H-mole

• After the case presentation, we the
nursing students will be able to acquire
new knowledge, enhance learned skills
and develop desirable attitudes towards
the care of a patient who is diagnosed
with Hydatidiform mole (H-mole)
utilizing the nursing process.

Knowledge:
• define and describe Hydatidiform mole (H-
mole);
• discuss the incidence and prevalence rate,
etiology, risk factors, signs and symptoms,
complications, diagnostic tests and
treatment of the said problem;

• discuss the anatomy and physiology of
female reproductive system related to the
patient’s condition;
• explain the pathophysiology of
Hydatidiform mole(H-mole) in relation to
patient’s condition;

Specifically, we will be
able to:

• compare the laboratory results with the
standard normal values, diagnostic test results
and identify its clinical significance; and
• enumerate the medications that have been
administered and know its dosage, actions,
adverse or side effects, contraindications and
nursing responsibilities involved.

Skills:
• assess the patient using the cephalo-caudal
format and identify problems related to the
patient’s condition.
• formulate nursing diagnosis in relation to
the patient’s condition using concept map.
• formulate and implement nursing care plan
that address patients’ identified problem.

• evaluate the patient’s response to medical
and nursing interventions rendered.
• apply effective therapeutic communication
with the patient and to her significant
others.

Attitude:
• acknowledge the patient and family’s
expression and feelings about her condition.
• develop understanding about patients’
behavior in relation to the experienced illness
and provide ways on how to cope with it; and
• display positive attitude when interacting
with the patient who has Hydatidiform mole.

is a decrease in the
hemoglobin in the blood
levels usually below the
normal range of 12-
16g/dl for women.

a part of the cell
that carries the
genetic material of
a person.

a procedure in which the
cervix is mechanically dilated
and the contents of the uterus
scraped or suctioned out. It is
performed after an
incomplete miscarriage.

a hormone produced during
pregnancy. Excreted in
urine, hCG is used in
testing to detect pregnancy.
This can also be detected
in serum specimen.

An abnormal
pregnancy in which
there is no fetus, only
an abnormal mass
growth.

a fluid filled vesicles that
rapidly grow causing the
uterus to be larger than
expected to the duration
of pregnancy.

an exaggerated form of morning
sickness characterized by
extreme, frequent, and severe
nausea and vomiting during
pregnancy, and sometimes
leading to dehydration and
hospitalization.

too much thyroid
hormone
production.

It involves removal
of the uterus which
ensures removal of
all tumor cells.

it is the first day of last
menstrual period, the date
that is used to calculate
the 40 weeks of
pregnancy and a woman's
due date.

is a black line that runs down the
center of the abdomen to the top of
the pubic bone. This darkening is
caused by pregnancy hormones. The
linea nigra may be more noticeable
in dark-skinned women than those
who are fair-skinned.

a layer of cells that
surrounds an
embryo finger-like
projection called
Villi.

• refers to blood often found on
underwear, the toilet paper, in
the toilet bowl or after sexual
intercourse. The blood loss may
or may not be accompanied by
other symptoms such as pain.

neoplastic
disorder that
originates in the
placenta

Hydatidiform mole (H-mole)also as known
Gestational Trophoblastic Disease (GTD) is a
rare mass or growth which arises from fetal
tissue that may form inside the uterus at the
beginning of a pregnancy. Frequently there is
no fetus at all. In the complete or classic mole,
there is marked edema and enlargement of the
villi with disappearance of the villous blood
vessels.

 There is proliferation of the trophoblastic lining
of the villi.
Hydatidiform mole (H-mole) also is a group of
rare tumors that involve abnormal growth of cells
inside a woman's uterus.
It also does not develop from cells of the uterus
like cervical cancer or endometrial (uterine lining)
cancer do. Instead, these tumors start in the cells that
would normally develop into the placenta during
pregnancy.

Hydatidiform mole (H-mole) or GTD also
begins in the layer of cells called
the trophoblast that normally surrounds an
embryo.
(Tropho- means nutrition, and -blast means bud
or early developmental cell.)
 Early in normal development, the cells of the
trophoblast form tiny, finger-like projections
known as villi. The villi grow into the lining of
the uterus.

In time, the trophoblast layer develops into the
placenta, the organ that protects and nourishes the
growing fetus.
Most Hydatidiform mole (H-mole) also are benign
(not cancer) and they don't invade deeply into body
tissues or spread to other parts of the body. But some
are malignant (cancerous).

Because not all of these tumors are cancerous, this
group of tumors may be referred to as gestational
trophoblastic disease, gestational trophoblastic
tumors, or gestational trophoblastic neoplasia. (The
word neoplasia simply means new growth.)
All forms of Hydatidiform mole (H-mole) also can
be treated. And in most cases the treatment produces
a complete cure.

Types of
Hydatidiform mole
(H-mole)

All trophoblastic villi swell
and become cystic. If an
embryo forms, it dies early at
only 1 to2 mm in size, with
no fetal blood present in the
villi.

On chromosomal analysis,
although the karyotype is
anormal 46XX or 46XY, this
chromosome component was
contributed only by a father or an
“empty ovum “was fertilized and
the chromosome material was
duplicated.

 With a partial mole, some of the
villi form normally.
The syncytiotrophoblastic layer of
thevilli, however, is swollen and
misshapen. A macerated embryo of
approximately 9 weeks; gestation
maybe present in the villi

 A partial mole has 69 chromosomes (a
triploid formation in which there is
three chromosomes instead of two for
every pair, one set supplied by an ovum
that apparently was fertilized by two
sperm or an ovum fertilized by one
sperm in which meiosis or reduction
division did not occur).

 This could also occur if one set
of 23 chromosomes was supplied
by one sperm and an ovum did not
undergo reduction division
supplied 46. In contrast to
complete moles, partial moles
rarely lead to choriocarcinoma.

Incidence
(World Wide and in the
Philippines)

• Although Hydatidiform mole (H-mole) is
rare approximately only 1 in every 1,500
occurs inpregnancies in North America,
Australia, New Zealand and Europe.
• In 2011 up to 2.0 per 1,000 pregnancies in
Southeast Asia & Japan.
• Up to 20% of these will require treatment
for malignant sequelae (2011).

• The incidence of Hydatidiform mole is
approximately 1 in every 1200 pregnancies
occur in the Philippines. (P. Sanchez,
2010).
• The condition tends to occur most often in
women who have a low protein intake, in
women older than age 35 years, in women
of Asian heritage, and in blood group A
women who marry blood group O men
(Aghajanian, 2007).

American Indians, Eskimos,
Hispanics, African Americans,
& Asians
extremes of maternal age:
•>35 or <21 risk is 1.9 times
higher
•>40 risk is 7.5 times higher

prior molar pregnancy – 10-20
times greater than general
population:
familial cluster are associated
with novel missense NLRP7 gene
mutation on chromosome19q.

anemia from blood loss
excessive nausea and vomiting
abdominal cramps (caused by
uterine distention
pallor- indicating anemia may
be present
Amenorrhea

vaginal bleeding as the main complaint;
due to the separation of vesicles from
the uterine wall and there may be blood-
stained, watery discharge (the watery
part is from the ruptured vesicles)
prune juice-like discharge may occur
brownish because it is retained for
sometime inside the uterine cavity.

blood may be concealed in the uterus,
thereby causing enlargement.
abdominal pain: may be dull-aching due to
rapid distension of uterine by mole or by
concealed hemorrhage; colicky due to start
of expulsion.
ovarian pain due to stretching of ovarian
capsule or complication in the cystic ovary
as torsion.

a test that measures levels of
pregnancy hormones in
additional blood tests - tests,
like those for anemia, may
provide evidence of H-mole.

performed after the third month
revealing grapelike clusters
rather than a fetus, no fetal
skeleton detected by ultrasound,
and evidence of a snowflakelike
pattern

an imaging technique
that uses sound waves to
produce an image on a
monitor of the
abdominal organs.

a noninvasive procedure that takes cross-
sectional images of the brain or other
internal organs; to detect any
abnormalities that may not show up on
an ordinary x-ray. The CT scan may
indicate enlarged lymph nodes - a
possible sign of a spreading cancer or of
an infection.

a diagnostic procedure that
uses a combination of large
magnets, radiofrequencies,
and a computer to produce
detailed images of organs and
structures within the body.

a type of scan that monitors the
biochemical functioning of cells
by detecting how they process
certain compounds, such as
glucose (sugar). Cancer cells
metabolize glucose at a much
higher level than normal tissues.

this is a hybrid technology combines
the strengths of two well-established
imaging techniques, allowing
physicians to precisely overlay the
metabolic data of the PET scan and
the detailed anatomic data of the CT
scan to pinpoint the location and
stage of tumors.

A urinary pregnancy test
should be performed 3 weeks
after medical management of
failed pregnancy if products of
conception are not sent for
histological examination.

Anti-D prophylaxis is required
following evacuation of a molar
pregnancy.
Preparation of the cervix
immediately prior to evacuation
is safe.

The use of oxytocic
infusion prior to
completion of the
evacuation is not
recommended.

If the woman is experiencing
significant haemorrhage prior to
evacuation, surgical evacuation
should be expedited and the need for
oxytocin infusion weighed up against
the risk of tumour embolisation.
Blood transfusion to treat severe
anemia due to vaginal bleeding.

Prophylactic course of
Methotrexate, the drug of choice
for choriocarcinoma.
Pelvic examinations and chest X-
rays at regular intervals.
Histophatology of evacuated
specimen from curettage.

 is a surgical procedure used to remove
non cancerous hydatidiform moles. The
opening in the cervix is dilated and the
inside uterus lining is scraped
(curetted) clean using suction and
curette (spoon-shaped instrument).

 D & C is commonly used to obtain
tissue for microscopic evaluation to
rule out cancer. D & C may also be
used to diagnose and treat heavy
menstrual bleeding, and to diagnose
endometrial polyp’s and uterine
fibroids.

D & C can also be used
as an early abortion
technique up to 16 weeks.

is the method of choice of evacuation for
complete molar pregnancies. It is also
the method of choice of evacuation for
partial molar pregnancies except when
the size of the fetal parts deters the use
of suction curettage and then medical
evacuation can be used.

 is procedure in which the
cervix is dilated and tissue is
removed from the uterus.
D&E is used to describe two
different procedures.

D&E can also be used to describe a surgical
removal of a fetus and placenta between 14-
20 weeks of gestation, called also late
abortion or second trimester abortion. To
accomplish dilatation/dilation and evacuation,
negative pressure/vacuum is used to aspirate
tissue from the inside of the uterus.
The procedures thought to be less traumatic
to the surface of the uterine cavity than a
sharp curettage.

• it is the removal of the uterus. This is
used rarely to treat hydatidiform moles
but may be chosen, particularly if the
woman does not want to become
pregnant again. It may be done through
the abdomen or the vagina.

•Others are:
oTumors in the uterus like uterine
fibroids or endometrial cancer
oCancer of the cervix or severe
cervical dysplasia (a
precancerous condition of the
cervix)

oCancer of the ovary
oEndometriosis, in those cases in
which the pain is severe and not
responsive to nonsurgical
treatments

oSevere, long-term (chronic)
vaginal bleeding that cannot be
controlled by medications
oProlapsed of the uterus
oComplications during
childbirth (like uncontrollable
bleeding)

Sagittal Section of the Female Pelvis

Normal human
embryonic
development.

Predisposing Factor
Resident of
Asian country
(Rate 15x higher
than U.S.)
Precipitating Factors
•Defects in ova
Abnormalities in uterus
Nutritional deficiency
Diet low in protein and folic acid
Chromosomal abnormalities
Hormonal imbalances
Coitus (Sex)

Haploid Ova (Triploid
formation)
•69XXX chromosomes
or
69XXY chromosomes
Haploid Sperm (Empty
ovum)
Duplicated sperm
90% 46XX
chromosomes
10% 46XY
chromosomes
Abnormal Fertilization

Hyperplasia
Swelling of Chorionic Villi
Excessive Uterine
Enlargement
Tumorous Growth in Placenta
Rapid increase in fundic height
Rapid increase in weight
Vaginal Bleeding
Thromboplastic Tissue
Formation
Formation of Moles
Passage of Grape-like clusters
High levels of hCG
Excessive nausea and
vomiting
Highly positive urine test
for pregnancy
COMPLETE MOLE

Hydatidiform
mole formation
video

Name: Ms. R. P. M.
Age: 23 years old
Sex: Female
Civil Status: Single
Religion: Roman Catholic
Birth Date: Jan. 27, 1992
Birth Place: Aranas Balete, Aklan
Current Address: Arcangel Sur Balete, Aklan
Educational Attainment: High School Graduate
Occupation: none

Chief Complaint: Vaginal bleeding
Date of Admission to ER: Feb. 18, 2015
Mode of Transportation upon Admission:
Transported via L300 van
Accompanied by: Husband
Emotional/ Mental Status upon Admission: Alert,
oriented and cooperative

Temperature- 36.7
Pulse Rate- 85 bpm
Respiratory Rate- 21 cpm
Blood Pressure- 120/70 mmHg

Attending Physicians:
(HOUSE CASE)
Admitting Physician: Dr. H.C.E.Q.
Surgeon: Dr. G.M.V.
Anesthesiologist: Dr. C.B.V.S.

Other APs:
•Dr. M.A.D.V
•Dr. F.I.G.
•Dr. J.S.R.B.
•Dr. D.A.M.
•Dr. K. G. S. M.
Co-management of Dept. of Internal
Medicine: Dr. M.V.G.B.

Admission/ Principal Diagnosis: G2P1
(1000) Hyadatiform Mole 14 weeks;
Severe Anemia
Surgery/ Procedures performed:
Suction Dilatation and Curettage / Blood
Transfusion
Source of Information: Primary:
Patient Secondary: Patient’s chart,
Attending Physician

On the 11th day of February 2015,
around 6:00 in the morning at
Archangel Sur, Balete, Aklan, Ms.
R.P.M. woke up because of a wet
feeling coming from her vagina, so she
rose from her bed to check it in the
bathroom, she then found out that it
was blood approximately 1 pad.

She thought it was just menstruation
because she thought she was just
delayed for two months on her
monthly menstruation that’s why she
did nothing with it, just wear napkin
and did her daily morning routine-
take her breakfast and do exercise.

But around 11:00 A.M. in the morning,
the bleeding progressed allowing her to
consume 3 pads of soaked napkins in
the morning and another 5 pads of
napkins in the afternoon until in the
evening. Next day, February 12, the
bleeding stopped and came back on
February 18 around 6:00 A.M.

And she started vomiting excessively
about 3 to 4 times approximately
100ml of clear whitish liquid. She was
then brought to the RHU in Balete by
her mother around 8:00 A.M. . In the
RHU, Dr. J.D. examined her and
requested her to do an abdominal
ultrasound.

She was referred by Dr. J.D. to be
admitted that day in DRSTMH but she
was required to have blood transfusion
and they had no blood available yet
that’s why they decided to went home
around 10:30 A.M. of the same day.
They continuously looked for blood on
February 19, 2015.

On, February 20, 2015, there was
blood available and around 3:30
P.M. Ms. R.P.M., accompanied by
her mother went to Kalibo via by a
L3 van for admission in DRSTMH.
4:15 P.M., Ms. R.P.M. And her
mother arrived to DRSTMH.

She was then brought to the E.R. and
was examined by Dr. H.C.E.Q. and was
diagnosed 14 weeks Molar Pregnancy.
During Admission the patient is
experiencing persistent cough. Fluimucil
600mg 1 tab in one half glass and
salbutamol 1neb every 6hours had been
prescribed by the Dr. J.S.R.B.

According to Ms. R.P.M., during her
childhood, she had received complete doses
of the required vaccines. She verbalized that
she never acquired chronic illness. As far as
Ms. R.P.M. could remember, only had
history of common colds, cough and flu. she
also said that she was once admitted in the
DRSTMH on September 08, 2014 because
of fetal death in utero during the 36th week
of her pregnancy.

According to Ms. R.P.M., her last menstrual
period was on November 11, 2014. She had
been pregnant twice. During her first
pregnancy, she was able to conceive the fetus
until 36th week but wasn’t able to deliver it
because her fetus died while it is still in her
uterus. Her second pregnancy, was 14 weeks
molar pregnancy.

According to Ms. R.P.M., her first
menstruation was when she was 15
years old. According to her, her
menstruation is regular that lasts for
3 days and usually consumed 2-3
pads of napkins per day.

She also verbalized, during her menstruation,
she never suffered dysmenorrhea but
suffered headache and dizziness and when
she had, she said she would just take a rest
and take over -the-counter medicine for her
headache. According to her, she never
consumed alcohol and drugs during her
pregnancies. Her family also doesn’t have
any history of genetic or chromosomal
abnormalities.

Father: 47 y/o
(+) H.P.N Alive
Mother: 45 y/o
(+) H.P.N Alive
R.M
(Female)
25y/o
(+) H.P.N
Alive
R.M
(Female)
20y/o
Alive and
well
R.M
(Female)
18y/o
(+)
Anemia
R.M
(Female)
23y/o
(patient)
diagnose
d with
H-Mole

She usually consumes 1 cup of
rice and vegetables and fish every
meal. They usually have meat once a
week whenever his husband has extra
money from his salary.

She usually sleeps before 7
in the evening and wakes up at
5 in the morning. She rarely
complains of sleeping
problems.

She defecates 1 to 2 times a
day to a brownish, well formed
stool and voids 3-4 times a day to
a yellowish colored urine. She has
no any complaints in defecation
and urination.

Mrs. R.P.M. claims that before she seeks
medical attention, she goes to “albularyo” to
lessen their financial burden. She doesn’t
believe in herbal drugs. Whenever she
experienced minor illnesses such as cough,
colds or fever, she drinks plenty of fluids and
takes OTC drugs such as Paracetamol or
Neozep.

Mrs. R.P.M. has routines of daily
living. According to her, she exercises
every morning such as walking for
15-30 minutes. She is also the one
doing household chores. Watching
TV is one of her relaxation at home.

In terms of decision making, it is
mainly her husband who does it and
sometimes whenever they are unable
to decide or unable to solve the
problem for themselves they ask for
their parent’s advice.

She is a Roman Catholic. She
often goes to church every Sunday.

She has a good relationship
with her husband, parents,
siblings, relatives and friends.

• Receive patient lying on bed. on supine position wearing
pink t-shirt and blue short. She is approximately 5’1 in
height. She has proportionate body built with symmetrical
facial contour. The client has an IVF of PLR 1L + 10 “U”
oxytocin at the level of approximately 900 ml. Patent and
infusing well at left cephalic vein. She is conscious, awake,
alert and coherent.
• Vital signs upon assessment: T: 37.2°C/ax. PR: 89bpm RR:
19 bpm BP: 110/70mmhg

Skin
• Skin is dry, warm to touch and brown in
color.
• Skin turgor is at 4 seconds and the client
temperature is uniform.
• Moles noted on the left shoulder (0.1
inches in diameter)
• Presence of striae on her lower abdomen.

Hair
• Hair is evenly distributed and no scalp dryness and scaling
observed.
• No brittleness observed.
• Hair is long, thick in distribution and black in color.
• Uses shampoo daily.
Nails
• Color and shape of the nail is pink and no clubbing.
• It is dirty and untrimmed. Hard, 160° and firmly attached to nail
bed.
• Capillary refill of less than 2 seconds and trims her nails twice a
week.

Head
• Head is rounded and symmetrical, hard skull contour.
• No nodule and masses observed.
Eyes
• Her eyes are symmetrical, black in color, almond shape.
• Pupils are equal in size specifically 5mm in diameter; constricts
when diverted to light and dilates when she gazes afar,
conjunctivas are pink.
• Eyelashes are equally distributed and skin around the eyes is
intact.
• Eyes involuntarily blink.

Ears
• Ears are equally aligned in proportion to eyes.
• Auricles are smooth, light brown in color and have no
lesions.
• No cerumen noted upon inspection.
Nose and sinuses
• Nose in midline no discharge or flaring and uniform in
color.
• Air moves freely as the client breaths through nares.
• No tenderness in sinuses upon inspection.

Mouth and Pharynx
• Dry mucous membrane.
• Lips are moist and pink in color.
• No dentures noted.
• Pink gums and no lesions or bleeding noted.
Neck
• Neck is short, proportional to neck and shoulder.
• Lymph nodes are non-palpable. No lumps and swelling noted.
• Trachea is in the midline.
• Neck has strength that allows movement back and forth, left and right.
• Patient is able to freely move her neck.

Breast and Axillae
• It is symmetrical, brown in color.
• Nipple and areola is circular in shape,
symmetry and no discharges on nipple and
areola.
• No nodes palpated on axilla and clavicle. No
scars noted.

• No reports of pain during the inhalation and
exhalation.
• Respiratory rate is 18 breaths/min; rhythm is
normal and eupnea upon assessment.
• Skin is intact (-) accessory muscle use, (-) nasal
flaring and barrel chest.
• Breathing pattern is quiet, rhythmic and
effortless respiration.

• She has history of allergy in
dust.
• Bilateral crackles upon
auscultation.
• With Productive cough of
whitish in color.

• There is no distention of jugular vein during
inspection.
• Neck vessels rhythm is regular it is symmetry
and no thrills as palpated.
• Upon percussion and auscultation no
abnormalities found.
• No history of heart problems.
• Blood Pressure of 110/70mmhg ; Pulse Rate of
89 beats per minute.

• Abdomen is rounded. There is
presence of stretch marks on lower
abdomen.
• Abdominal movement present during
respiration respiration.
• No rashes, no mark pulsation, no
visible peristalsis and no discoloration
noted.

• Patient refused for physical examination of
the genitals.
• But she verbalized that there was minimal
bleeding of color bright red approximately
1 pad per day.
• Urine output: Approximately voids 4x day
to 250cc of yellowish urine.

• Symmetrical muscles on both sides of the body.
• There are no contractures or shortening of the
muscle and tendons.
• Muscle strength is equal on each sides of the
body graded as 5/5.
• There are no deformities on the bones.
• Both extremities, joint moves smoothly and
effortless.

• There is no problem mentioned in the impressions.
• Patient is oriented to time and place.
• She is responsive to the questions we asked.
• She’s able to sense touch and temperature on various
areas of the body.
• The client can identify familiar object by touch able to
determine draw numbers in palm of hand.
• She was able to recall immediate recent and remote
memory.

• Test for Cranial Nerves:
CN I- Olfactory Nerve.
• No anosmia. Patient smelled and identified the substance.
CN II- Optic Nerve.
• Patient is sensitive to light.
CN III, IV, VI- Oculomotor, Trochlear, Abducens.
• Intact and able to move eye in six cardinal field. Pupils equally
round, reactive to light and accommodation.
CN V- Trigeminal Nerve.
• Intact, No difficulty mastication noted. Able to sense object put
on.

CV VI- Facial Nerve.
• Patient is able to do different facial expressions.
• Able to sense different textures on the face.
CN VII- Acoustic Nerve
• Patient is able to hear the tiktok sound from a wristwatch
approximately 1 inch away from the ear.
CN IX, X- Glossopharyngeal and Vagus Nerves.
• Patient is able to swallow and able to say “AH”. Positive
gag reflex using tongue depressor.

CN XII- Hypoglossal Nerve.
• Patient sticks out tongue and moves it from side to side.
CN XI- Spinoaccessory Nerve.
• Patient shrugs or turns head against resistance.

Check Glasgow Coma Scale (GSC):
I. Motor Response (6) - Obeys commands fully.
II. Verbal Response (5) - Alert and Oriented.
III. Eye Opening (4) - Spontaneous eye opening
Score: GCS =15

REPORT:
The uterus is anteverted with globular contour and homogenous echopattern
measuring 18.2 x 13.7 x 10.3 cm. (cervix measures 2.9 x 2.6 2.8 cm).
The endometrial cavity is filled with a complex heterogeneous mass measuring
12.6 x 10.9 X 8.1 cm with numerous anechoic cystic spaces of varying size and
shapes (volume 582.0 cc). The subendometrial halo is intact.
The thinnest portion of the myometrium measures 0.3 cm at the antero-fundal
area.
The right ovary is converted to a septated anechoic mass measuring 4.3 x 3.7 x
3.9 cm.
The left ovary is also converted to a similar mass measuring 5.1 x 3.0 x 3.7 cm.
There is no free fluid n the cul de sac.

• Endometrial mass consider
Gestational Trophoblastic Disease
probably Hydatidiform Mole.
• Theca lutein cysts, bilateral

Rationale: To determine
significant deviation of blood
components from normal
values.

Date Normal Values Results Significance
February 20,2015
1:36 PM
February 22, 2015
6:40 AM
Hemoglobin 120-160 g/L
Hematocrit 0.36-0.41v vol Fr
RBC count 4.20-5.40x1012/L
WBC count 4.50-11.00 g/L
Platelet Count 150-460 g/L
Neutrophil 0.36-0.66 g/L
78
0.22
2.71
4.9
400
0.58
111
0.31
Decrease. This
signifies anemia
related to inadequate
iron intake.
Due to blood loss
from vaginal bleeding.
Decrease. This signifies
leucopenia or infection.
Normal
Normal
Decrease. This signifies to
anemia inadequate iron
intake and blood loss.

Date Normal Values Results Significance
February 22, 2015/ 10:54 PM
February 25, 2015/ 6:06 AM
RBC count 4.20-5.40x1012/L
RBC count 4.20-5.40x1012/L
3.69
8.5
0.72
111
0.30
95
0.26
3.10
6.6
0.33
Decrease. This signifies anemia.
Normal
Increased. This signifies infection
Increase from previous reading due
to BT.
This signifies anemia related to
blood loss.
Decreased. This Signifies Anemia
related to blood loss
Normal
Increase. This signifies infection.
Normal

Rationale: To determine significant
deviation of urine components from
normal values.
Date: February 23, 2015/3:50 PM

Test Results
Normal
Values
Significance
Color
Dark
yellow
Straw, Amber Normal
Transparency Slightly hazy Clear/
Slightly hazy
Normal
Specific
Gravity
1.025 0.010-1.025 Normal
Protein Negative Negative Normal
Sugar Negative Negative Normal

Red Blood
Cell
0-1 hPF 0-2 hPF Normal
Pus Cells 0-3 hPF 0-3 hPF Normal
Mucous
Threads
Moderate Few Inflammation/
infection
Epithelial
Cells
Moderate Few Inflammation/
infection
Urates Few Few Normal

HYPOTHETICAL
NURSING CARE
PLANS

Subjective/Objective Cues:
(Hypothetical: Depending on the
presenting s/sx of patient)
Nursing Diagnosis: Deficient
Knowledge

Nursing Diagnosis: Deficient Knowledge
May be related to:
• Lack of exposure/recall, information misinterpretation
• Unfamiliarity with information resources
Possibly evidenced by:
• Statement of the problem/concerns, misconceptions
• Request for information
• Inappropriate, exaggerated behaviors (e.g., agitated,
apathetic, hostile)
• Inaccurate follow-through of instructions/development
of preventable complications

Objectives
General:
• Verbalize understanding of disease
process/perioperative process and postoperative
expectations.
• Correctly perform necessary procedures and
explain reasons for the actions.
• Initiate necessary lifestyle changes and
participate in treatment regimen.

Nursing Interventions:
Independent
• Assess patient’s level of understanding.
Rationale: Facilitates planning of preoperative teaching program,
identifies content needs.
• Review specific pathology and anticipated surgical procedure. Verify
that appropriate consent has been signed.
Rationale: Provides knowledge base from which patient can make
informed therapy choices and consent for procedure, and presents
opportunity to clarify misconceptions.
• Use resource teaching materials, audiovisuals as available.
Rationale: Specifically designed materials can facilitate the patient’s
learning.

• Preoperative or postoperative procedures and expectations, urinary
and bowel changes, dietary considerations, activity levels/
transfers, respiratory/ cardiovascular exercises; anticipated IV lines
and tubes NGT, drains, and catheters).
Rationale:Enhances patient’s understanding or control and can
relieve stress related to the unknown or unexpected.
• Preoperative instructions: NPO time, shower or skin preparation,
which routine medications to take and hold, prophylactic
antibiotics, or anticoagulants, anesthesia premedication.
Rationale:Helps reduce the possibility of postoperative
complications and promotes a rapid return to normal body function.

• Intraoperative patient safety: not crossing legs during
procedures performed under local or light anesthesia.
Rationale: Reduced risk of complications or untoward
outcomes, such as injury to the peroneal and tibial nerves with
postoperative pain in the calves and feet.
• Expected or transient reactions (low backache, localized
numbness and reddening or skin indentations).
Rationale: Minor effects of immobilization and positioning
should resolve in 24 hr. If they persist, medical evaluation is
required.

• Discuss individual postoperative pain management plan.
Identify misconceptions patient may have and provide
appropriate information.
Rationale: Increases likelihood of successful pain
management.
• Provide opportunity to practice coughing, deep-
breathing, and muscular exercises.
Rationale:Enhances learning and continuation of activity
postoperatively

Subjective/Objective
Cues: (Hypothetical:
Depending on the
Nursing Diagnosis:
Anxiety

Nursing Diagnosis: Anxiety
• May be related to:
• Situational crisis; unfamiliarity with
environment
• Change in health status; threat of death
• Separation from usual support systems

Nursing Diagnosis: Anxiety
• Increased tension, apprehension, decreased
self-assurance
• Expressed concern regarding changes, fear
of consequences
• Facial tension, restlessness, focus on self
• Sympathetic stimulation

Objectives
General:
• Acknowledge feelings and identify healthy
ways to deal with them.
• Appear relaxed, able to rest/sleep
appropriately.
• Report decreased fear and anxiety reduced
to a manageable level.

Independent
• Provide preoperative education, including visit with OR personnel
before surgery when possible. Discuss anticipated things that may
concern patient: masks, lights, IVs, BP cuff, electrodes, bovie pad, feel
of oxygen cannula or mask on nose or face, autoclave and suction
noises, child crying.
Rationale: Can provide reassurance and alleviate patient’s anxiety, as
well as provide information for formulating intraoperative care.
• Inform patient of nurse’s intraoperative advocate role.
Rationale: Develops trust and rapport, decreasing fear of loss of control
in a foreign environment.

• Identify fear levels that may necessitate postponement of surgical
procedure.
Rationale: Overwhelming or persistent fears result in excessive stress
reaction, potentiating risk of adverse reaction to procedure and/or
anesthetic agents.
• Validate source of fear. Provide accurate factual information.
Rationale: Identification of specific fear helps patient deal
realistically with it.
• Note expressions of distress and feelings of helplessness,
preoccupation with anticipated change or loss, choked feelings.
Rationale: Patient may already be grieving for the loss represented by
the anticipated surgical procedure, diagnosis or prognosis of illness.

• Tell patient anticipating local or spinal anesthesia that drowsiness
and sleep occurs, that more sedation may be requested and will be
given if needed, and that surgical drapes will block view of the
operative field.
Rationale: Reduces concerns that patient may “see” the procedure.
• Introduce staff at time of transfer to operating suite.
Rationale: Establishes rapport and psychological comfort.
• Compare surgery schedule, patient identification band, chart, and
signed operative consent for surgical procedure.
Rationale: Provides for positive identification, reducing fear that
wrong procedure may be done.

• Prevent unnecessary body exposure during transfer and in
OR suite.
Rationale: Patients are concerned about loss of dignity and
inability to exercise control.
• Give simple, concise directions and explanations to sedated
patient. Review environmental concerns as needed.
Rationale: Impairment of thought processes makes it difficult
for patient to understand lengthy instructions.
• Control external stimuli.
Rationale: Extraneous noises and commotion may accelerate
anxiety

• Refer to pastoral spiritual care, psychiatric nurse,
clinical specialist, psychiatric counseling if indicated.
Rationale: May be desired or required for patient to deal
with fear, especially concerning life-threatening
conditions, serious and/or high-risk procedures.
• Discuss postponement or cancellation of surgery with
physician, anesthesiologist, patient, and family as
appropriate.
Rationale: May be necessary if overwhelming fears are
not reduced or resolved.

Collaborative:
• Administer sedatives, hypnotics as prescribed.
Rationale: Used to promote sleep the evening before
surgery; may enhance coping abilities.
• Administer anti-anxiety agents as prescribed.
Rationale: May be provided in the outpatient admitting or
preoperative holding area to reduce nervousness and
provide comfort.

Nursing Diagnosis:
Perioperative Positioning, risk for
injury

Nursing Diagnosis: Perioperative Positioning,
risk for injury
Risk factors may include
• Disorientation; sensory/perceptual disturbances
due to anesthesia
• Immobilization; musculoskeletal impairments
• Obesity/emaciation; edema

Nursing Diagnosis: Perioperative
Positioning, risk for injury
Possibly evidenced by
• Not applicable. A risk diagnosis is not
evidenced by signs and symptoms, as the
problem has not occurred and nursing
interventions are directed at prevention.

Objectives
General:
• Be free of injury related to perioperative
disorientation.
• Be free of untoward skin/tissue injury or
changes lasting beyond 24–48 hr following
procedure.
• Report resolution of localized numbness,
tingling, or changes in sensation related to
positioning within 24–48 hr as appropriate.

Independent
• Note anticipated length of procedure and customary position. Be
aware of potential complications.
Rationale: Supine position may cause low back pain and skin pressure
at heels, elbows, or sacrum; lateral chest position can cause shoulder and
neck pain, plus eye and ear injury on the patient’s downside.
• Review patient’s history, noting age, weight, height, nutritional status,
physical limitation and preexisting conditions that may affect choice
of position and skin or tissue integrity during surgery.
Rationale: Elderly persons, lack of subcutaneous padding, arthritis,
diabetes, obesity, abdominal stoma, hydration status and temperature are
some factors.

• Stabilize both patient cart and OR table when transferring
patient to and from OR table, using an adequate number of
personnel for transfer and support of extremities.
Rationale: Unstabilized cart or table can separate, causing
patient to fall.
• Anticipate movement of extraneous lines and tubes during
the transfer and secure or guide them into position.
Rationale: Prevents undue tension and dislocation of IV lines,
NG tubes, catheters, and chest tubes; maintains gravity
drainage when appropriate.

• Secure patient on OR table with safety belt as appropriate,
explaining necessity for restraint.
Rationale: OR tables and arm boards are narrow, placing patient at
risk for injury, especially during fasciculation.
• Protect body from contact with metal parts of the operating table.
Rationale: Reduces risk of electrical injury.
• Prepare equipment and padding for required position, according to
operative procedure and patient’s specific needs. Pay special
attention to pressure points of bony prominences (arms, ankles) and
neurovascular pressure points (breasts, knees).
Rationale: Depending on individual patient’s size, weight, and
preexisting conditions, extra padding materials may be required to
protect bony prominences, prevent circulatory compromise and nerve
pressure, or allow for optimum chest expansion for ventilation.

• Position extremities so they may be periodically checked for safety,
circulation, nerve pressure, and alignment. Monitor peripheral pulses,
skin color and temperature.
Rationale: Prevents accidental trauma, hands, fingers, and toes could
inadvertently be scraped, pinched, or amputated by moving table
attachments; positional pressure of brachial plexus, peroneal, and ulnar
nerves can cause serious problems with extremities; prolonged plantar
flexion may result in foot drop.
• Place legs in stirrups simultaneously (when lithotomy position used),
adjusting stirrup height to patient’s legs, maintaining symmetrical
position. Pad popliteal space and heels and/or feet as indicated.
Rationale: Prevents muscle strain; reduces risk of hip dislocation in
elderly patients. Padding helps prevent peroneal and tibial nerve damage.

• Provide footboard and/or elevate drapes off toes. Avoid
and monitor placement of equipment, instrumentation on
trunk and extremities during procedure.
Rationale: Continuous pressure may cause neural,
circulatory, and skin integrity disruption.
• Reposition slowly at transfer from table and in bed.
Rationale: Myocardial depressant effect of various agents
increases risk of hypotension and/or bradycardia.

• Determine specific postoperative positioning guidelines,
elevation of head of bed following spinal anesthesia, turn
to unoperated side following pneumonectomy.
Rationale: Reduces risk of postoperative complications.
• Recommend position changes to anesthesiologist and/or
surgeon as appropriate.
Rationale: Close attention to proper positioning can
prevent muscle strain, nerve damage, circulatory
compromise, and undue pressure on skin and/or bony
prominences.

(Hypothetical: Depending on
the presenting s/sx of
patient)
Nursing diagnosis: Risk for
Infection

Nursing diagnosis: Risk for Infection
Risk factors may include:
• Broken skin, traumatized tissues, stasis of
body fluids
• Presence of pathogens/contaminants,
environmental exposure, invasive
procedures

Nursing diagnosis: Risk for Infection
• Not applicable. A risk diagnosis is not
evidenced by signs and symptoms, as
the problem has not occurred and
nursing interventions are directed at
prevention.

Objectives
General:
• Identify individual risk factors and
interventions to reduce potential for
infection.
• Maintain safe aseptic environment.

Nursing Interventions
Independent:
• Adhere to facility infection control, sterilization, and
aseptic policies and procedures.
Rationale: Established mechanisms designed to prevent infection.
• Verify sterility of all manufacturers’ items.
Rationale: Prepackaged items may appear to be sterile; however,
each item must be scrutinized for manufacturer’s statement of sterility,
breaks in packaging, environmental effect on package, and delivery
techniques.

• Review laboratory studies for possibility of systemic infections.
Rationale: Increased WBC count may indicate ongoing infection,
which the operative procedure will alleviate; or presence of systemic
or organ infection, which may contraindicate or impact surgical
procedure and/or anesthesia.
• Verify that preoperative skin, vaginal, and bowel cleansing
procedures have been done as needed depending on specific
surgical procedure.
Rationale: Cleansing reduces bacterial counts on the skin, vaginal
mucosa, and alimentary tract.
• Prepare operative site according to specific procedures.
Rationale: Minimizes bacterial counts at operative site.

Examine skin for breaks or irritation, signs of infection.
• Rationale: Disruptions of skin integrity at or near the
operative site are sources of contamination to the wound.
Maintain dependent gravity drainage of indwelling catheters,
tubes, and/or positive pressure of parenteral or irrigation lines.
• Rationale: Prevents stasis and reflux of body fluids.
Identify breaks in aseptic technique and resolve immediately on
occurrence.
• Rationale: Contamination by environmental or personnel
contact renders the sterile field unsterile, thereby increasing the
risk of infection.

• Contain contaminated fluids and materials in specific site in
operating room suite, and dispose of according to hospital protocol.
Rationale: Containment of blood and body fluids, tissue, and
materials in contact with an infected wound. Patient will prevent
spread of infection to environment and/or other patients or personnel.
• Apply sterile dressing.
Rationale: Prevents environmental contamination of fresh wound.
• Provide copious wound irrigation, e.g., saline, water, antibiotic, or
antiseptic.
Rationale: May be used intraoperatively to reduce bacterial counts at
the site and cleanse the wound of debris, e.g., bone, ischemic tissue,
bowel contaminants, toxins.

• Obtain specimens for cultures or Gram stain.
Rationale: Immediate identification of type of infective
organism by Gram stain allows prompt treatment, while
more specific identification by cultures can be obtained in
hours or days.
Dependent
• Administer antibiotics as indicated.
Rationale: May be given prophylactically for suspected
infection or contamination.

Nursing Diagnosis: Risk for
Altered Body Temperature

Nursing Diagnosis: Risk for Altered Body
Temperature
Risk factors may include:
• Exposure to cool environment
• Use of medications, anesthetic agents
• Extremes of age, weight; dehydration

Nursing Diagnosis: Risk for Altered Body
Temperature
• Not applicable. A risk diagnosis is not evidenced
by signs and symptoms, as the problem has not
occurred and nursing interventions are directed at
prevention.
Desired Outcomes
• Maintain body temperature within normal range.

Independent
• Note preoperative temperature.
Rationale: Used as baseline for monitoring intraoperative temperature.
Preoperative temperature elevations are indicative of disease process:
appendicitis, abscess, or systemic disease requiring treatment
preoperatively, perioperatively, and possibly postoperatively.
• Assess environmental temperature and modify as needed: providing
warming and cooling blankets, increasing room temperature.
Rationale: May assist in maintaining or stabilizing patient’s
temperature.

• Cover skin areas outside of operative field.
Rationale: Heat losses will occur as skin (legs, arms, head) is
exposed to cool environment.
• Provide cooling measures for patient with preoperative
temperature elevations.
Rationale: Cool irrigations and exposure of skin surfaces to air
may be required to decrease temperature.
• Note rapid temperature elevation or persistent high fever and
treat promptly per protocol.
Rationale: Malignant hyperthermia must be recognized and
treated promptly to avoid serious complications and/or death.

• Increase ambient room temperature (e.g., to 78°F or 80°F) at
conclusion of procedure.
Rationale: Helps limit patient heat loss when drapes are removed and
patient is prepared for transfer.
• Apply warming blankets at emergence from anesthesia.
Rationale: Inhalation anesthetics depress the hypothalamus, resulting in
poor body temperature regulation.
• Monitor temperature throughout intraoperative phase.
Rationale: Continuous warm or cool humidified inhalation anesthetics
are used to maintain humidity and temperature balance within the
tracheobronchial tree. Temperature elevation and fever may indicate
adverse response to anesthesia. Note: Use of atropine or scopolamine
may further increase temperature.

Dependent:
• Provide iced saline as indicated.
Rationale: Lavage of body cavity with iced saline
may help reduce hyperthermic responses.
• Obtain dantrolene (Dantrium) for IV administration.
Rationale: Immediate action to control temperature is
necessary to prevent death from malignant
hyperthermia.

Subjective/Objective cues:
the presenting s/sx of patient)
Nursing Diagnosis:
Ineffective Breathing Pattern

Nursing Diagnosis: Ineffective
Breathing Pattern
May be related to:
• Decreased lung expansion, energy
• Tracheobronchial obstruction

Nursing Diagnosis: Ineffective Breathing Pattern
• Changes in respiratory rate and depth
• Reduced vital capacity, apnea, cyanosis, noisy
respirations
Desired Outcomes:
• Establish a normal/effective respiratory pattern
free of cyanosis or other signs of hypoxia.

• Maintain patient airway by head tilt, jaw hyperextension, oral
pharyngeal airway.
Rationale: Prevents airway obstruction.
• Auscultate breath sounds. Listen for gurgling, wheezing, crowing,
and/or silence after extubation.
Rationale: Lack of breath sounds is indicative of obstruction by
mucus or tongue and may be corrected by positioning and/or
suctioning. Diminished breath sounds suggest atelectasis. Wheezing
indicates bronchospasm, whereas crowing or silence reflects partial-
to-total laryngospasm.

• Observe respiratory rate and depth, chest expansion, use of
accessory muscles, retraction or flaring of nostrils, skin color;
note airflow.
Rationale: Ascertains effectiveness of respirations immediately so
corrective measures can be initiated.
• Monitor vital signs continuously.
Rationale: Increased respirations, tachycardia, and/or bradycardia
suggests hypoxia.
• Position patient appropriately, depending on respiratory effort
and type of surgery.
Rationale: Head elevation and left lateral Sims’ position prevents
aspiration of secretions or vomitus; enhances ventilation to lower
lobes and relieves pressure on diaphragm

• Initiate “stir-up” (turn, cough, deep breathe) regimen as
soon as patient is reactive and continue in the postoperative
period.
Rationale: Active deep ventilation inflates alveoli, breaks up
secretions, increases O2 transfer, and removes anesthetic
gases; coughing enhances removal of secretions from the
pulmonary system.
• Elevate head of bed as appropriate. Get out of bed as soon
as possible.
Rationale: Promotes maximal expansion of lungs,
decreasing risk of pulmonary complications.

Dependent:
• Suction as necessary.
Rationale: Airway obstruction can occur because of blood or mucus in throat or trachea.
• Administer supplemental O2 as indicated.
Rationale: Maximizes oxygen for uptake to bind with Hb in place of anesthetic gases to
enhance removal of inhalation agents.
• Provide and maintain ventilator assistance
Rationale: Depending on cause of respiratory depression or type of surgery (pulmonary,
extensive abdominal, cardiac), endotracheal tube (ET) may be left in place and mechanical
ventilation maintained for a time.
• Assist with use of respiratory aids: incentive spirometer.
Rationale: Maximal respiratory efforts reduce potential for atelectasis and infection.

Subjective/Objective
cues: (Hypothetical:
Depending on the
Nursing Diagnosis:
Acute Pain

Nursing Diagnosis: Acute Pain
May be related to:
• Disruption of skin, tissue, and muscle
integrity; musculoskeletal/bone trauma
• Presence of tubes and drains.

Nursing Diagnosis: Acute Pain
May be related to:
• Disruption of skin, tissue, and muscle integrity;
musculoskeletal/bone trauma
• Presence of tubes and drains.
• Reports of pain
• Alteration in muscle tone; facial mask of pain
• Distraction/guarding/protective behaviors
• Self-focusing; narrowed focus
• Autonomic responses.
Desired Outcomes
• Report pain relieved/controlled.
• Appear relaxed, able to rest/sleep and participate in activities
appropriately.

Independent:
• Note patient’s age, weight, coexisting medical or psychological
conditions, idiosyncratic sensitivity to analgesics, and intraoperative
course.
• Rationale: Approach to postoperative pain management is based on
multiple variable factors.
• Evaluate pain regularly (every 2 hrs noting characteristics, location,
and intensity (0–10 scale). Emphasize patient’s responsibility for
reporting pain/ relief of pain completely.
Rationale: Provides information about need for or effectiveness of
interventions.

• Note presence of anxiety or fear, and relate with nature
of and preparation for procedure.
Rationale: Concern about the unknown (e.g., outcome of a
biopsy) and/or inadequate preparation (e.g., emergency
appendectomy) can heighten patient’s perception of pain.
• Assess vital signs, noting tachycardia, hypertension, and
increased respiration, even if patient denies pain.
Rationale: Changes in these vital signs often indicate
acute pain and discomfort.

• Assess causes of possible discomfort other than operative
procedure.
Rationale: Discomfort can be caused or aggravated by
presence of non-patent indwelling catheters, NG tube,
parenteral lines (bladder pain, gastric fluid and gas
accumulation, and infiltration of IV fluids or medications).
• Reposition as indicated: semi-Fowler’s; lateral Sims’.
Rationale: May relieve pain and enhance circulation. Semi-
Fowler’s position relieves abdominal muscle tension and
arthritic back muscle tension, whereas lateral Sims’ will
relieve dorsal pressures.

• Provide additional comfort measures: backrub, heat or cold
applications.
Rationale: Improves circulation, reduces muscle tension and
anxiety associated with pain. Enhances sense of well-being.
• Improves circulation, reduces muscle tension and anxiety
associated with pain. Enhances sense of well-being.
Rationale: Relieves muscle and emotional tension; enhances
sense of control and may improve coping abilities.

• Document effectiveness and side and/or
adverse effects of analgesia.
Rationale: Respirations may decrease on
administration of narcotic, and synergistic
effects with anesthetic agents may occur.

Dependent
• Give analgesic as indicated.
Rationale: Analgesics given IV reach the pain centers
immediately, providing more effective relief with small
doses of medication.
• Local anesthetics: epidural block or infusion
Rationale: Anesthetics may be injected into the operative
site, or nerves to the site may be kept blocked in the
immediate postoperative phase to prevent severe pain.

Subjective/Objective cues:
the presenting s/sx of patient)
Nursing Diagnosis:
Impaired Skin/Tissue
Integrity

Nursing Diagnosis: Impaired Skin/Tissue
Integrity
May be related to
• Mechanical interruption of skin/tissues
• Altered circulation, effects of medication;
accumulation of drainage; altered metabolic
state

Nursing Diagnosis: Impaired Skin/Tissue
Integrity
• Disruption of skin surface/layers and tissues
Desired Outcomes
• Achieve timely wound healing.
• Demonstrate behaviors/techniques to promote
healing and to prevent complications.

Independent :
• Reinforce initial dressing and change as indicated. Use strict
aseptic techniques.
Rationale: Protects wound from mechanical injury and
contamination. Prevents accumulation of fluids that may cause
excoriation.
• Gently remove tape (in direction of hair growth) and dressings
when changing.
Rationale: Reduces risk of skin trauma and disruption of wound.

• Apply skin sealants or barriers before tape if needed. Use
hypoallergenic tape or Montgomery straps or elastic
netting for dressings requiring frequent changing.
Rationale: Reduces potential for skin trauma and/or
abrasions and provides additional protection for delicate skin
or tissues
• Check tension of dressings. Apply tape at center of
incision to outer margin of dressing. Avoid wrapping tape
around extremity.
Rationale: Can impair or occlude circulation to wound and
to distal portion of extremity.

• Inspect wound regularly, noting characteristics and integrity
Rationale: Early recognition of delayed healing or developing
complications may prevent a more serious situation. Wounds may heal
more slowly in patients with comorbidity, or the elderly in whom reduced
cardiac output decreases capillary blood flow.
• Assess amounts and characteristics of drainage.
Rationale: Decreasing drainage suggests evolution of healing process,
whereas continued drainage or presence of bloody or odoriferous exudate
suggests complications
• Maintain patency of drainage tubes; apply collection bag over drains
and incisions in presence of copious or caustic drainage.
Rationale: Facilitates approximation of wound edges; reduces risk of
infection and chemical injury to skin and tissues.

• Elevate operative area as appropriate.
Rationale: Promotes venous return and limits edema formation.
Note: Elevation in presence of venous insufficiency may be
detrimental.
• Caution patient not to touch wound.
Rationale: Prevents contamination of wound.
• Cleanse skin surface (if needed) with diluted hydrogen peroxide
solution, or running water and mild soap after incision is sealed.
Rationale: Reduces skin contaminants; aids in removal of drainage
or exudate.

• Apply ice if appropriate.
Rationale: Reduces edema formation that may cause undue pressure
on incision during initial postoperative period.
• Irrigate wound; assist with debridement as needed.
Rationale: Removes infectious exudate or necrotic tissue to promote
healing
• Monitor or maintain dressings: hydrogel, vacuum dressing.
Rationale: May be used to hasten healing in large, draining wound/
fistula, to increase patient comfort, and to reduce frequency of
dressing changes. Also allows drainage to be measured more
accurately and analyzed for pH and electrolyte content as appropriate.

Dependent:
• Use abdominal binder if indicated.
Rationale: Provides additional support for high-risk
incisions (obese patient).

Nursing Diagnosis: Deficient
Knowledge
May be related to
• Lack of exposure/lack of recall,
information misinterpretation
• Unfamiliarity with information
resources
• Cognitive limitation

Nursing Diagnosis: Deficient Knowledge
• Questions/request for information;
statement of misconception
• Inaccurate follow-through of
instructions/development of preventable
complications

Desired Outcomes
• Demonstrate adequate perfusion
evidenced by stable vital signs,
peripheral pulses present and
strong; skin warm/dry; usual
mentation and individually
appropriate urinary output.

• Review specific surgery performed and procedure done and future
expectations.
• Rationale: Provides knowledge base from which patient can make
informed choices.
• Review and have patient or SO demonstrate dressing or wound
when indicated.
• Identify source for supplies.
• Rationale: Promotes competent self-care and enhances
independence.

• Review avoidance of environmental risk factors: exposure
to crowds or persons with infections.
Rationale: Reduces potential for acquired infections
• Discuss drug therapy, including use of prescribed and
OTC analgesics.
Rationale: Enhances cooperation with regimen; reduces risk
of adverse reactions and/or untoward effects.
• Identify specific activity limitations.
Rationale: Prevents undue strain on operative site

• Recommend planned or progressive exercise.
Rationale: Promotes return of normal function and
• Schedule adequate rest periods.
Rationale: Prevents fatigue and conserves energy for
healing, enhances feelings of general well-being.
• Review importance of nutritious diet and adequate fluid
intake.
Rationale: Provides elements necessary for tissue
regeneration or healing and support of tissue perfusion
and organ function.

• Encourage cessation of smoking.
Rationale: Smoking increases risk of pulmonary infections, causes
vasoconstriction, and reduces oxygen-binding capacity of blood,
affecting cellular perfusion and potentially impairing healing.
• Identify sign and symptoms requiring medical evaluation, e.g.,
nausea and/or vomiting; difficulty voiding; fever, continued or
odoriferous wound drainage; incisional swelling, erythema, or
separation of edges; unresolved or changes in characteristics of
pain.
Rationale: Early recognition and treatment of developing
complications (ileus, urinary retention, infection, delayed healing)
may prevent progression to more serious or life-threatening situation

• Stress necessity of follow-up visits with providers, including therapists,
laboratory
Rationale: Monitors progress of healing and evaluates effectiveness of
regimen.
• Include SO in teaching program or discharge planning. Provide written
instructions and/or teaching materials. Instruct in use of and arrange for
special equipment.
Rationale: Provides additional resources for reference after discharge.
Promotes effective self-care.
• Identify available resources: home care services, visiting nurse,
outpatient therapy, contact phone number for questions.
Rationale: Enhances support for patient during recovery period and
provides additional evaluation of ongoing needs and new concerns

Altered Tissue Perfusion
May be related to:
• Interruption of flow: arterial,
venous
• Hypovolemia

Nursing Diagnosis: Risk for Altered Tissue
Perfusion
• Not applicable. A risk diagnosis is not evidenced by
signs and symptoms, as the problem has not
occurred and nursing interventions are directed at
prevention.
Desired Outcomes
• Demonstrate adequate perfusion evidenced by
stable vital signs, peripheral pulses present and
strong; skin warm/dry; usual mentation and
individually appropriate urinary output.

• Change position slowly initially.
Rationale: Vasoconstrictor mechanisms are depressed and quick
movement may lead to orthostatic hypotension, especially in the early
postoperative period.
• Assist with range-of-motion (ROM) exercises, including active ankle
and leg exercises.
Rationale: Stimulates peripheral circulation; aids in preventing venous
stasis to reduce risk of thrombus formation.
• Encourage and assist with early ambulation.
Rationale: Enhances circulation and return of normal organ function.

• Avoid use of knee gatch and/or pillow under knees. Caution
patient against crossing legs or sitting with legs dependent for
prolonged period.
• Rationale: Prevents stasis of venous circulation and reduces risk
of thrombophlebitis.
• Assess lower extremities for erythema, edema, calf tenderness
(positive Homans’ sign).
• Rationale: Circulation may be restricted by some positions used
during surgery, while anesthetics and decreased activity alter
vasomotor tone, potentiating vascular pooling and increasing
risks of thrombus formation.

• Monitor vital signs: palpate peripheral pulses; note skin
temperature/ color and capillary refill. Evaluate urinary
output/time of voiding. Document dysrhythmias.
Rationale: Indicators of adequacy of circulating volume and tissue
perfusion or organ function. Effects of medications or electrolyte
imbalances may create dysrhythmias, impairing cardiac output and
tissue perfusion.
• Investigate changes in mentation or failure to achieve usual
mental state.
Rationale: May reflect a number of problems such as inadequate
clearance of anesthetic agent, oversedation (pain medication),
hypoventilation, hypovolemia, or intraoperative complications

• Administer IV fluids or blood products as needed.
Rationale: Maintains circulating volume; supports
perfusion.
• Apply antiembolitic hose as indicated.
Rationale: Promotes venous return and prevents
venous stasis of legs to reduce risk of thrombosis.

Status Post
Suction Curettage
for H-Mole
NCP#1. Risk for
Fluid volume
deficit r/t
maternal blood
loss
NCP#3. Ineffective airway
clearance related to
increased mucus
production as evidenced
by persistent cough
NCP#2. Grieving
related to
unexpected fetal
loss.incision.

• Straight Arrow: denotes direct relationship
from medical diagnosis/ chief complaint
• Broken Arrow: demotes Risk Nursing
Diagnosis
• Dotted Arrow: or denotes
linking relationship between or among Nursing
Diagnoses
• Diamond Arrow: denotes readiness for
enhanced Wellness of Health promotion Diagnosis
after intervention.

ASSESSMENT:
Subjective Data:
“Ginadugo gyapon ako
it Sangkiri” as
verbalized by the
patient
Objective data:
• minimal vaginal
bleeding with two pads
use not fully soaked.
• weakness/fatigue
• pale/appearance
• dry mucous membrane
at the mouth
• dry skin
• Skin turgor (4secs)
Vital signs:
• T: 36.7°c/ax RR:
19cpm PR: 89bpm
BP: 110/70 mmHg

Fluid volume deficit r/t
maternal blood loss

Objectives/ Outcome Criteria
General: To facilitate the maintenance of fluid balance in the
body.
Specific: At the end of the 8 hour shift the patient will be able
to:
• reduce vaginal bleeding from two soaked pads to 1 soaked
pad
• exhibit elastic skin turgor (2 sec.)
• exhibit moist akin and mucous membrane
• verbalized diminished of fatigue/ weakness
• improve vital signs

Nursing Intervention
Independent:
• Assessed skin turgor and moisture of mucous membranes
Rationale: Indicators of hydration status/ degree of deficit
• Monitored Vital signs. Evaluate peripheral pulses, capillary refill.
Rationale: to have a baseline data, reflects adequacy of circulating
volume
• Monitored I&O; include all output sources (e.g., emesis, diarrhea
Rationale: Decreasing renal output and concentration of urine
suggest developing dehydration and need for fluid replacement.

• Weighed daily.
Rationale: Sensitive measurement of fluctuations in fluid balance
• Observed for bleeding tendencies; Note the amount, lochia/color
of the vaginal discharge
Rationale: Early identification of problems (which may occur as a
result of cancer), allows for prompt intervention.
• Encouraged increase fluid intake as tolerated
Rationale: To compensate with the fluid volume deficit problem
• Encouraged rest.
Rationale: Prevent unnecessary energy expenditure related to
vomiting (as may trigger) and bleeding (loss of blood/RBC)

Dependent
• Administered fresh whole blood as prescribed.
Rationale: To replace blood loss.
• Administered Tranexamic Acid 500 mg IVTT as ordered.
Rationale: To prevent further fluid loss due to hemorrhage.

Evaluation: Goals Met. The patient is able to exhibit the
elastic skin turgor, moist skin and mucous membrane and
verbalized diminished for fatigue/weakness. Further
evaluation can be achieved through repeat laboratory
exams.

Assessment
Subjective Data: “Gakasubo ako hay
namatay akon unga” as verbalized by
the patient
Objective data:
• Restless
• Appears sad
• Appears weak

Nursing Diagnosis: Grieving
related to unexpected fetal
loss.

Objectives:
General: To identify positive and negative expressions,
feelings and reactions related to fetal loss.
Specific: After 8 hours of nursing intervention the patient
will be able to:
• Express feelings of guilt, fear and sadness.
• Discuss personal response to grieving.
• Develop new skills and behavior to integrate and manage life
experiences.
• Function at normal developmental level.

Independent
• Allow the patient to express feelings about the unexpected
fetal loss.
Rationale: Support and normalize the grieving process.
• Listen attentively to what the patient states about the
unexpected loss.
Rationale: To evaluate the patient’s response regarding the
situation.

• Reinforce additional factual information as soon as
it is available about the cause of the fetal demise.
Rationale: Promotes understanding of the
physiologic etiology of the loss and acceptance of
the loss as real.
• Provide emotional and moral support to the patient.
Rationale: To help the patient cope with her
grieving.

Dependent:
• Refer for supportive counseling.
Rationale: Supportive counseling may help the patient to
gain strength and overcome situation.

Evaluation: Goal met. The patient
expresses feelings about the situation.

Assessment
Subjective: “Gina ubo gihapon ako” as
verbalized by the patient.
Objective:
• With productive cough of whitish in color
• Restlessness
• Pale and weak in appearance

Nursing Diagnosis:
Ineffective airway
clearance related to
increased mucus production
as evidenced by persistent
cough

Objectives
General: The client will be able to maintain airway patency.
Specific: After the end of the shift, the patient will be able to
achieve patent airway as evidenced by:
• return-demonstrate chest-physiotherapy to maintain patent
airway
• Respiratory rate will be in normal limits
• Mucus secretion will decrease
• Moderate persistent coughing with bilateral crackles upon
auscultation will be minimize

Independent
• Place patient into a high fowler position.
Rationale: To maximize lung expansion and decrease
respiratory effort
• Demonstrated proper technique on chest-physiotherapy
Rationale: To maintain patent airway and loosen the
secretions.

• Advise patient to do back tapping with the help of her
folks
Rationale: To manually help loosen or dislodge secretions
• Asses airway patency.
Rationale: It helps check for any obstruction
or accumulation of fluids and maintain adequate airway
patenc.
• Auscultate lung fields, noting areas of decrease or
absence of airflow and adventitiousbreath sounds.
Rationale: To identify areas of consolidation
and determine possible bronchospasm or obstruction

• Advise to increase fluid intake.
Rationale: Keeps mucus secretions moist and easier to expel
• Maintain a relax, calm and non-stimulating environment.
Rationale: Establish optimal rest/pattern

Dependent
• Administer following medications as prescribed.
Rationale: For compliance of therapeutic regimen.

Evaluation: Goal met. The patient maintained
airway patency as evidenced by expectorating
clear secretions after chest-physiotherapy &
clear lung sounds.

Prescribed Medication: Salbutamol 1 neb
q6h
Classification: Bronchodilators
Action: Relaxes bronchial, uterine, and
vascular smooth muscle by stimulating
beta2 receptors.
Indication: To prevent or treat bronchospasm
in patients with reversible obstructive
airway disease. To prevent exercise-
induced bronchospasm

Adverse effects:
CNS: tremor, nervousness, headache, hyperactivity, weakness,
CNS stimulation, malaise
CV: tachycardia, palpitations
EENT: dry and irritated nose and throat with inhaled form,
epistaxis,hoarseness
GI: heartburn, altered taste, increased appetite
METABOLIC: hypokalemia
RESPI: Bronchospasm, dyspnea, bronchitis, increased sputum
OTHER: hypersentivity reactions

Nursing Responsibilities
• Monitor patient’s history.
Rationale: To assess for any signs of allergy in
medication.
• Monitor vital signs especially BP.
Rationale: Drug may cause hypertension.
• Eat frequent small meals.
Rationale: To prevent nausea and vomiting.

Prescribed Medication: Cefuroxime 750mg IVTT
(ANST) prior to evacuation curettage.
Classification: Second-generation cephalosporin/ antibiotic
Action: Second-generation cephalosporin that inhibits cell-
wall synthesis, promoting osmotic instability; usually
bactericidal.
Indication: Perioperative prevention.
Other Indications: UTI’s, infections of the urinary and
lower respiratory tracts, skin and skin-structure
infections, bone and joint infections, septicemia,
meningitis, and gonorrhea.

• Adverse effects:
• CNS: headache, dizziness, lethargy, paresthesia
• GI: nausea, vomiting, anorexia, abdominalpain, flatulents,
pseudomembranous colitis, hepatoxicity.
• GU: nephrotoxicity
• HEMA: bone marrow depression (low WBC, low platelet,
low hematocrit)
• LOCAL: pain, abscess at the injection site, phlebitis,
inflammation at IV site.
• OTHER: superinfection

• Culture infection site and arrange for sensitivity test before
and after or during therapy.
Rationale: To check the effectiveness of drug.
• Give oral drug with foods.
Rationale: To decrease GI upset.
• Discontinue drug if hypersensitivity occur.
Rationale: To prevent further complications.

• Avoid vigorous activities.
Rationale: Dizzines may occur.
• Swallow drugs or tablets whole. Do not crush.
Rationale: To avoid unusual taste.

Prescribed Medication:
Diphenhydramine 50mg tab
30 mins PTBT
Classification: antihistamine,
anti-motion-sickness drug,
antiparkinsonian, cough
suppressant,

Action: Competitively blocks the effects of
histamine at H1-receptor sites on effector cells.
Indication: amelioration of allergic reactions to
blood or plasma, active and prophylactic
treatment of motion sickness, night time sleep
aid, relief of symptoms associated with
perennial and seasonal allergic rhinitis;
vasomotor rhinitis; allergic conjunctivitis,
sedation

Adverse effects
• CNS: drowsiness, sedation, dizziness, disturbed
coordination, fatigue, confusion, restlessness, excitation,
nervousness, tremor, headache, blurred vision, diplopia
• CV: hypotension, palpitations, bradycardia, tachycardia
• GI: epigastric distress, anorexia, increased appetite and
weight gain, nausea, vomiting, diarrhea or constipation
• GU: urinary frequency, dysuria, urinary retention,
decreased libido, impotence

• HEMA: hemolytic anemia, hypoplastic anemia,
thrombocytopenia, leokupenia, agranulocytopenia,
pancytopenia
• RESPI: thickening of bronchial secretions, chest tightness,
wheezing, nasal stuffiness, dry mouth, dry nose, dry throat,
sore throat
• OTHER: urticaria, rash, anaphylactic shock,
photosensitivity, excessive perspiration

• Tell the patient to take Diphenhydramine with food
or milk.
Rationale: To reduce GI distress
• Inform the patient about the use of sugarless gum,
hard candy or ice chips. Rationale: It may reduce dry
mouth Check lab results.
Rationale: To determine the effectiveness of the drug

• Instruct patient to increase fluid intake if diarrhea
may occur.
Rationale: To prevent dehydration
• Instruct patient to increase food that is high in fiber.
Rationale: To relieve constipation
• Instruct the patient to avoid alcohol
Rationale: Serious sedation could occur

• Caution the patient when performing task that
requires alertness.
Rationale: Diphenhydramine may cause dizziness
and drowsiness
• Tell patient to notify the prescriber if tolerance
develops.
Rationale: The prescriber may increase the dosage of
the drug

Prescribed Medication: Ranitidine
Hydrochloride (Geoxer) 50mg IV
PTOR
Classification: Histaimine2 (H2)
Antagonist; (Anti secretory)

Action: Competitively inhibits the action of histamine
at H2receptors of the partial cells of the stomach,
inhibiting basal gastric acid secretion and that is
stimulated by food, insulin, histamine, cholinergic
agonists gastrin and pentagastrin.
Indication: Prior to OR indication.
Other Indications: For prophylaxis of gastric ulcer

Adverse Effects:
• CNS: Contusion agitation, or hallucinations,
vertigo, dizziness, insomnia
• CV: Tachycardia, bradycardia, PVC (Rapid IV
admin)
• GI: Abdominal pain, hepatitis, increase ALT
Levels
• Hem: Leukopenia granulocytopenia,
Thrombocytopenia, Pancytopenia

•Local: Local burning an itching IV site
• GU: Gynecomastia, Impotence,
decrease libido
•Dermatologic: Rash, alopecia
• Others: Arthralgias

• Monitor patient’s vital signs especially the pulse rate before
administering the drug
Rationale: To determine any alteration based on the baseline data.
• Check the patency at the IV line.
Rationale: Obstructed tubing may alter the admin of the drug.
• Administer the drug at least 2 minutes.
Rationale: Rapid admin of the drug may cause hypotension and
arrhythmias.
• Asses for redness or inflammation on the IV site.

Metoclopramide 10mg IV
PTOR
Classification: Antiemetic
Indication: for prophylaxis of post
op nausea and vomiting

Other Indications: Prevention of
chemotherapy induced emesis. To stimulate
gastric emptying.
Action: Blocks dopamine receptors in
chemoreceptor trigger zone of the CNS.
Stimulates motility of the upper GI tract
and accelerates gastric emptying.

Adverse Effects:
• GI: Nausea &Vomiting, Diarrhea, Intestinal
Spasm & Cramping.
• CV: Declining of blood pressure and heart
rate
• CNS: Weakness and fatigue.

• Monitor blood pressure carefully if giving drug
intravenously.
Rationale: To detect and consult with the prescriber about
treatment for sudden drops in blood pressure.
• Provide importance info about drug such as including
name of drug, dosage, problems and the importance of
periodic monitoring and evaluation.
Rationale: To enhance patient knowledge about drug
therapy and promote compliance with drug regimen.

Prescribed Medication: Fluimucil 600mg
1 tab in ½ glass
Classification: Mucolytic
Action: Mucolytic activity: splits links in
the mucoproteins contained in the
respiratory mucos secretion, decreasing
the viscosity of the mucus. Antidote to
acetaminophen hepatoxicity; protects
liver cells by maitaing cell fuction.

Indication: Mucolytic adjuvant therapy for
abnormal viscid or inpissated mucus secretion
in acute and chronic bronchopulmonary
disease.
Other Indication: pulmonary complications
associated with surgery, anesthesia, post-
traumatic chest condition, diagnostic
bronchial studies.

Adverse effects:
• GI: nausea, GI upset.
• DERMA: Urticaria
• Respi: brochospasm, increased productive
cough
• Other: rhinorrehea

• Assess patient’s history
Rationale: To assess patient’s allergy to the drugs.
• Eat frequent small meals.
Rationale: To maintain nutrition.

Prescribed Medication: Cefuroxime 750mg
IVTT q8h
Classification: Second-generation cephalosporin/
antibiotic
Action: Second-generation cephalosporin that
inhibits cell-wall synthesis, promoting osmotic
instability; usually bactericidal.

Indication: Prophylaxis for possible surgical site
infection.
Other Indications: Perioperative prevention, UTI’s,
infections of the urinary and lower respiratory
tracts, skin and skin-structure infections, bone and
joint infections, septicemia, meningitis, and
gonorrhea.

Adverse effects:
• CNS: headache, dizziness, lethargy, paresthesia
• GI: nausea, vomiting, anorexia, abdominalpain,
flatulents, pseudomembranous colitis, hepatoxicity.
• GU: nephrotoxicity

• HEMA: bone marrow depression (low WBC, low
platelet, low hematocrit)
• LOCAL: pain, abscess at the injection site, phlebitis,
inflammation at IV site.
• OTHER: superinfection

• Culture infection site and arrange for sensitivity test
before and after or during therapy.
Rationale: To check the effectiveness of drug.
• Give oral drug with foods.
Rationale: To decrease GI upset.
• Discontinue drug if hypersensitivity occur.
Rationale: To prevent further complications.

• Avoid vigorous activities.
Rationale: Dizzines may occur.
• Swallow drugs or tablets whole. Do not crush.
Rationale: To avoid unusual taste.
• Complete medication regimen as prescribed.
Rationale: Compliance for therapeutic regimen.

Methotrexate 0.5 ml IM, OD
for 5 days
Classification: Antineoplastic,
Antimetabolites

Action: Inhibits folic acid reductase, leading to
inhibition of DNA synthesis and inhibition of
cellular replication; selectively affects the most
rapidly dividing cells.
Indication: Treatment of hyaditiform mole,
gestational carcinoma, chorioadenoma
destruens.

Adverse effects:
• CNS: fatigue, malaise, dizziness
• GI: ulcerative colitis, hepatic toxicity
• GU: effects on fertility (menstrual
dysfunction, infertility, defective oogenesis)

• Dermatologic: erythematous rashes
• Hema: severe bone marrow depression,
increase susceptibility to infection.
• Respiratory: interstitial Pneumonitis
• Hypersensitivity: anaphylaxis and sudden
death.

• Monitor patient history.
Rationale: To assess for any signs of allergy in medication.
• Provide small, frequent meals; Frequent mouth care & dietary
consultation.
Rationale: To prevent nausea and vomiting & maintain nutrition
when GI effects are severe.
• Instruct patient to avoid driving or using dangerous equipment.
Rationale: Possible drowsiness may occur.

• Encouraged patient to avoid crowd places, sick
people, and working in soil.
Rationale: To avoid infection.
• Avoid alcohol while taking the drug.
Rationale: Serious side effects may occur.
• Arrange for Adequate Hydration during therapy.
Rationale: To reduce the risk of hyperurecemia.

Tranexamic Acid 1000mg
IV q8h x 3days
Classification:
Antifibrinolytic

Action: Displace plasminogen from surface of
fibrin by binding to high- affinity lysine site of
plasminogen. The diminishes dissolution of
hemostatic fibrin, which decreases bleeding.
Indications: For Post-op preventive measure for
hemorrhage.
Other Indications: To treat cyclic heavy
menstrual bleeding

Adverse effect:
• CNS: cerebral thrombosis,dizziness, fatigue,
headache, migraine
• CV: deep vein thrombosis
• EENT: central retinal artery, and vein obstruction,
feeling of throat tightness, impaired color vision,
ligneous conjunctivitis, sinusitis, visual
abnormalities
• GU: Acute renal cortical necrosis

• HEME: anemia
• MS: Arthralgia, muscle cramps and spasms,
myalgia, backpain
• RESP: dyspnea, pulmonary embolism,
respiratory congestion
• SKIN: allergic skin reactions, facial flushing
• OTHER: anaphylaxis, multiple allergies
including seasonal

NURSING RESPONSIBILITIES
• Monitor patient closely for allergic reactions to tranexamic acid
such as dyspnea, a feeling of throat tightness, and facial flushing
that may require emergency medical treatment,
Rationale: to avoid further complications to patient and to stop
taking drug.
• Advise patient to report any changes in vision or ocular
discomfort,
Rationale: The prescribing physician may stop administering the
drug.

TRAMADOL (ULTRAM)
375mg; 1 cap PO TID x 2 days
start
Classification: Analgesic,
centrally acting

Adverse effects:
• CNS: Dizziness, headache, somnolence, vertigo,
seizures, anxiety, CNS stimulation, confusion,
coordination disturbance, euphoria, malaise,
nervousness, sleep disorder.
• CV: Vasodilation.
• EENT: Visual disturbances.

Action: Unknown. A centrally acting
synthetic analgesic compound not
chemically related to opioids. Thought to
bind to opioid receptors and inhibit reuptake
of norepinephrine and serotonin.
Indication: For post op pain management.

• GI: Constipation, nausea, vomiting, abdominal
pain, anorexia, diarrhea, dry mouth, dyspepsia,
flatulence.
• GU: Menopausal symptoms, proteinuria, urinary
frequency, urine retention.
• RESPIRATORY: Respiratory depression.
• SKIN: Diaphoresis, pruritus, rash.

• Control environment (temperature, lighting) if sweating or CNS
effects occur.
Rationale: to prevent adverse effects and provide immediate
interventions if these occurs.
• Avoid performing tasks that require alertness.
Rationale: to prevent any injuries because the drug causes
dizziness.
• Report severe nausea, dizziness and severe constipation.
Rationale: to provide immediate intervention.

• Assess type, location and intensity of pain before and after
administration.
Rationale: to ensure the effectiveness of the drugs.
• Assess respiratory rate before and periodically during
administration.
Rationale: respiratory depression may occur
• Assess bowel function routinely. Prevention of
constipation should be instituted with increased intake of
fluids and bulk.
Rationale: to minimize constipating effects.

Discharge to a patient
plan undergone Suction
Dilatation and
Curettage.

• Encourage the patient for compliance of
medication.
Rationale: To prevent drug resistance and
to ensure effectiveness of the drug.
• Educate the patient and the significant
others about the adverse effect of the
medication as manifested by untoward
symptoms that may require immediate
notifications of the physician.
Rationale: To become aware of when to
seek medical attention and address the
problem immediately.

• Instruct the significant others to
provide the client a calm and well
ventilated environment.
Rationale:To provide restful
environment to the client.
• Instruct the significant others to
maintain environmental sanitation.
Rationale: The patient is susceptible
in contracting infections as she
undergone surgery.

• Encourage the patient to seek
for follow-up check up.
Rationale: To determine
client’s current medical
condition.

• Educate the patient on how to perform
proper perineal care such as washing
the vagina from front to back.
Rationale: Proper perineal care prevents
infection.
• Teach the client the necessary measures
of maintaining good skin integrity.
Rationale: Bathing and inspecting the
skin will preserve skin integrity.

• Advice the client to use their
Philhealth card if there is any
to avail its benefits.
Rationale: To reduce financial
problem.

• Encourage the family to prepare nutritious foods
such as vegetables, fruits and meat.
Rationale: Provide more energy, Vitamins and
minerals necessary in medical illness and repair of
damage tissues.
• Advice the family to give the patient’s foods rich in
vitamins C such as oranges and calamansi juice.
Rationale: Vitamin C helps boost patient’s immunity.
• Recommend restrictions of caffeine.
Rationale: Because this substance could affect the
effectiveness of the drugs.

• Encourage family members to
assist and support the client in
meeting his needs and allow open
communication.
Rationale: To enhance
coordination and continuity of
care.

• Pelvic is recommended for 4-6 weeks
after evacuation of the uterus, and the
patient is instructed not to become
pregnant for 12months. Adequate
contraception is recommended.
Rationale: To avoid any confusion about
the development of malignant disease.
If pregnancy occurs, the elevation in
beta-HCG levels cannot be
differentiated from the disease process.

REFERENCES:
http://www.ncbi.nlm.nih.gov/pubmed/16313080
http://www.cancer.org/cancer/gestationaltrophoblasticdisease/detailedguide/gestatio
nal-trophoblastic-disease-what-is-g-t-d
http://en.wikipedia.org/wiki/Gestational_trophoblastic_disease#Etiology
http://nursingcrib.com/nursing-notes-reviewer/gestational-trophoblastic-disease/
http://www.ehow.com/list_6327219_signs-symptoms-gestational-trophoblastic-
disease.html
http://cancer.stanford.edu/gynecologic/gtd/diagnosis.html
http://www.patient.co.uk/doctor/gestational-trophoblastic-disease

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