from abdominal pain and has undergone
cholecystectomy surgery.
In my Patient
In the 1st post-operative day my patient was unable to perform her activities by herself so I
assisted her in morning care, mobilization and also changing positions frequently. I also
assisted her in deep breathing and coughing exercise.

46
3. Theory of nursing System:
Nursing system is a continuing series of actions produced when nurses link one way or a
number of ways of helping to their own actions or the actions of persons under care that are
directed to met person’s therapeutic self-care demands or to regulate their self-care agency. It
is designed by the nurse, is based on the self care needed and abilities of the patient to perform
self care activities.
Orem has identified following three classifications of nursing systems to meet the self care
requisites of the patient:
 Wholly compensatory system: The system accomplishes the client's therapeutic self care,
compensates for the clients inability to participate in their self care, provides support and
protects the client. In this system nurse becomes active and patient is totally inactive.
Nurse must ensure that all of his/her needs are met including elimination, oxygenation,
nutrition, hygiene etc.

 Partially compensatory system: In this system, patient and nurse both are active. Patient
can perform number of his task but requires other’s assistance. Patient accepts care and
assistance from nurse, regulates self care agency and perform self care measures.

 Supportive educative system: The system that requires assistance in decision making,
behavior control and acquisition of knowledge and skills. Under this system, patients are
able to perform self care with assistance.

In my patient

I applied wholly compensatory nursing system during few hours after surgery on OT day
by administering oxygen and intravenous fluids because she was totally inactive to fulfill
her needs because of effects of general anesthesia.

After recovering from anesthesia, I applied partially compensatory system until the period
of hospitalization because she can perform number of activities with other’s support and

47
 accept care and assistance from nurse. For this, I kept the patient in comfortable position,
assisted in ambulation, assisted to maintain personal hygiene, encouraged for deep
breathing and coughing exercise, monitored vital signs to find out any changes, provided
psychological support and prescribed medicines to relieve pain,encouraged patient for self
care and suggested the patient party to help the patient in performing self care activities.

I applied supportive educative system also during hospitalization and especially during
discharge because she had knowledge deficit and requires assistance in acquisition of
knowledge & skill, decision making and behavior control. So,I advised her to have
proteinious diet for fast wound healing and avoid heavy lifting for 2 weeks. I taught about
importance of personal hygiene, care of wound, use of medication and follow up visit.

In this way, I applied Orem’s Self Care Theory while providing care to my patient Mrs.
Usha Shrestha.

Nursing Diagnosis

 Pre-operative
1) Anxiety related to the surgical procedure.
2) Knowledge deficit related to treatment regimen and surgery.
 Post-operative
1) Alteration in body temperature related to disease condition.
2) Pain related to surgical incision evidenced by verbalization and grimace.
3) Nutritional imbalance less than body requirement due to anorexia.
4) Risk of infection related to open surgical wound.

48
 NURSING CARE PLAN

S.N Assessment Diagnosis Goal Planning Implementation Rational Evaluation

1. Subjective Alteration Patient’s -Assess the -Patient’s -Helps to My set goal

data: “I am in body temperature condition of condition know the was met
feeling cold temperatur will be the patient. assessed. degree of completely
and am e related to reduced fever as fever
shivering.” disease within 1-2 -Open doors - Proper maintained
condition. hours. & windows ventilation Temperature at
to maintain maintained reduced by temperature
proper convection 98F.
Objective ventilation.
data:
Patient’s - Give cold - Cold
temperature sponge compression - Body
was 100F. compression. given. temperature
- Encourage reduced by
-Encouraged to conduction
to take take plenty of
plenty of Fluid prevent
fluids. the patient
fluids.
from
-Give dehydration.
antipyretic - Antipyretic
drug as drug given. - Given PCM
ordered Inj works in
PCM 1gm hypothalamu
IV s help to
reduce fever.

49
S.N Assessment Diagnosis Goal Planning Implementation Rational Evaluation

50
2. Subjective Knowledge Patient will be 1.Assess the 1.Assessed the 1.To provide Goal was
data: Patient deficit able to level of level of information met as the
said “How to related to verbalize knowledge and knowledge and accordingly. patient
adjust the treatment understanding understanding parents was able
situation and regimen and of disease of parents. understanding. to
how the surgery process, 2.It helps verbalize
surgery is procedure treatment and 2.Provide 2.Provided and
complete information them to
done.” surgery. know about understand
information about the the
about disease disease and how the disease
condition diseased
condition ,treat the surgery is condition
Objective ment and done. and its
treatment and the
data: Patient surgery.
protocol. surgical
exhibiting
procedure.
feeling and
being 3. counsel
overwhelmed. parents on the 3.counseled 3.Helps
pre-operative parents on pre- reduce
and post operative and possibility
operative post-operative of post-
management. management. operative
complication

And anxiety
regarding
surgery.

4.Provided 4.Helps to
4.Give health recover from
teaching on health teaching
on infection the disease
infection condition.
prevention and control and diet
nutrition. that helps the
incision wound
heal faster.

S.N Assessment Diagnosis Goal Planning Implementation Rational Evaluation

51
 3. Subjective Anxiety Patient will be 1.Assess the 1.Assessed the 1It helps to Goal was
data: “Patient related to the free from level of level of anxiety. deal with met
complained disease anxiety before anxiety. patient partially
fear about the condition. discharge. accordingly. as the
disease the patient
disease 2. Try to find was still
condition.” out the cause of 2. Find out the 2. It helps to anxious.
anxiety cause of anxiety reduce
ie,disease anxiety.
condition.
Objective
data: Patient 3. Encourage to 3. Encouraged
looks sad and share feeling the patient to 3. It helps
was terrified. and problems. share feeling to be free
and problems. from anxiety

4. Encourage to 4. Encouraged 4. It helps to

share feeling the patient to know the
and problems share feeling patient’s
and problems. problems
more
clearly.
5. Explained
5. Explain about the 5. It helps to
about the disease understand
disease condition in about the
condition in detail. disease.
detail.
6. Encouraged 6. It helps to
6. Encourage the patient in be free from
the patient in diverse anxiety.
diverse activities like
activities like talking with
talking with others, reading
others, reading books.
books.

S.N Assessment Diagnosis Goal Planning Implementation Rational Evaluation

52
4. Subjective Pain related to Pain will Determine Determine pain To find out Goal was
Data: Patient surgical be characters of location, severity of achieved
said “I have incision as tolerable pain. duration and pain. as patient
pain in the evidenced by within an intensity. states of
incision site” patient’s hour. pain relief.
verbalization
and grimace. Provided non
Objective data: Provide non pharmacological It promotes
pharmacological
Patient was pain relief relaxation
grimacing and pain relief measures such and enhance
sweaty due to measures such as: pain relief.
pain. as :
Comfortable
Comfortable position,
position, distraction.
distraction

Provided
Give analgesic analgesic Inj. It controls
at prescribed Ketorolol 30mg pain.
interval. IV as prescribed
interval.

S.N Assessment Diagnosis Goal Planning Implementation Rational Evaluation

53
5. Subjective Intake of The patient 1.Assess the 1.Assessed the 1.To obtain My set
Data: Patient insufficient will be able to general nutrition pattern baseline data objective
said “I don’t to meet the was met as
increase condition and of the patient. for further
feel like metabolic evidenced
eating and I need appetite within nutritional intervention. by the
feel weak. hospitalization. status of the verbalization
on the
patient.
patientthat
2.Encouraged 2.To she was
Objective 2.Encourage
data: maintain taking food
him to take her to take
on time.
plenty of fluids fluid and
Patient plenty of
looked weak as additional electrolyte
fluids.
and fatigued. balance.
fluids.

3.Provide 3.To
3.Provided
nutritious maintain
nutritious foods
foods. nutritional
to prevent
malnutrition. status.

4.Boost the 4.The patient 4.To

was provided stimulate
visitor to give
the foods he appetite.
food in
liked the most
attractive way in small
in amount.
smallamount.

54
 DAILY PROGRESS NOTE

2076/11/12, Monday (1st day of admission)

A 39 years female patient with diagnosis fibroid uterus was admitted in bed no.309 on
2076/11/12 at 11am in cabin today. During admission, her chief complaint was pain in lower
abdomen in hypogastric region.

Surgery was planned at 4pm. Vital signs are within normal range as Temperature: 98.6° F,
Pulse : 72/min, Respiration : 22/min, B.P : 130/90 mm of Hg. Head to toe physical
examination done and Vein was opened with inj. DNS 500 ml. She was kept in NPO. Easyvac
enema was given at 2pm. All investigation reports were collected and patient was shifted to
post-op ward at 3pm. Pre-operative medication Inj, xone 1gm , Inj pantop 40mg and inj.
Ondem 4mg stat.was given. All the other pre-operative preparation done. Patient and family
members seemed anxious about surgery. So, psychological support was given by explaining
about the disease condition and its prognosis and patient was sent to operation theatre at 4
PM.

2016/11/13, Tuesday

Today is the 1st post-operative day. Patient general condition seems conscious and oriented to
time, place and person. Vital signs at 10am; Temp: 100° F, Pulse: 98/min, Respiration:
22/min, B.P: 130/80 mm of Hg, SPO2: 98% without O2. Inj. paracetamol 1gm was given.
Patient had complaint of pain in operation site and seemed anxious. Psychological support
was given and administered analgesic inj. Keterolol 30mg IV. I provided assistance to the
patient in ambulation and dress change. Biopsy was sent. Patient was in liquid diet and foly’s
catheter was removed at 1pm and after that patient was shifted to cabin ward. Tab cefixime
2oomg BD, Tab metron 400mg was added in morning round.

2076/11/14, Wednesday

Today is the 2nd post-operative day Patient’s general condition seems alert. Vital signs are
within normal range; Temp: 98.4° F, Pulse: 76/min, Respiration: 20/min, B.P: 120/80 mm of
Hg. Patient had complain of productive cough She had difficulty in breathing to some extent.

55
So, patient was assisted for ambulation. I provided steam inhalation and taught and
encouraged for deep breathing and coughing exercise. She was having diet as tolerated and
urine self-voided. Intake and output is balanced.

On doctor’s morning round syrup Beta-2 expectorant 7.5ml TDS and Tab levocet 5mg PO HS
was added for cough. Plain Nebulization with N/S was ordered 6hourly. Dressing was done
by DR. Rosy Malla. Discharge was planned as the visitors requested for it.

2076/11/15, Thursday

Today is the 3rd day of surgery. Patient’s general condition seems active and is improving than
in previous day. Vital signs are within normal range; Temp: 98.6° F, Pulse : 74/min,
Respiration : 22/min, B.P : 130/80 mm of Hg. Patient’s cough had decreased and she had
easy breathing. She was advised for normal diet as tolerated. I encouraged for mouth care,
ambulation, steam inhalation and deep breathing and coughing exercise. She has decreased
pain in incision site.

On doctors morning round she was planned for discharge in the evening. She was advised to
come for follow up after 1week.

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 DIVERSIONAL THREAPY

Diversional therapy is most important therapy to minimize the stress of patient and family
members by diverting the mind from an unpleasant experience.

Hospital is a very threatening and stressful place to everyone. The patient and family members
have fear about the disease condition and operative procedure, new environment, rules and
policies of hospital, doctors, sisters and different procedures etc. So, diversional therapy is one
of the most important therapies which help to overcome the stress. Diversional therapy should
be applied according to the age and developmental task of the patient.

Being a nurse, it is our duty and responsibility to help and support the patient and family
coping with disease condition by applying different measures. So, I applied following
diversional therapy to patient and family members:

 Established communication and interaction with the patient and family members
time to time which encourage them to express their feeling.
 Provided opportunity to the patient to talk with family members.
 Encouraged patient to take deep breathing as she had pain and ineffective breathing
patterns, this helps to expand the lungs as well as alveoli. So, there will be more
oxygen in the body.
 Encouraged for listening soft music, reading newspaper and roaming here and there
which help to prevent unnecessary thinking.
 Encouraged patient to participate in self-care activities.
 Encouraged and assisted patient for ambulation.
 Encouraged patient and family members to participate in recreational activities to
divert their mind.

57
 The result of all those diversional measures in my patient and family
members was positive.

DISCHARGE TEACHING AND HEALTH TEACHING

Discharge planning is an integral part of nursing process. The entire plan for the hospital care is
geared towards discharge of the patient. It is considered the nurse’s responsibility to plan and
suggest the for continuity of care at home or to refer to other agency for better care, recovery and
maintenance, discharge teaching is very much needed to patient as well as his family member.
Health teaching during discharge and hospitalization can prevent complication, promote health
and maintain normal life style. It is the most important aspect in providing holistic nursing care.
During my posting, my patient was not planned to discharge, therefore I only gave teaching on
the basis of following objectives:

Objectives of discharge teaching plan:

 To provide and maintain health and prevent from illness in home after discharge.
 To consider primary health care concept in health teaching plan.
 To provide need based health education.
 To provide holistic nursing care to my patient

I gave following teaching to the patient and family:

Diet:
• Eat soft and easily digestible diet high in protein, vitamin and carbohydrate.
• Eat small and frequent meal.
• Eat food that have been thoroughly cooked and that are still hot and steaming.
• Avoid raw vegetables and food that cannot be peeled.
• Wash fruits properly with clean water.
• Avoid fatty foods, alcohol and smoking.
Fluid Intake:

• Drink plenty of water.

Personal Hygiene:

58
 • Personal hygiene should be maintained to remain healthy.
• Wash hand before and after having food, going to toilet, after touching dirty objects.
• Prevent flies and cockroach from food.
• Patient is also advised for daily brushing.
Rest:

• Take adequate rest.

Medication:

• Prescribed medication need should be taken in time as well.

Follow up visit:

• Follow up after 1 week.

• If any complication appears bring patient to hospital for prompt management

59
 LEARNING FROM CASE STUDY

Case study is the effective method of learning about related disease in depth and practice.
Case study gives the comprehensive study of one selected patient and comparison with book
in a real situation.

During my case study of fibroid uterus, I collected information from different resources such
as; different books and materials from library, internet and consulted with doctors, senior
sisters of the ward, teachers and with my friends. I learned and experienced many things from
case study of fibroid uterus which are listed below;

1. About patient:-
During case study, I was completely involved and attached with my patient & his
family members. I came to know the reaction of the patient about treatment and
disease process. I also got an opportunity to learn about family background and
environment including socio-cultural, educational, religious and economic status of
patient.

2. About nursing care :-

I got an opportunity to learn the application of knowledge of nursing theory, and basic
science while caring the patient and use of nursing process. It enhanced the scientific
method of caring the patient.

3. About diversional therapy and stress management :-

I got chance to detect the stressful factors in patient and family and different therapy to
overcome these stress. I got chance to use diversional therapy in practical to patient &
other family members also.

4. About documentation :-
During case study, I also developed further skills in documentation in a more revised
manner.

60
5. About hospital policy :-
During case study, I was involved in many sectors for activities like reporting,
recording, admission, discharge procedure, investigations etc. So, I got a lot of
knowledge about hospital policy.

Finally, I think that case study is one of the best ways to develop individual
knowledge, skill and attitude.

61
 CONCLUSION

Case study is one of the most important parts of nursing practice. It is a best method of learning
concerned with the individualized care which helps to gain knowledge and provide holistic nursing
care including physical, psychological, social, spiritual and cultural beliefs.

According to curriculum of Post basic Bachelor of Nursing program (1st Year), I had taken a case of
fibroid uterus in Kantipur hospital for case study, named Mrs. Usha Shrestha, 39 years female. During
this case study, I collected relevant health history from patient and her father. Her chief complaints was
pain in lower abdomen since 1 year with dysmenorrhea and menorrhagia. Then, I performed head to toe
physical examination of the patient. From this I gathered lots of facts and formulated nursing diagnosis. I
provided holistic nursing care by using nursing process.

I deeply studied about disease condition (uterine fibroids); its introduction, incidence,
pathophysiology, clinical features, causes, diagnostic procedures, medical & surgical management,
nursing management and from books and co-relate them with my patient. I also studied the available
developmental task and developmental crisis of young adult and compared it with patient.

I provided health teaching in different topics and diversional therapy to the patient and family
members during hospitalization. Including pharmacotherapy, supportive therapy & counseling was
also provided. Patient’s condition was improved day by day. So, she discharged on 4 th day of
admission with oral SOS medicines. Discharge teaching was given and advised for follow-up visit
after a week.

Thus, I completed one case study during 4 days period (started from 1st day of admission) by
going to depth and gaining various knowledge. So, it is quite beneficial for my study as well as
learning and I have taken it as a golden opportunity.

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REFERENCES

 DUTTA, D., 2008. TEXTBOOK OF GYNAECOLOGY. In: Kathmandu: Vidyarthi

Pustak Bhandar.

 Rai, L., 2015. In: Nursing Concepts Theories and Principles. s.l.:s.n.

 Tamrakar, A., 2069. In: A Textbook of GYNAECOLOGICAL NURSING. s.l.:Vidyarthi

Pustak Bhandar.

 Tripathi, K., n.d. In: Essential of Medical Pharmacy. s.l.:Jypee Publication.

 Tuitui, R., 2001. Human Anatomy & Physiology. In: s.l.:Vidyarthi Prakashan.

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