Case Right ovarian tumor with Left ovarian cyst

Patient Information

Doctor treatment

Patient sign and symptom

Nursing problem and Nursing Intervention

Chief complain

Present illness

Past history

Underlying disease

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%

29/03/2022

  1. Patient has flatulence.

28/03/22

28/0302022

  1. 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

29/03/65

30/03/65

28/03/65

Nursing goal

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

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.

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.

Patient be safe from complication of anesthesia

Criteria

  1. Normal V/S
    -BP = 90-120/60-80 mmHg.
    -PR = 60-100bpm.
    -RR = 18-22bpm.
    -O2sat = 96-100% room air

30/03/65

Supportive data

Subjective data : Patient said "I has flatulence,I no defecation today."

Objective data : 1.Patient has less ambulate after operation. 2.Patient got antipyretic drugs during operating.

  1. No sign of CHF leakage include headache, dizziness, nausea and vomoitting.

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.

Discharge plan

Supportive data

Nursing goals :

Subjective data : Patient said “The doctor order me to go home today”.

Objective data : The doctor plans discharge the patient today.

Nursing criteria :

Nursing Intervention :

Evaluation:

The patient able to take care of themselves properly.

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 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.

3.Test understand by having the patient tell or answer questions how to take care of themselves. And giving patient opportunities to ask questions.

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

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

Operation

Patient came to hospital for operation appointment.

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 5.13.44.6 cm vol.41.77 cm3 thin ET 0.5 cm. mixed echoic cyst size 14.59.314 cm. with solid part R/O ovarian tumor. The doctor was appointed patient to operation.

Food allergy (shrimp : After eating, Have mount swelling and rash.).

None

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

Specimen

  1. Rt.Adnexa
  1. Lt.Ovarian cyst
  1. Myoma
  1. Lt.Prlvic LN
  1. Rt. Pelvic LN
  1. Omentum
  1. No sign of respiratory failure include difficult to breathing and downsiness
  1. No sign of Peripheral nerve damage include numbness.

Nursing intervention

  1. Assess V/S every 2 hr.
  1. Assess neuro sign for evaluated nervous system
  1. Observe sign of CHF leakage include headache, dizziness, nausea and vomitting.
  1. Observe sign of respiratory failure include difficult to breathing and drowsiness.
  1. Patient has pain after operation

Supportive data

Evaluation

S: Patient said “I feel pain at surgical wound”

O:

  1. PS=3/10
  2. Facial expression of patient show about frown
  3. Patient doesn't have more movement of her body.

Nursing goal

Pain can releive

Criteria

  1. PS not more than 3/10
  1. PR=60-100bpm.
  1. BP90/60-120-80mmHg
  1. RR=16-24bpm.
  1. Face of patient when she move
    not show about frown

Nursing intervention

  1. Assess pain of patien
  1. Promote deep breathing technique
  1. Provide semi fowler’s position for reduce pressure to wound
  1. Provide medicine for relieve pain follow doctor order
    (Tramadol 50mg./ml. IV prn every 4 hr. 3 days.)

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.

After operation, patient has bikini line around 7cm. at pubis.

  1. Observe sign of Peripheral nerve damage include numbness.

Normal vital sign. She no headache, dizziness, nausea and vomiting.
No difficult to breathing and drowsines. No numbness at hand and feet.

  1. 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.

  1. BT = 36.5-37.4c

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.