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Case Right ovarian tumor with Left ovarian cyst - Coggle Diagram
Case Right ovarian tumor with Left ovarian cyst
Patient Information
Chief complain
Patient came to hospital for operation appointment.
Present illness
1 month PTA Patient came to hospital for annual health check up. The doctor was palpated founded ovarian tumor. So, patient came to hospital for special laboratory >> TAS+TVS found uterus size 5.1
3.4
4.6 cm vol.41.77 cm3 thin ET 0.5 cm. mixed echoic cyst size 14.5
9.3
14 cm. with solid part R/O ovarian tumor. The doctor was appointed patient to operation.
Past history
Food allergy (shrimp : After eating, Have mount swelling and rash.).
Underlying disease
None
Thai female 30 years old. HN:55362729. Dx: Rt ovarian tumor with Lt ovarian cyst. Admission date: 26/3/2022 at 8.05A.M.
Student give patient to take care: 28/3/2022 to 30/3/2022. Weight: 63.5 kg. Height: 160 cm. BMI: 24.8
Vital sign: T: 36.7 c, P: 90 bpm, PB: 120/71 mmHg,
RR: 20 bpm, O2: 98%
Operation
Rt. Salpingo ooprorecromy with Lt.ovarian cystectomy with myomectomy with Bilateral pelvic node sampling with omental biopsy with peritoneal washing under SB with morphine with GA with ET
After operation, patient has bikini line around 7cm. at pubis.
Specimen
Rt.Adnexa
Lt.Ovarian cyst
Myoma
Lt.Prlvic LN
Rt. Pelvic LN
Omentum
Doctor treatment
28/03/22
One day order
10.05am.
off foley’s cath
NSS lock
off IV fluid
Paracetamol 500 mg. 1tab prn. every 6 hr. 1day.
Ambulate
1.50pm.
Education
Ambulation gait training
Continuous order
10.05am.
Dietary order
Simethicone 80mg. 1x3 pc. 5days
4.00pm.
Cephalexin 500mg. 1x4 ac. 7days
Ibuprofen 400mg. 1x3 pc. 10days
29/03/22
One day order
00.00am.
Soft diet (morning,lunch,dinner)
30/03/65
One day order
00.10am.
Soft diet (Morning,lunch)
8.30am.
Removal of suture by doctor
Off NSS lock
Discharge with homemed
Follow up
10.40am.
Dressing by doctor
Continuous orders
08.40am. Homemed
Cephalexin 500mg. 1x4 ac. 7days
Paracetamol 500 mg. 1tab every 6 hr. 5day.
Simethicone 80mg. 1x3 pc. 5days
Ibuprofen 400mg. 1x3 pc. 10days
26/03/22
One day order
8.00am.
CT whole abdomen with contrast + notify doctor at 8.00am.
Admit at ward 8
Set OR for Fertility sparing surgery staging on 27/03/22 at 2.00pm.
Dexamethasone 4mg/ml IV stat
CPM 10mg/ml IV stat
Swab covid
NPO AMN.
Prep skin abdomen & mons pubis
SSE hs. and before go to OR.
Reserve LPRC 2 unit
5%DN/2 1000ml IV rate 120ml.hr.
Cefazolin 2g. go to OR
Retained Foley’s cath at OR
Xannax (0.5) 1tab hs.
Omeprazole 40mg. IV on 27/04/22 at 6.00am.
27/03/22
One day order
1.00am.
OR for Rt.SO with Lt. ovarian cystectomy with myomectomy with BPNS with Omental biopsy under SB with morphine with GA with ET
Continuous order
6.00pm.
Metoclopramide 10mg/2ml IV prn. every 4 hr. 3days
Tramadol 50mg./ml. IV prn every 4 hr. 3 days.
CPM 10mg/ml IV prn. every 6 hr. 3days.
Patient sign and symptom
29/03/65
Post operation day 2, Patient has normal Vital sign,She has pain at surgery wound. Pain score 3/10. Wound at bikini line close with gauze. no discharge, no swelling and no redness at wound. Patient have flatulence. Start soft diet. Plan discharge on tomorrow.
30/03/65
Post operation day 3 Patient has normal Vital sign,Patient said " I have flatulence." but She can void by herself. She has pain at surgery wound. Pain score 2/10. Wound at bikini line close with gauze. no discharge, no swelling and no redness at wound.
28/03/65
Post operation day 1 Patient has normal Vital sign and good consciousness. Pain score 3/10. Wound at bikini line close with gauze and hypafix. no discharge, no swelling and no redness at wound. On F/C >>urine can flow, yellow color. On IV fluid>> no phlebitis. No N/V. No numbness
Nursing problem and Nursing Intervention
29/03/2022
Patient has flatulence.
Supportive data
Subjective data : Patient said "I has flatulence,I no defecation today."
Nursing goals : 1.Patient not has flatulence.
Nursing Criteria : 1.Patient can excretion by herself without relying on laxatives.
Nursing Intervention
2.Administer Air-X as doctor order and explain the action and side effect of drug.
3.Position the patient in assuming a semi-Fowler’s position.
1.Assist the patient ambulate in doing physical activity and exercise.
Nursing Evaluation : Patient still flatulence but feel more comfortable.
Objective data : 1.Patient has less ambulate after operation. 2.Patient got antipyretic drugs during operating.
28/0302022
Complication from anesthesia
Supportive data
S: -
O: Patient has operation about Rt.SO with Lt. ovarian cystectomy with myomectomy with BPNS with Omental biopsy under SB with morphine with GA with ET
Nursing goal
Patient be safe from complication of anesthesia
Criteria
Normal V/S
-BP = 90-120/60-80 mmHg.
-PR = 60-100bpm.
-RR = 18-22bpm.
-O2sat = 96-100% room air
No sign of CHF leakage include headache, dizziness, nausea and vomoitting.
No sign of respiratory failure include difficult to breathing and downsiness
No sign of Peripheral nerve damage include numbness.
Nursing intervention
Assess V/S every 2 hr.
Assess neuro sign for evaluated nervous system
Observe sign of CHF leakage include headache, dizziness, nausea and vomitting.
Observe sign of respiratory failure include difficult to breathing and drowsiness.
Observe sign of Peripheral nerve damage include numbness.
Evaluation
Normal vital sign. She no headache, dizziness, nausea and vomiting.
No difficult to breathing and drowsines. No numbness at hand and feet.
Patient has pain after operation
Supportive data
S: Patient said “I feel pain at surgical wound”
O:
PS=3/10
Facial expression of patient show about frown
Patient doesn't have more movement of her body.
Nursing goal
Pain can releive
Criteria
PS not more than 3/10
PR=60-100bpm.
BP90/60-120-80mmHg
RR=16-24bpm.
Face of patient when she move
not show about frown
BT = 36.5-37.4c
Nursing intervention
Assess pain of patien
Promote deep breathing technique
Provide semi fowler’s position for reduce pressure to wound
Provide medicine for relieve pain follow doctor order
(Tramadol 50mg./ml. IV prn every 4 hr. 3 days.)
Provide nursing care with gentleness
Evaluation
On 28/3/22
PS=3/10 PR=72-82bpm. BP=106-90/65-46mmHg. RR=20bpm. BT=36-37.3C When she moves her abdomen, she has frown on her face.
On 29/3/22
PS=3/10 PR=62-80bpm. BP=100-110/60-64mmHg.
RR=20bpm. BT=36.5-37.0C. When she moves her abdomen, she has frown on her face.
On 30/3/22
PS=2/10 PR=62-76bpm. BP=108-110/64-70mmHg.
RR=20bpm. BT=36.8-37.0C. When she moves her abdomen, she has frown on her face a little.
30/03/65
Discharge plan
Supportive data
Nursing goals :
Nursing criteria :
Nursing Intervention :
Evaluation:
The patient able to tell and answer questions properly in 5/5 of questions.
1.Assessed knowledge and understanding to take care of themselves.
2.Preparing the patient before discharge followed D-METHOD.
D Diagnosis : Rt ovarian tumor with Lt ovarian cyst with subserous myoma.
M Medication : Cephalexin 500mg 1cap po qid ac is used to treat infections. Paracetamol 500mg 1tap po q 6hr prn when pain. Simethicone 80mg 1tap po tid pc for antiflatulent. Ibuprofen 400mg 1tap po tid pc is used to reduce fever and treat pain or inflammation.
E Environment and Economic : Organize the environment, such as keep your object/equipment at the right level, not high or low. Avoid take heavy object/equipment.
T Treatment : Make an appointment for the patient to come to the dressing wound and Provide information how to observe infected wound
H Health : Encourage patients to exercise by walking and get enough rest.
O Outpatient referral : Should see a doctor immediately when there are abnormal symptoms. Make an appointment with the patient for follow-up.
D Diet : Provide information about avoid food color black, red , brown. And eat more fruits and vegetables to prevent constipation. And protein and vitamin C
3.Test understand by having the patient tell or answer questions how to take care of themselves. And giving patient opportunities to ask questions.
The patient able to tell or answer questions about how to take care of themselves properly in 4/5 of questions.
The patient able to take care of themselves properly.
Subjective data : Patient said “The doctor order me to go home today”.
Objective data : The doctor plans discharge the patient today.