Pamantasan ng Lungsod ng Marikina

Rainbow St., SSS Village, Concepcion Dos, Marikina City

COLLEGE OF HEALTH SCIENCES

In Partial Fulfillment of the Requirement in

Care of Mother and Child at-risk or with Problems (Acute and Chronic) (RLE)

A CLINICAL CASE STUDY

Total Abdominal Hysterectomy with Bilateral Salpingo-Oophorectomy (TAHBSO)
St. Mattheus Medical Hospital

Presented by:
Camposo, Jurizt Nesperos, Cherry Kyle L.

Canale, Dianne Irish L. Parane, Ronnie B.

De Jesus, Mariel G. Pastor, Mica Larice C.

Delos Reyes, Carla Rabina, Tresia Anne G.

Domingo, Randell Jordan P. Santos, Lance B.

Lacaba, Kevin

Level II Bachelor of Science in Nursing, Batch 2023-2027

CLINICAL INSTRUCTOR:
Prof. Evelyn P. Cailao, RN, MAN

FEBRUARY 2025
 ACKNOWLEDGEMENT

The student nurses express their utmost gratitude to everyone who has, in any capacity,

contributed their efforts and support in bringing this case study to success. The completion of

this case study would not have been achievable without the participation and assistance of these

significant individuals.

The student nurses would also like to express their gratitude specifically to the

following:

To patient “L. J.” for participating in the interviews, assessments, and nursing

interventions that the group has performed. Also, for giving her utmost trust to give information

and important data to the student nurses.

To their respective Clinical Instructor, Prof. Evelyn P. Cailao, RN, MAN for having

the patience, guidance, and full support to each of the group member throughout the meaningful

journey filled with learning that makes this case study a success.

To their lecture professor, Mr. Alex Estanislao, RN, MAN, RM, RMT, PHD for his

expertise and giving the necessary knowledge and wisdom regarding the subject matter.

To their loving Dean, Dr. Marissa S. Tolentino, MAN, RN, for giving her utmost

support to the students of the college of health sciences for the completion of this study.

To their family and friends that gave financial and emotional support throughout the

process of this study. Thank you very much.

And to the Almighty God, who gave the guidance, strength, and wisdom to the student

nurses in achieving of fulfilling this study.

 TABLE OF CONTENTS

I. INTRODUCTION

II. OBJECTIVES OF THE STUDY

III. THEORETICAL FOUNDATIONS

IV. NURSING HISTORY

a. Biographical Data
b. Reason for seeking healthcare
c. History of Present Illness
d. Past Health History
e. Family Health History
f. Social History

V. IMMUNIZATION/EXPOSURE TO COMMUNICABLE DISEASES

VI. ALLERGIES

VII. HOME MEDICATION/ALTERNATIVE MEDICINE

VIII. PSYCHOSOCIAL HISTORY

IX. OBSTETRICAL HISTORY

X. ANATOMY AND PHYSIOLOGY

XI. PATHOPHYSIOLOGY
XII. GORDON’S 11 FUNCTIONAL HEALTH ASSESSMENT PATTERNS

XIII. PHYSICAL ASSESSMENT

XIV. DIAGNOSTIC/LABORATORY EXAMINATIONS

XV. THE MEDICAL DIAGNOSIS

XVI. DRUG STUDY

XVII. MEDICAL/SURGICAL MANAGEMENT

XVIII. NURSING CARE PLAN

XIX. DISCHARGE PLAN

XX. REFERENCES
INTRODUCTION
 OBJECTIVES OF THE STUDY

GENERAL OBJECTIVES

By the end of the case study, the study nurses are expected to gain knowledge and learn

about the skills for a post cesarean section delivery.

SPECIFIC OBJECTIVES

Attitude

1. The student nurses will be able to build rapport with the patient.

2. The patient will entrust the student nurses for the pertinent care she needs.

Knowledge

1. To be able to gain proper knowledge about post cesarean section delivery; its causes,

risks, care, and management.

2. To be able to analyze the case and plan proper interventions for the patient.

Skills

1. To be able to apply nursing interventions to a post cesarean delivery patient.

2. To be able to give pertinent nursing care and management to the patient.

THEORETICAL FOUNDATIONS
 NURSING HISTORY

A. BIOGRAPHICAL DATA

Name: Patient L. J.

Age: 46 years old

Gender: Female

Date of birth: December 25, 1978

Place of Birth: Pasig City

Marital status: Married

Nationality: Filipino

Address: Concepcion Dos, Marikina City

Occupation: Housewife

Admission date: February 6, 2025

Admitting diagnosis: G3P3 (30003) - Myoma

Final diagnosis: S/p Total Abdominal Hysterectomy with Bi-lateral Salpingo-

oophorectomy

Vital signs upon the admission:

BP RR PR TEMP O2 HEIGHT WEIGHT BMI
140/90 25.4
20 bpm 18 cpm 38.2 0C 98% 155 cm 61 kg
mmHg (Overweight)
B. Reason for seeking healthcare

The patient complained about her recurrent Urinary Tract Infection.

C. Present Medical History

The patient was admitted on February 6,2025 with an admitting diagnosis of

Myoma. The patient complained about her bulky cyst that is prominent in her

abdomen when in a supine position with a pain scale of 5/10. After the admission,

the patient was scheduled for the procedure of Total Abdominal Hysterectomy

with Bi-lateral Salpingo-oophorectomy

D. Past Medical History

According to the patient, her first complaint is about recurrent UTI on the month

of November 2024. After her check-up and several laboratory check-ups, she was

diagnosed of Uterine Fibroids (Mayoma) that causes her UTI. The patient also stated that

she does not have any medical complications before the surgery and was not hospitalized

before or had a medical surgery.

E. Present Surgical History

Patient’s present surgical history is on February 6, 2025, under the procedure of

Total Abdominal Hysterectomy with Bi-lateral Salpingo-oophorectomy.

F. Past Surgical History

 According to the patient, she did not undergo any kind surgery before.

G. Family Health History

The patient was diagnosed of hypertension 10 years ago and was diagnosed of having myoma on
November 20204. According to the patient, both diseases came from her mother side that passed
genetically through her family’s bloodline.
IMMUNIZATION/EXPOSURE TO COMMUNICABLE DISEASES

ALLERGIES

HOME MEDICATION/ALTERNATIVE MEDICINE

PSYCHOSOCIAL HISTORY

OBSTETRICAL HISTORY

PEDIATRIC HISTORY
 ANATOMY AND PHYSIOLOGY

Figure 1: The Female Reproductive Organ

Female Reproductive System

It is a complex network of organs that work together to enable pregnancy and childbirth

and including the menstrual cycle and menopause.

INTERNAL ORGAN

1. Ovary - almond-shaped organs that produce eggs (ova) and female hormones (estrogen and
progesterone).
2. Fallopian tube - The female reproductive cell that, when fertilized by sperm, develops into an
embryo.
3. Uterus - thin tubes that transport eggs from the ovaries to the uterus. Fertilization typically
occurs here.
4. Cervix - a muscular organ where a fertilized egg implants and develops into a fetus during
pregnancy.
5. Vagina - a muscular canal that leads from the cervix to the external genitalia. It serves as the
passageway for childbirth and menstruation.
 Figure 2: Female Reproductive Organ: Uterine Fibroids

Uterine Fibroids

Uterine fibroids (leiomyomas) are non-cancerous tumors causing abnormal bleeding,

pelvic pressure, and sometimes urinary or intestinal issues, infertility, or pregnancy

complications. Diagnosed via pelvic exams or imaging, treatment depends on symptoms, fertility

desires, and surgical preferences, including medication (estrogen-progestin contraceptives,

progestin therapy, tranexamic acid) or surgery (hysterectomy, myomectomy).

Leiomyomas, the most common solid pelvic tumors in women, cause symptoms in about

25% of reproductive-age women. However, with thorough examination, the prevalence rises to

over 70% as many are asymptomatic. On average, affected uteri have six to seven fibroids.

Uterine fibroids come in various types depending on their location in the uterus.

1. Intramural Fibroids: These are the most common type, located within the muscular wall

of the uterus. They can cause heavy menstrual bleeding, pelvic pain, and pressure.
2. Subserosal Fibroids: These develop on the outer surface of the uterus and can grow

large, sometimes causing pressure on nearby organs such as the bladder and bowel,

leading to symptoms like frequent urination or constipation.

3. Submucosal Fibroids: These grow just beneath the lining of the uterine cavity and can

protrude into the uterus. They often cause severe menstrual bleeding and can affect

fertility.

4. Pedunculated Fibroids: These fibroids are attached to the uterine wall by a stalk-like

structure. They can develop both inside (submucosal) or outside (subserosal) the uterus,

potentially causing pain and pressure due to their movement.

PATHOPHYSIOLOGY
GORDON’S 11 FUNCTIONAL HEALTH ASSESSMENT PATTERNS
 PHYSICAL ASSESSMENT
ACTUAL ANALYS
BODY PART NORMAL FINDINGS NURSING ALERT
FINDINGS IS

The patient exhibits a

normal facial
expression appropriate The body build is
to the situation, a Warning: A BMI of
steady gait, small frame, with 25.4 in a small-
appropriately worn framed individual
an upright posture suggests excess
and clean clothing, a
well-proportioned and a smooth, weight, increasing
body within a normal the risk of
rhythmic gait. cardiovascular
weight range, an
upright and relaxed Clothing is disease, diabetes,
posture, and no and
appropriate, with musculoskeletal
apparent discomfort or
distress in their resting no noticeable odor strain.
position. Normal
General and no physical Implication:
Appearance deformities. Height Monitor diet,
Reference: is 5'1" (155 cm), physical activity,
Berk, S. L., & Verghese, A. (2016). weight is 61 kg, and posture, and

General Appearance. resulting in a BMI provide health

of 25.4, which falls education to

Nih.gov; Butterworths.
in the overweight prevent further
https://www.ncbi.nlm.nih.go
category. complications.
v/books/NBK330/
 Inspection:
Clear speech, rational Warning: Monitor
thought processes, for any changes in
intact memory, sound consciousness,
judgment, appropriate The patient is orientation, or
mood and affect, and communication
alertness are all conscious and alert, ability, as these
examples of normal oriented to person, may indicate
mental status findings. neurological or
place, and time. psychological
Reference: Emotionally, the concerns.

Mental Berk, Martin, D. C. (2021). patient is Implication:

Status cooperative, Normal The patient’s
The Mental Status
responds awareness and
Examination.
appropriately to cooperation
National Library of
questions, and uses suggest stable
Medicine;
simple words in mental status, but
Butterworths. ongoing
conversation
https://www.ncbi.nlm. assessment is
nih.gov/books/NBK3 essential to detect

20/ any subtle changes.

Abdomen Inspection: Abdomen is Warning: Unusual

discharge from the
slightly rounded.
Abdomen should be Normal surgical site,
No scars noted redness, edema, or
flat or slightly
abdominal
except for surgical
rounded, symmetrical, distention could be
sutures from a signs of wound
with smooth skin,
dehiscence,
recent procedure.
uniform color, and no hematoma, or
No pitting edema infection.
visible lesions or
and erythema
abnormal movements. Implication:
noted. • Keep an eye out
for symptoms of a
wound infection,
such as fever, pus,
redness, and
 warmth.
• Check for
distention, which
may be a sign of
intestinal issues or
internal bleeding.
• As necessary,
reinforce and make
sure the wound is
well dressed.

Warning: Severe
guarding or
discomfort could
indicate
anastomotic
leakage, internal
bleeding, or
peritonitis.
Palpation: Abnorma
Deferred due to Implication:
l (not
The abdomen should voluntary muscle • Check for
be soft, non-tender, guarding and assessed rebound soreness,
and without masses. reported severe which is a sign of
due to
Deep palpation should tenderness with a inflammation in the
not reveal organ pain scale of 10/10 pain and peritoneum.
enlargement or cause upon light touch. • Keep an eye out
guarding
pain. for symptoms of
) shock, such as
tachycardia or
hypotension.
• Inform the doctor
right away if the
patient continues to
report excruciating
pain in spite of
analgesia.
Percussion: Deferred due to Abnorma Warning: Guarding
l (not and extreme pain
patient’s severe
Tympany is the assessed have caused the
dominant sound due to abdominal pain. due to percussion to be
air in the intestines, pain and postponed. It is
with dullness over guarding impossible to rule
solid organs like the ) out potential
liver and spleen. consequences such
internal bleeding,
 ascites, or intestinal
obstruction.

Implication:
• Pay special
attention to any
changes in bowel
function, increasing
pain, or gradual
distention of the
abdomen.
• Keep an eye out
for rebound
soreness and a hard
abdomen, which
are symptoms of
peritoneal
irritation.
• For additional
assessment, report
right away if the
patient exhibits any
new symptoms,
such as vomiting,
lack of bowel
sounds, or
hypotension.

Warning:
Postoperative ileus,
Auscultation:
a typical side effect
following
Normal bowel sounds
Normal active abdominal surgery,
are irregular, high-
may be indicated
pitched, and occur 5- bowel sounds heard
Normal by absent or
15 seconds, no
in all four hypoactive bowel
vascular bruits should
sounds.
be heard. quadrants.
Implication:
• To promote
gastrointestinal
motility, encourage
 Reference: early ambulation.
• Keep an eye out
Clinical Nursing
for symptoms like
Skills | OpenStax.
Openstax.org; nausea, vomiting,
OpenStax. or difficulty
https://openstax.org passing gas.
/books/clinical- • If bowel sounds
nursing-skills/pages/
27-2-physical- are absent for
assessment
extended periods of
time, let the doctor
know.
Upper Inspection: Inspection: Inspection:
The upper extremities The upper Nursing Alert: If
extremities
appear normal, with extremities have no Normal discoloration,
even skin color, discoloration, cyanosis, or
warmth, and no lesions, or edema. delayed capillary
lesions or ulcers. Capillary refill is refill (>3 seconds)
There is no swelling, normal, with the is noted, it may
and capillary refill is nail bed returning indicate poor
less than 3 seconds in to red in less than 3 circulation,
the fingers. The nails seconds. The nails possible vascular
are pink and are pink, with no insufficiency, or
translucent, with no signs of cyanosis. respiratory issues.
signs of cyanosis or The skin is warm to
abnormalities. the touch. Implication:
Abnorma • Monitor for
Palpation: Palpation: further signs of
l
Muscle tone is firm The patient can impaired perfusion
with slight resistance and assess for
voluntarily move
to passive movement, underlying
with no signs of her upper conditions such as
spasticity or flaccidity. peripheral artery
extremities, though
Muscle strength is disease (PAD) or
equal bilaterally, with a slightly slow venous
graded 5/5 (full insufficiency.
pace. She is able to
strength), and the
patient is able to move perform flexion Palpation:
against gravity and Nursing Alert: If
and extension of
full resistance. muscle weakness,
the elbows and limited range of
motion, or
wrists, as well as
asymmetrical
open and close her strength is
observed, it may
 hands, but does so
slowly, with visible
signs of mild
difficulty on her
facial expression.
Neck movement is suggest
neuromuscular
intact, with the
disorders, stroke, or
ability to turn her nerve damage.
head to the right
Implication:
and left, and • Evaluate for
neurological
perform flexion,
deficits and assess
extension, and the patient's ability
to perform daily
hyperextension.
activities.
Muscle strength is • If weakness is
graded 4/5 present, implement
bilaterally, as she fall precautions and
can resist applied consider physical
force during therapy referral if
shoulder shrugging needed.
and neck resistance
testing (placing a
hand on her cheek
and applying
pressure).
Inspection: Inspection: Inspection:
The lower extremities The skin color is Normal Nursing Alert: If
appear normal, with even, and the skin discoloration,
even skin color, extremities are ulcers, or edema
Lower
warmth, and no warm to the touch. are present, it may
extremities lesions or ulcers. There is one scar indicate venous
There is no swelling, noted, but no stasis, deep vein
and capillary refill is edema is present. thrombosis (DVT),
less than 2 seconds in Capillary refill in or circulatory
the toes. The toenails the toenails is less impairment.
 Delayed capillary
refill (>2 seconds)
may suggest
peripheral vascular
disease (PVD) or
shock.
appear normal, with than 2 seconds, and
Implication:
no fungal there are no signs
• Assess for
discoloration or of discoloration or
additional signs of
infections. infection.
vascular
compromise (e.g.,
Palpation: Palpation:
cool skin,
Muscle tone is firm The patient is able
diminished pulses,
with slight resistance
to move the lower pain).
to passive movement,
• Elevate the legs if
with no signs of extremities,
venous stasis is
spasticity or flaccidity.
although suspected or keep
Muscle strength is
them in a neutral
equal bilaterally, movement is
position if arterial
graded 5/5 (full
slightly slow. insufficiency is a
strength), and the
concern.
patient is able to move Despite this, she
• If DVT is
against gravity and
can perform flexion suspected, avoid
full resistance. Abnorma
excessive
and extension of
l movement and
the legs and feet. report findings
immediately.
Muscle strength is
graded 4/5 Palpation:
Nursing Alert: If
bilaterally, as both
the patient has slow
legs successfully movement, pain, or
weakness in the
performed the heel-
lower extremities,
to-shin test, this may indicate
neuromuscular
demonstrating
impairment, injury,
equal strength. or post-surgical
complications.

Implication:
• Monitor for
changes in mobility
and strength, as
decreased function
 can increase the
risk of falls and
pressure injuries.
• Encourage range
of motion exercises
to prevent muscle
atrophy and
maintain joint
flexibility.
• If severe
weakness or pain
persists, refer for
further
neurological or
musculoskeletal
assessment.
 DIAGNOSTIC/LABORATORY EXAMINATIONS

LABORATORY
AND
RESULT NORMAL VALUES INTERPRETATION ANALYSIS
DIAGNOSTIC
TEST

Cells Present:
Satisfactory Hormonal
Evaluation: Normal
Inflammation: NONE
Negative There were no
Epithelial Smear
Pap Smear abnormal cells
lesions or Normal
Characteristics: detected. The
malignancy Negative for Malignant result was normal.
Cells Cells Appear
Normal
Cytotechnologist:
WSM

Normal heartbeat
per minute shows
The rhythm
consistent
is normal, Normal range of HR
rhythm,P
ECG with no (Heart Rate) 60-100 Normal wave,PR interval,
abnormalitie beats per minute.
QRS complex,ST
s detected
segment and T
(85 bpm).
wave.

There's no
250,000 150,000-450,000
CBC Platelets Normal internal bleeding
(10^3/µL) (10^3/µL) in the body of the
patient.

Normal Posterior
to Anterior (PA)
Clear lungs and a and clean lungs
Clean
Chest X-ray healthy heart and no Normal with no
Lungs fractures in the rib abnormalities
structure. detected in the
heart, lungs, and
ribs.
 This finding
suggests that the
Normal size, shape, and
patient has a
echotexture of the
fibroid
Trans-vaginal Pedunculate uterus,ovaries and No
Abnormal development in
Ultrasound d Fibroids evidence of cysts,
the uterus, which
fibroids, masses, or
causes cysts or
other abnormalities.
masses to adhere
to the gallbladder.

MEDICAL DIAGNOSIS

Patient “L. J`s” admitting diagnosis is G3P3 (3003), The "3003" refers to the number

associated with her GTPAL (gravida, term, pre-term, abortion and living) score. In simple terms,

the patient had two (3) pregnancies and two (3) live births.

An Internal Examination (IE) was conducted to evaluate the internal structures of the

uterus thoroughly. During the examination, a significant mass was detected at the opening of the

cervix. To confirm the findings, a trans-vaginal ultrasound was performed. The ultrasound

revealed that there was a mass inside the patient's uterus with an approximate diameter of 10

centimeters, leading to the confirmation that the mass was indeed a uterine fibroid, also known

as a myoma.

Given the diagnosis of a myoma, the patient was advised to undergo a surgical procedure

known as Total Abdominal Hysterectomy with Bilateral Salpingo-Oophorectomy (TAHBSO).

This procedure involves the removal of the uterus, cervix, both ovaries, and fallopian tubes. The

surgery was carried out and lasted for nearly two hours. Following the successful completion of

the surgery, the patient is now in the recovery phase, where they will be monitored and cared for

to ensure a smooth and complete recovery.

 DRUG STUDY

Mechanism Side Adverse Nursing

Drug Indication Contraindication
of Action Effects Effects Responsibilities

Generic Name: Ketorolac is Inhibits - Nausea - Peptic ulcer, - Hypersensitiv - Assess onset, type,
Ketorolac primarily indicated COX-1 and - GI bleeding, ity to ketorolac, location, and duration
for the short-term COX-2 Vomiting gastritis, and aspirin, or other of pain
Pharmacological management of enzymes, - severe hepatic NSAIDs.
Classification: moderately severe resulting in Diarrhea reaction - Monitor renal
Produces acute pain that decreased - (cholestasis, - Intracranial function, LFT, and
analgesic, requires analgesia prostaglandin Dizziness jaundice) occur bleeding, urinary output.
antipyretic, and at the opioid level. synthesis; - rarely. hemorrhagic
antiinflammatory It is commonly reduces Headache diathesis, - Monitor daily pattern
effects. used for conditions prostaglandin - Rash - Nephrotoxicity incomplete of bowel activity and
such as: levels in (glomerular hemostasis, high stool consistency.
Postoperative pain: aqueous nephritis, risk of bleeding
humor interstitial -Observe for occult
Rheumatoid
nephritis, - Concomitant use blood loss.
arthritis:
nephrotic of aspirin,
Osteoarthritis: syndrome) may NSAIDs, - Assess for therapeutic
Ankylosing occur in pts probenecid, or response: relief of pain,
spondylitis: with preexisting pentoxifylline stiffness, swelling;
renal increased joint
Menstrual impairment. mobility; reduced joint
disorders:
tenderness; improved
Headaches: - Acute grip strength
hypersensitivity
Spinal and soft
 tissue pain: reaction (fever, -Advise the patient to
chills, joint avoid aspirin and
pain) occurs alcohol.
rarely.
- Report abdominal
pain, bloody stools, or
vomiting blood.

Mechanism of Side
Drug Indication Adverse Effects Contraindication Nursing Responsibilities
Action Effects

Generic Name: Ampicillin is Ampicillin - Nausea - Pseudomemb - Hypersensitiv - Monitor for signs of
Ampicillin indicated for works by ranous colitis ity: History of allergic reactions,
the treatment binding to - hypersensitivity to especially after the first
Pharmacological of infections specific Vomiting - Serum any penicillin or dose.
Classification: caused by penicillin- sickness-like cephalosporin
Beta-lactam susceptible binding - reactions antibiotics. - Assess renal function
antibiotics bacteria. proteins Diarrhea and liver enzymes
(PBPs) located -Stevens- - Infectious periodically during
in the bacterial - Rash Johnson Mononucleosis: treatment.
cell wall. syndrome Use is avoided
due to the risk of - Evaluate for therapeutic
- Toxic rash. effectiveness and
epidermal potential side effects.
necrolysis - Caution is
advised in - Ensure that the oral
- patients with renal suspension is well-shaken
Hypersensitivity impairment or before use.
 reactions hepatic
dysfunction - Educate patients to take
the medication at evenly
spaced intervals and
complete the full course
even if they feel better.

- Monitor the patient’s

response to the
medication.

- Evaluate therapeutic
response.

Mechanism of Adverse Nursing

Drug Indication Side Effects Contraindication
Action Effects Responsibilities

Generic Name: Antibiotic It - Nausea - Anaphylaxis - A known allergy - Monitor for signs of
Amoxicillin belonging to competitively - Vomiting (severe to penicillins or allergic reactions,
the binds to - Diarrhea allergic other B-lactam especially after the first
Pharmacological aminopenicillin penicillin- - Rash reaction) antibiotics. dose.
Classification: class binding (including - Clostridium
Beta-lactam proteins allergic difficile- - A history of - Inform patients about
antibiotic (PBPs), which reactions) associated severe allergic potential side effects and
are essential - Yeast diarrhea reactions or when to seek medical
for the cross- infections - Hepatic anaphylaxis to attention.
linking of (due to dysfunction any penicillin.
 peptidoglycan disruption - Hemolytic - Discuss the importance
layers in of normal anemia. - Caution in of adhering to
bacterial cell flora). patients with renal prescribed dosages and
walls. impairment, as schedules to prevent
dosage antibiotic resistance.
adjustments may
be necessary. - Monitor the patient’s
response to the
medication.

- Evaluate therapeutic
response.

Mechanism of Nursing
Drug Indication Side Effects Adverse Effects Contraindication
Action Responsibilities

Generic Name: Treatment Inhibits - Nausea - - Known - Assess onset, type,

Mefenamic of mild to cyclooxygenase- Gastrointestinal hypersensitivity to location, and duration of
moderate 2, the enzyme - Vomiting bleeding or mefenamic acid pain/inflammation.
Pharmacological pain responsible for ulcers or other NSAIDs.
Classification: prostaglandin - Diarrhea - Assess renal function
NSAID, COX-2 synthesis. - Severe skin - Active through urine output and
selective. - Dizziness reactions (e.g., gastrointestinal laboratory tests.
Stevens-Johnson bleeding or peptic
- Headache syndrome, toxic ulcer disease. - Administer mefenamic
epidermal acid as prescribed,
- Rash. necrolysis) - Severe renal typically with food to
 impairment. minimize
- Anemia gastrointestinal
- History of irritation.
- Kidney cardiovascular
impairment. events, - Inform patients about
particularly if potential side effects
there is a recent and when to seek
history of heart medical attention.
attack or stroke. - Explain to the patient
and to the caregiver
what the drug does.

- Monitor the patient’s

response to the
medication.

- Evaluate therapeutic
response.

Mechanism Nursing
Drug Indication Side Effects Adverse Effects Contraindication
of Action Responsibilities

Generic Name: For the Binds to Nausea, allergic - Nephrotoxicity - Patients with - Assess the patient’s
Cefuroxime treatment of bacterial reactions such as especially in known allergy to allergies and previous
many cell rash, pruritus, patients with antibiotics. reactions to
Pharmacological different membranes urticaria, or preexisting renal medications before
Classification: types of and inhibits Thrombophlebitis disease. - Severe administering.
 β-lactam agent bacterial cell wall (pain, redness, hypersensitivity
infections synthesis. swelling at - Antibiotic- reaction for the - Monitor the input and
injection site) assoc patient with a output of the patient
iated colitis history of
(abdominal penicillin allergy - Explain to the patient
cramps, severe and to the caregiver
watery diarrhea, what the drug does.
fever)
- Monitor the patient’s
response to the
medication.

- Evaluate therapeutic
response.

Mechanism Adverse Contraindicatio Nursing

Drug Indication Side Effects
of Action Effects n Responsibilities

Generic Name: Short-term Analgesic: - - Anorexia - Hypersensitiv - Assess the patient’s

Paracetamol treatment of Activates Hypersensitivity ity to paraceta allergies and
moderate descending reaction - Nausea mol and propa previous reactions to
Pharmacological pain serotonergic cetamol HCI medications before
Classification: inhibitory - Diaphoresis (prodrug of administering
Analgesic/Antipyretic pathways in paracetamol).
CNS. - Fatigue - Check the drug-
- Severe drug and drug-food
Antipyretic: - Vomiting hepatocellular interaction.
 Inhibits insufficiency.
hypothalamic - Check if the
heatregulating patient is not taking
center. any other
medication
Therapeutic containing
Effect: paracetamol.
Results in
antipyresis - Monitor the
and produces patient's liver or
analgesic kidney dysfunction
effect. for potential adverse
effects and adjust
the dosage
accordingly.

- Monitor the
patient’s response to
the medication.

- Evaluate
therapeutic
response.
 MEDICAL/SURGICAL MANAGEMENT

Total Abdominal Hysterectomy with Bilateral Salpingo-Oophorectomy (TAHBSO) is

performed to treat heavy menstrual bleeding, uterine fibroids, endometriosis, uterine prolapse,

cancer (uterus, cervix, ovaries, fallopian tubes), chronic pelvic pain, or high risk of ovarian

cancer. In this case, the procedure was done to remove the formed uterine fibroid/myoma in the

uterus of the patient.

The medical and surgical management for Total Abdominal Hysterectomy with Bilateral

Salpingo-Oophorectomy (TAHBSO) involves several steps: Preoperative, Intraoperative, and

Postoperative procedure:

Preoperative Management:

1. Medical Evaluation: Comprehensive assessment including medical history, physical

examination, and necessary laboratory tests (e.g., blood tests, imaging studies).

2. Medication Review: Adjusting current medications to avoid potential interactions and

complications during surgery.

3. Patient Education: Informing the patient about the procedure, potential risks, benefits,

and postoperative care.

Intraoperative Management:

1. Anesthesia: Spinal anesthesia is administered to ensure the patient will have a pain-free

procedure.
 2. Surgical Procedure: An incision is made in the lower abdomen to access and remove the

uterus, cervix, ovaries, and fallopian tubes. The surgery is performed vertically, median

longitudinal; Infraumbilical Incision.

Postoperative Management:

1. Monitoring: Close monitoring in the patient’s room to check for any immediate

complications such as bleeding, infection, or reactions to anesthesia.

2. Pain Management: Administration of pain relief medications as prescribed by the doctor

to manage postoperative pain.

3. Wound Care: Proper care of the surgical incision to prevent infection and promote

healing.

4. Activity Restrictions: Advising the patient to avoid strenuous activities, heavy lifting, and

sexual activity for about 6 weeks.

5. Follow-up Care: Regular follow-up appointments to monitor recovery, manage any

complications, and provide emotional support.

Long-term Management:

1. Lifestyle Adjustments: Encouraging a healthy lifestyle, including a balanced diet, regular

exercise, and smoking cessation to improve overall health and well-being.

 NURSING CARE PLAN
1. Actual NCP
NURSING
ASSESSMENT PLANNING IMPLEMENTATION RATIONALE EVALUATION
DIAGNOSIS

Subjective: Severe pain Short term: Independent: Independent: Short term:

Within 2-4 - Non-pharmacological - This method can help reduce the The patient reports
from the
“Masakit pa e. hours of pain management perception of pain and promote a pain level of
Kapag surgical nursing relaxation. 2/10 within 4
gumagalaw intervention, - Proper Positioning hours after
incision
parang the patient - Minimizing pressure on the interventions
pumipitik.” related to will report Dependent: surgical site can reduce pain and
pain relief of promote comfort Long term:
TAHBSO,
Objective: less than - Give medication or - By discharge, the
as 3/10, or a administer medication as Dependent: patient
- Facial tolerable prescribed by the doctor demonstrates the
evidenced
grimace level. - To manage the patient's ability to perform
- 10/10 pain by the Collaborative: condition and relieve symptoms. daily activities
scale Long term: with minimal
patient's
- Guarding of The patient - Advise the patient not Collaborative: complaints of
the affected verbalizatio will to move too much to pain.
area demonstrate prevent the wound from - To promote quicker healing of
n of pain.
the ability to hurting and to allow it to her surgical wound and avoid pain - Upon discharge,
perform daily heal quickly. the patient
activities - Early detection and verbalizes
without - Assess the wound for management of infection can confidence in
complaints of signs of infection. prevent further complications and managing pain at
pain by pain. home.
discharge. - Observe or ask the - Wound is healing
patient about the pain - To monitor the effectiveness of without signs of
around her surgical the intervention and assess the infection.
wound. patient's pain status.
 2. Actual NCP
NURSING
ASSESSMENT PLANNING IMPLENTATION RATIONALE EVALUATION
DIAGNOSIS

Subjective: The px Activity STG: INDEPENDENT • The patient

verbalize "Before Intolerance • The patient will tolerated
surgery di naman related to post demonstrate improved • Monitored vital signs • Ensured patient activity with
ako madaling surgical tolerance to activity before, during, and after safety during stable vital
mapagod, ngayon recovery within 24–48 hours activity. exertion. signs, minimal
lang nung na postoperatively. fatigue, and no
operahan" • Encouraged the • Prevented signs of
Tissue damage • The patient will patient to perform deconditioning and hypoxia.
report reduced fatigue activities independently promoted self-care.
→ as much as possible.
Objective: and discomfort after • The patient
BP: 130/80 mmHg Inflammatory performing light • Prevented hypoxia
• Scheduled activities engaged in
PR: 93 bpm activities. during exertion.
response → with less periods.
RR: 20 cpm activities with
Temp: 36.8°C Pain and • Prevented fatigue
DEPENDENT little assistance,
SPO2: 95 LTG:( week/months) and supported
swelling →
Pain Scale: 10/10 • The patient will gradual recovery. reported
Fatigue → gradually regain pre- • Provided
supplemental oxygen as reduced pain,
The patient shows surgical activity levels
Reduced ordered. • Reduced pain for
slow execution of within 4–6 weeks. and
better mobility
flexion and oxygen supply
• Administered demonstrated
extension of the •️The patient will
→ Muscle prescribed analgesics
elbows, wrists, and • Improved energy improved
demonstrate improved before activity.
legs, with visible weakness →
levels for activity energy levels
facial expressions muscle strength and
Activity COLLABORATIVE
indicating mild tolerance. from nutritional
endurance with
discomfort during intolerance
• Referred to a dietician support.
movement. minimal fatigue.
for nutritional support.
 3. Risk NCP
Nursing
Assessment Planning Implementation Rationale Evaluation
Diagnosis
Subjective: Risk for Short term: Independent: Independent: Short term:
As the patient Within 2-4 The patient
infection
was asked if hours of - Emphasize the importance of - Proper hygiene helps by verbalized comfort
there were from the nursing proper hygiene limiting exposure to and relief with a
any concerns intervention, harmful microorganism much more eased
recent
she had in the patient will - Basic incision care that was that may cause the appearance.
mind the surgical report lessened advised by the potential infection.
patient discomfort and doctor/registered nurse.
operation. Long term:
verbalized show relief.
“Nangangati Dependent: - Incision care minimizes - By discharge, the
lang banda sa Long term: - Administer/monitor the risk of infections, patient
tahi ko”. The patient medication regimen (e.g., reduces pain, and promotes demonstrates the
will antimicrobials, antibiotics etc.) a smoother recovery. ability to perform
Objective: demonstrate as prescribed by the doctor and daily activities
Vital Signs understanding note the client’s response to Dependent: while still
2/8/25 of causative determine effectiveness of demonstrating
factors of therapy or presence of side - To manage the patient's preventive
BP: 130/90 infections and effects. condition and relieve behaviors towards
mmHg identify symptoms. risk of infection.
T: 36.4 0C different - Cleanse incisions and
PR: 85 bpm interventions insertion sites per facility - Lessen the chance of The patient learned
RR: 20 cpm to protocol with appropriate infection, clear away different ways of
O2: 98 % prevent/reduce antimicrobial topical or harmful debris, encourage appropriate coping
risk of solution to reduce the potential healthy healing, and enable behaviors and
Weak developing for catheter-related early detection of possible needed
appearance infection. bloodstream infections, and to issues, all of which assist in lifestyle changes.
prevent the growth of bacteria avoiding more severe
problems down the line.
Collaborative: Collaborative:

- Include information in - To address complicated

preoperative teaching about problems with unresolved
ways to reduce the potential for concerns, to establish
postoperative infection (e.g., infection reduction
respiratory measures to prevent objectives and plan.
pneumonia, wound and
dressing care, avoidance of
others with infection).
 DISCHARGE PLAN

MEDICATION - Advil (60p mg every 6 hours) as needed for cramps

(administer according to the - Tylenol (1-2 tablets every 4 hours) as needed for pain
physician's order)
- No physical activity 2 weeks post operation
- Do not lift, pull or push any heavy objects for 6 weeks
EXERCISES post operation
- Light physical activity (walking, climbing stairs etc.)
can be done at patient's own pace
- Clean the incision area with antiseptic
TREATMENT
- Change dressing as instructed by the physician
Monitor for exudates, redness, swelling, and pain in the
incision area (report to the physician if there is any
abnormal observations)
HEALTH TEACHING - Monitor vaginal bleeding (report to the physician if
there are any abnormal observations)
- Monitor urine output and bowel movement (report
problem to the physician)
OUT-PATIENT FOLLOW UP - 2 weeks and 6 weeks post operation
- Patient may resume normal full diet after discharge
- Eat plenty of nutrient rich foods such as green leafy
DIET vegetables and protein to restore tissue
- Drink plenty of water to decrease risk for urinary tract
infection
- Support from family and friends is essential for fast
recovery
SPIRITUAL/SEX
- Sexual intercourse and using of tampons are prohibited
6 weeks post operation
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