Question

1. Setting: Emergency Room

 This is a case of a 47-year-old lady who was brought to the emergency room due to the complaint of abdominal enlargement and abdominal pain at her hypogastric area. Hence, referred to Surgery Department for further management.

 At 5:15pm patient ABC is seen & examined by Dr. M (Surgeon). The attending physician ordered for admission. The admitting diagnosis of Bilateral Ovarian Cysts, Larger at the Left Ovary most likely a Dermoid Cyst with the following orders:

- Schedule for TAHBSO tomorrow 4th case (2pm).

- Secure consent

- TPR q4H

- Inform OR

- Inform Dr. U for Anesthesia

- Inform Dr. Y for Assist during surgery

- Soft diet then NPO post-midnight

- Secure 2 units PRBC of patient’s blood type properly screened and cross matched and standby for OR use.

- Attach CP clearance

- Labs:

• CBC, Blood Typing

- Full bath at 8am

- Insert IVF of PNSS 1-liter after full bath and regulate at 30 gtts/min.

- Pre op Medications:

• Cefazolin 1gm IVTT ANST prior to OR

• Ranitidine 50mg/2mL amp IVTT prior to OR

• Diphenhydramine 25mg amp, on call to OR IVTT at 3pm

• Cefazolin 500mg vial IVTT prior to OR

• Metoclopramide 5mg/mL amp IVTT prior to OR

• Dulcolax 2tabs at HS

• Fleet enema at 1pm prior to OR

Patients Profile:

Name: Patient ABC Age: 47 Sex: Female Civil Status: Married

Date and Time of admission: JAN 1 2020 @ 4:15 PM

Chief complaint: Abdominal enlargement and abdominal pain at her hypogastric area 2 weeks PTA.

Baseline Vital Signs:

T – 37.2 C PR – 82

RR – 20

BP – RU – 110/70 mmhg LU - 100/60 mmhg

Pain Scale: 8 /10

Laboratory Result:

Complete Blood Count:

- WBC – 5.0

- RBC - 4.6

- Hemoglobin – 10.4g/dL

- Hematocrit – 33.4

- MCV – 88.7

- MCH – 30.4

- MCHC – 34.3

- Platelet – 350

Blood Chemistry:

- SGPT – 26.60

- Cholesterol – 216.15 mg/dL

- Triglycerides – 93.93 mg/dL

- Potassium – 4.24 mEq/L

- Uric Acid – 6.05 mg/dL

- FBS – 106.72

UTZ: FINDINGS:

- Right ovary measures 4.1 x 2.0 x 3.7 cm with a cystic mass measuring 3.4 x

2.2 x 2.0 cm with internal echoes while the left ovary is obscured. A large cystic mass measuring 8.81 x 6.20 x 8.68 cm with internal low-level echoes and hyperechoic cap is seen in the left adnexa.

IMPRESSION:

- Normal sized retroverted uterus with proliferative endometrium. IUD in site.

- Bilateral ovarian cysts, larger in the left most likely dermoid cyst.

- Sonographically normal cervix

X- RAY: IMPRESSION:

- Mild Cardiomegaly

Guide Questions:

1. Identify the clinical manifestations that can support the Diagnosis? (aside from symptoms showed by the client).

2. Make an inference of the laboratory results.

3. Identify the important data you want to know during endorsement as an OR Nurse as you received the patient from ward.

4. What are the most common causes of Ovarian cyst?

5. What are the reasons why your provider may suggest a hysterectomy and salpingectomy?

6. Enumerate possible risks of this procedure.

7. Make drug study in all medications of the patient

8. Identify at least 5 priority NCP

 At 1:00pm patient SL was cleared for Operation and endorsed directly to OR via stretcher.

2. Setting: Intraoperative (at OR)

3pm:

- General anesthesia inducted by Anesthesiologist

- Foley balloon catheter inserted by the circulating SN aseptically

- Surgical scrubbing done

- Skin prep done by student nurse

- Apply draping

- Started the procedure

- A horizontal incision is made in the lower abdomen along the pubic hair, or bikini, line.

- 2 units of PRBC hooked and transfused after proper cross matching

- Bleeders clamped and cauterized

- Suctioning done

- Ovary, uterus, and fallopian tubes removed

- Final counting of instruments, sponges, and sutures done - complete

- Suturing done

- Post op dressing done aseptically 5pm:

- Operation ended

3. Setting: PACU

Post op Orders:

- To Recovery room (PACU)

- Take vital signs q15 mins for 1 hour; q30 mins for 2 hours: qH for 4 hours and q4 hours until stable

- Regulate present IVF of PNSS 1L at 30 gtts/min

- IVF to Follow: 2 bottles of D5LR 1L regulate at same rate

- Monitor I and O q2H and record

- NPO until further orders

- Refer for any unusualities

- Post op Medications:

• Ciprofloxacin 500 mg vial IVTT q8H

• Metronidazole 500 mg vial IVTT q8H

• Tramadol 50 mg/mL q6H IVTT

• Cefaclor 1 gm IVTT q8H

• Tranexamic acid 500 mg IVTT q8H x 2 doses only

• Ketorolac 30 mg IVTT every 6H x 4 doses

Answer 1

QUESTION:

1. Identify the clinical manifestations that can support the Diagnosis? (aside from symptoms showed by the client).

2. Make an inference of the laboratory results.

3. Identify the important data you want to know during endorsement as an OR Nurse as you received the patient from ward.

4. What are the most common causes of Ovarian cyst?

5. What are the reasons why your provider may suggest a hysterectomy and salpingectomy?

6. Enumerate possible risks of this procedure.

7. Make drug study in all medications of the patient

8. Identify at least 5 priority NCP

ANSWERS:

1. Identify the clinical manifestations that can support the Diagnosis? (aside from symptoms showed by the client).

• Symptoms showed by the client: Abdominal enlargement and abdominal pain at her hypogastric area for 2 weeks.
• Most ovarian cysts are small and don't cause symptoms.
• If a cyst does cause symptoms, patient may have pressure, bloating, swelling, or pain in the lower abdomen on the side of the cyst. This pain may be sharp or dull and may come and go.
• If a cyst ruptures, it can cause sudden, severe pain.
• If a cyst causes twisting of an ovary, patient may have pain along with nausea and vomiting.
• Less common symptoms include:
  • Pelvic pain
  • Dull ache in the lower back and thighs
  • Problems emptying the bladder or bowel completely
  • Pain during sex
  • Unexplained weight gain
  • Pain during your period
  • Unusual (not normal) vaginal bleeding
  • Breast tenderness
  • Needing to urinate more often

2. Make an inference of the laboratory results.

Complete Blood Count:

lnvestigation –patient value-inference-normal value

WBC   – 5.0 –  normal - 4.5 to 11.0x10⁹/L

RBC - 4.6 -normal -4.2 TO 5.4 MILLION CELLS /mcL

Hemoglobin – 10.4g/Dl -decreased-12.0 to 15.5 gm/dl

Hematocrit – 33.4 -decreased-36% to 48%

MCV – 88.7 -normal -80 to 100fL

MCH – 30.4 -normal -27.5 TO 33.2 pg

MCHC – 34.3 -normal -32 to 36 g/dl

Platelet – 350 -normal -150 to 400x10⁹/L

Blood Chemistry:

Investigation –patient value-inference-normal value

SGPT – 26.60 -normal -7 TO 56 UNITS PER LITRE OF SERUM

Cholesterol – 216.15 mg/Dl-increased -<200mg/dl

Triglycerides – 93.93 mg/dL -normal -<150mg/dL

Potassium – 4.24 mEq/L—normal -3.6 TO 5.2 mmol/L

Uric Acid – 6.05 mg/dL-shlightly increased-2.4 to 6.0mg/dl

FBS – 106.72 -slightly increased-<100mg/dl

3. Identify the important data you want to know during endorsement as an OR Nurse as you received the patient from ward.

• All patients transferred to from one clinical area to another clinical area require handover to be documented in the EMR. This includes details of the transfer time indicating a transfer of professional responsibility and accountability
• Positive Patient identification process occurs to confirm full name, date of birth and Medical Record Number (MRN) to the EMR as per the RCH Patient Identification Procedure
• Clinical alerts are identified (e.g. FYI flags, allergies, infection control precautions, MET modifications)
• The handover is documented in the EMR
• A patient can be transported by CARPs, parents/ carers if the patient is assessed as:

• Stable
• Predictable
• Having no fluids or blood product transfusions running
• Requiring clinical observations <4 hourly
• Handover can be conducted over the phone to the receiving nurse/ AUM/ appropriate health practitioner who will then assume responsibility and accountability for the patient
• A patient must be escorted by the nurse if the patient is assessed as:
  
  • Unstable
  • Having fluids or blood transfusions running
  • Requiring clinical observations <4 hourly
  • Handover occurs between the nurse that holds responsibility for care and the nurse who will be assuming responsibility for the care of the patient

4. What are the most common causes of Ovarian cyst?

Corpus luteum cyst

Most ovarian cysts develop as a result of menstrual cycle (functional cysts). Other types of cysts are much less common.

Functional cysts

Your ovaries normally grow cyst-like structures called follicles each month. Follicles produce the hormones estrogen and progesterone and release an egg when patient ovulate.

If a normal monthly follicle keeps growing, it's known as a functional cyst. There are two types of functional cysts:

· Follicular cyst. Around the midpoint of your menstrual cycle, an egg bursts out of its follicle and travels down the fallopian tube. A follicular cyst begins when the follicle doesn't rupture or release its egg, but continues to grow.

· Corpus luteum cyst. When a follicle releases its egg, it begins producing estrogen and progesterone for conception. This follicle is now called the corpus luteum. Sometimes, fluid accumulates inside the follicle, causing the corpus luteum to grow into a cyst.

Functional cysts are usually harmless, rarely cause pain, and often disappear on their own within two or three menstrual cycles.

Other cysts

Types of cysts not related to the normal function of your menstrual cycle include:

· Dermoid cysts. Also called teratomas, these can contain tissue, such as hair, skin or teeth, because they form from embryonic cells. They're rarely cancerous.

· Cystadenomas. These develop on the surface of an ovary and might be filled with a watery or a mucous material.

· Endometriomas. These develop as a result of a condition in which uterine endometrial cells grow outside your uterus (endometriosis). Some of the tissue can attach to ovary and form a growth.

CAUSES:

· Hormonal problems. These include taking the fertility drug clomiphene (Clomid), which is used to ovulate.

· Pregnancy. Sometimes, the cyst that forms when you ovulate stays on ovary throughout pregnancy.

· Endometriosis. This condition causes uterine endometrial cells to grow outside uterus. Some of the tissue can attach to your ovary and form a growth.

· A severe pelvic infection. If the infection spreads to the ovaries, it can cause cysts.

· A previous ovarian cyst.

5. What are the reasons why your provider may suggest a hysterectomy and salpingectomy?

Hysterectomy is a surgery to remove the uterus and cervix. “Abdominal” is the surgical technique that will be used. This means the surgery will be done through an incision in your abdomen. A bilateral salpingo-oophorectomy is surgery to remove both of your ovaries and fallopian tubes. The hysterectomy and bilateral salpingo-oophorectomy will both be done during one procedure. This surgery will remove the uterus, cervix, ovaries, and fallopian tubes. Patient may need to have a bilateral salpingo-oophorectomy along with hysterectomy if she is high risk for ovarian cancer, have certain types of breast cancer, or have ovarian masses or cysts.

6. Enumerate possible risks of this procedure?.

There are some potential complications of a hysterectomy. As for any surgical procedure, the general complications include risk of haemorrhage, infection and pain. There is also a general anaesthetic risk.

The specific complications of hysterectomy include:

· Damage to the bladder and/or the ureter (seven women in every 1000) and/or long-term disturbance to the bladder function (uncommon)

· Damage to the bowel: four women in every 10 000 (rare)

· Haemorrhage requiring blood transfusion, 23 women in every 1 000 (common)

· Return to theatre because of bleeding/wound dehiscence, and so on: seven women in every 1000 (uncommon)

· Pelvic abscess/infection: two women in every 1000 (uncommon)

· Venous thrombosis or pulmonary embolism, four women in every 1000 (uncommon)

· Risk of death within 6 weeks, 32 women in every 100 000 (rare). The main causes of death are pulmonary embolism and cardiac disease.

· Fever and infection

· Heavy bleeding during or after surgery

· Injury to the urinary tract or nearby organs

· Blood clots in the leg that can travel to the lungs

· Breathing or heart problems related to anesthesia

· Death

There are risks to any type of surgery, including a bad reaction to anesthesia. Laparoscopy can take more time than open surgery, so patient may be under anesthesia longer. Other risks of salpingectomy include:

• develop a fever and chills
• have worsening pain or nausea
• notice discharge, redness, or swelling around the incisions
• have unexpected heavy vaginal bleeding
• can’t empty your bladder

• infection (the risk of infection is lower with laparoscopy than with open surgery)
• internal bleeding or bleeding at the surgical site
• hernia
• damage to blood vessels or nearby organs

7. Make drug study in all medications of the patient

1.Cefazolin

Name of drug: Cefazolin

Dose/route/frequency: 1gm IVTT ANST prior to OR

Indications: Cefazolin is an antibiotic used to treat a wide variety of bacterial infections. It may also be used before and during certain surgeries to help prevent infection

Contra-indications: allergy

Mechanism of action: Cephalosporins exert bactericidal activity by interfering with the later stages of bacterial cell wall synthesis through inactivation of one or more penicillin-binding proteins and inhibiting cross-linking of the peptidoglycan structure.

Adverse effects :Diarrhea, oral candidiasis (oral thrush), mouth ulcers, vomiting, nausea, stomach cramps, epigastric pain, heartburn, flatus, anorexia and pseudomembranous colitis. Onset of pseudomembranous colitis symptoms may occur during or after antibacterial treatment Anaphylaxis, eosinophilia, urticaria, itching, drug fever, skin rash, Stevens-Johnson syndrome. Pruritus (including genital, vulvar and anal pruritus, genital moniliasis, and vaginitis).Dizziness, fainting, lightheadedness, confusion, weakness, tiredness, hypotension, somnolence and headache.

2. Ranitidine

Name of drug: Ranitidine

Dose/route/frequency: 50mg/2mL amp IVTT prior to OR

Indications: Ranitidine has been used to treat and prevent ulcers in the stomach and intestines. It also was used to treat conditions in which the stomach produces too much acid, such as Zollinger-Ellison syndrome..

Ranitidine was also used to treat gastroesophageal reflux disease (GERD) and other conditions in which acid backs up from the stomach into the esophagus, causing heartburn.

Contra-indications:Allergy

Mechanism of action: Ranitidine belongs to a group of drugs called histamine-2 blockers. It works by reducing the amount of acid your stomach produces.

Adverse effects: stomach pain, loss of appetite; dark urine, jaundice (yellowing of the skin or eyes);fever, chills, cough with mucus, chest pain, feeling short of breath;

fast or slow heart rate;easy bruising or bleeding; or problems with skin or hair. Common ranitidine

3. Diphenhydramine

Name of drug: Diphenhydramine

Dose/route/frequency: 25mg amp, on call to OR IVTT at 3pm

Indications: Diphenhydramine is used to treat sneezing, runny nose, watery eyes, hives, skin rash, itching, and other cold or allergy symptoms.

Diphenhydramine is also used to treat motion sickness, to induce sleep, and to treat certain symptoms of Parkinson's disease.

Contra-indications: blockage in your digestive tract (stomach or intestines);bladder obstruction or other urination problems;a colostomy or ileostomy;liver or kidney disease; asthma, chronic obstructive pulmonary disease (COPD), or other breathing disorder;cough with mucus, or cough caused by smoking, emphysema, or chronic bronchitis;heart disease, low blood pressure;glaucoma;a thyroid disorderchild younger than 2 years old.

Mechanism of action: Diphenhydramine is an antihistamine that reduces the effects of natural chemical histamine in the body.

Adverse effects: pounding heartbeats or fluttering in chest;painful or difficult urination;

little or no urinating; confusion, feeling like pass out; or tightness in neck or jaw, uncontrollable movements of tongue.

4. Metoclopramide

Name of drug: Metoclopramide

Dose/route/frequency: 5mg/mL amp IVTT prior to OR

Indications: to treat heartburn caused by gastroesophageal reflux in people who have used other medications without relief.Metoclopramide oral is also used to treat gastroparesis (slow stomach emptying) in people with diabetes, which can cause heartburn and stomach discomfort after meals.Metoclopramide injection is used to treat severe diabetic gastroparesis. The injection is also used to prevent nausea and vomiting caused by chemotherapy or surgery, or to aid in certain medical procedures involving the stomach or intestines.

Contra-indications: tardive dyskinesia (a disorder of involuntary movements);stomach or intestinal problems such as a blockage, bleeding, or perforation (a hole or tear in stomach or intestines);epilepsy or other seizure disorder;an adrenal gland tumor (pheochromocytoma); or

Mechanism of action: Metoclopramide increases muscle contractions in the upper digestive tract. This speeds up the rate at which the stomach empties into the intestines.

Adverse effects: confusion, depression, thoughts of suicide or hurting yourself; slow or jerky muscle movements, problems with balance or walking; mask-like appearance in face;

a seizure; anxiety, agitation, jittery feeling, trouble staying still, trouble sleeping; swelling, feeling short of breath, rapid weight gain; or severe nervous system reaction very stiff (rigid) muscles, high fever, sweating, confusion, fast or uneven heartbeats, tremors.

5.Dulcolax

Name of drug: Dulcolax

Dose/route/frequency: 2tabs at HS

Indications:Dulcolax is used to treat constipation or to empty the bowels before surgery, colonoscopy, x-rays, or other intestinal medical procedure.

Contra-indications: stomach pain, nausea, or vomiting.

Mechanism of action: Dulcolax (bisacodyl) is a laxative that stimulates bowel movements.

Adverse effects: stomach pain or discomfort; feeling light-headed; or rectal burning.

6.Fleet enema

Name of drug: Fleet enema

Dose/route/frequency: at 1pm prior to OR

Indications: It is used to treat constipation.

It is used as a laxative to clean out the colon before an exam.

Contra-indications: Bowel block, belly pain, upset stomach, rectal bleeding

Mechanism of action: increase bowel movement and clean out the colon

Adverse effects: Belly pain. Stomach cramps. Burning.

8. Identify at least 5 priorities NCP

· Acute Pain

· Altered Nutrition: Less Than Body Requirements

· Anticipatory Grieving

· Situational Low Self-Esteem

· Risk for Fluid Volume Deficit

· Fatigue

· Risk for Infection

· Risk for Altered Oral Mucous Membranes

· Risk for Impaired Skin Integrity

· Risk for Constipation/Diarrhea

· Risk for Altered Sexuality Patterns

· Risk for Altered Family Process

· Fear/Anxiety