NURSING CASE STUDY
TOTAL ABDOMINAL HYSTERECTOMY BILATERAL SALPINGO OOPHORECTOMY
, NURSING CASE STUDY
ADMISSION/FINAL DIAGNOSIS
I. HEALTH HISTORY
A. DEMOGRAPHIC (BIOGRAPHICAL DATA)
1. Client’s initials: J. L. B.
2. Gender: Female
3. Age: 44 years old Birthdate: April 24, 1969; Birthplace: San Mateo, Rizal
4. Marital (Civil) Status: Married
5. Nationality: Filipino
6. Religion: Roman Catholic
7. Address and Phone Number: 376 Lipahan, Pulong Bunga, Silang, Cavite 09209640936
8. Educational Background/Other Significant Framing: High School Graduate
9. Occupation (usual and present): Housewife
10. Usual Source of Medical Care: Hospital
B. SOURCE AND RELIABILITY OF INFORMATION
Data were obtained from the patient who seems reliable. The client’s chart was also
incorporated as a secondary source of information.
C. REASONS FOR SEEKING CARE OR CHIEF COMPLAINTS (top 3)
“sobrang sumasakit ang puson ko”
“sobrang lakas ng regla ko, nag umpisa sya ng ganito kalakas nung April netong taon
lang..umpisa nun buwan buwan na ganito”
“napapatagal yung buwanang dalaw ko”
D. HISTORY OF PRESENT ILLNESS/ OR PRESENT HEALTH
Two months prior to admission, the client experienced abnormally heavy and prolonged
menstruation and dysmenorrhea as well. She reported that from three feminine pads moderately
soaked it increased to five pads fully-soaked per day, and from her regular three-day period, it
increased to five days accompanied with menstrual pains (a scale of eight out of ten from the pain
scale) but no consultation occurred.
Two weeks prior to admission, there was persistence of the above symptoms and the
client decided to consult a doctor and had an ultrasound (trans-v) which showed the back part of
her uterus to have an abnormality and also showed that her left ovary has an overgrowth. After
these discoveries, she was scheduled for an operation to remove her uterus, fallopian tubes and
her ovaries. The client was admitted to the hospital two days before her scheduled operation.
E. PAST MEDICAL HISTORY OR PAST HEALTH
J.L.B. is a housewife who considers daily household chores to be her exercise. As a child,
she did not experience any serious illnesses, just had simple cough and colds. She also did not
experience any injuries or accidents in the past and this is her first hospitalization and operation.
J.L.B. had her menarche at the age of twelve and her last menstrual period was June 10,
2013. She is G2P2; G1 - 1996, girl, 7 lbs, NSD; G2 - 1998, girl, 6.7 lbs, NSD. Had a history of UTI
with her second pregnancy, unrecalled medications but treated completely. She undergone Total
Abdominal Hysterectomy and Bilateral Salpingooophorectomy due to an overgrowth on part of her
, F. FAMILY HISTORY
Grandfather, Grandmother, old Grandfather, Grandmother,
unrecalled age and age unrecalled age and unrecalled age and
cause of death cause of death cause of death
Father, 77 Mother, 76, rheumatoid
lung disease arthritis and HTN
Patricio, 52, Zenaida, 51, Anna,48, had Eduardo,46, Patient, 44, Priscilla, 38,
rheumatoid had myoma;hyste- healthy adenomyosis healthy
arthritis hysterectomy rectomy
According to the family genogram, her grandparents, paternal side, are deceased and she
does not know her grandfather’s cause of death but her grandmother died due to old age. Patient’s
grandparents on the maternal side are already deceased and the patient does not recall the
causes of death. The patient’s father died due to a lung problem (patient does not know the exact
lung illness). Her mother has rheumatoid arthritis and also has hypertension. The genogram also
shows that two of her sisters also undergone hysterectomy before. The client is the fifth child of her
parents.
G. SOCIO-ECONOMIC
The client is a plain housewife and currently living with her husband and two daughters and
both of them are still students. The family’s source of income is from her husband who is a
supervisor in a resort. She claimed that her husband’s income is enough for them.
H. DEVELOPMENTAL HISTORY
Middle Adulthood: 35 to 55 or 65
Ego Development Outcome: Generativity vs. Self absorption or Stagnation
Basic Strengths: Production and Care
Now work is most crucial. Erikson observed that middle-age is when we tend to be
occupied with creative and meaningful work and with issues surrounding our family. Also, middle
adulthood is when we can expect to "be in charge," the role we've longer envied.
The significant task is to perpetuate culture and transmit values of the culture through the
family (taming the kids) and working to establish a stable environment. Strength comes through
care of others and production of something that contributes to the betterment of society, which
Erikson calls generativity, so when we're in this stage we often fear inactivity and
meaninglessness.
As our children leave home, or our relationships or goals change, we may be faced with
TOTAL ABDOMINAL HYSTERECTOMY BILATERAL SALPINGO OOPHORECTOMY
, NURSING CASE STUDY
ADMISSION/FINAL DIAGNOSIS
I. HEALTH HISTORY
A. DEMOGRAPHIC (BIOGRAPHICAL DATA)
1. Client’s initials: J. L. B.
2. Gender: Female
3. Age: 44 years old Birthdate: April 24, 1969; Birthplace: San Mateo, Rizal
4. Marital (Civil) Status: Married
5. Nationality: Filipino
6. Religion: Roman Catholic
7. Address and Phone Number: 376 Lipahan, Pulong Bunga, Silang, Cavite 09209640936
8. Educational Background/Other Significant Framing: High School Graduate
9. Occupation (usual and present): Housewife
10. Usual Source of Medical Care: Hospital
B. SOURCE AND RELIABILITY OF INFORMATION
Data were obtained from the patient who seems reliable. The client’s chart was also
incorporated as a secondary source of information.
C. REASONS FOR SEEKING CARE OR CHIEF COMPLAINTS (top 3)
“sobrang sumasakit ang puson ko”
“sobrang lakas ng regla ko, nag umpisa sya ng ganito kalakas nung April netong taon
lang..umpisa nun buwan buwan na ganito”
“napapatagal yung buwanang dalaw ko”
D. HISTORY OF PRESENT ILLNESS/ OR PRESENT HEALTH
Two months prior to admission, the client experienced abnormally heavy and prolonged
menstruation and dysmenorrhea as well. She reported that from three feminine pads moderately
soaked it increased to five pads fully-soaked per day, and from her regular three-day period, it
increased to five days accompanied with menstrual pains (a scale of eight out of ten from the pain
scale) but no consultation occurred.
Two weeks prior to admission, there was persistence of the above symptoms and the
client decided to consult a doctor and had an ultrasound (trans-v) which showed the back part of
her uterus to have an abnormality and also showed that her left ovary has an overgrowth. After
these discoveries, she was scheduled for an operation to remove her uterus, fallopian tubes and
her ovaries. The client was admitted to the hospital two days before her scheduled operation.
E. PAST MEDICAL HISTORY OR PAST HEALTH
J.L.B. is a housewife who considers daily household chores to be her exercise. As a child,
she did not experience any serious illnesses, just had simple cough and colds. She also did not
experience any injuries or accidents in the past and this is her first hospitalization and operation.
J.L.B. had her menarche at the age of twelve and her last menstrual period was June 10,
2013. She is G2P2; G1 - 1996, girl, 7 lbs, NSD; G2 - 1998, girl, 6.7 lbs, NSD. Had a history of UTI
with her second pregnancy, unrecalled medications but treated completely. She undergone Total
Abdominal Hysterectomy and Bilateral Salpingooophorectomy due to an overgrowth on part of her
, F. FAMILY HISTORY
Grandfather, Grandmother, old Grandfather, Grandmother,
unrecalled age and age unrecalled age and unrecalled age and
cause of death cause of death cause of death
Father, 77 Mother, 76, rheumatoid
lung disease arthritis and HTN
Patricio, 52, Zenaida, 51, Anna,48, had Eduardo,46, Patient, 44, Priscilla, 38,
rheumatoid had myoma;hyste- healthy adenomyosis healthy
arthritis hysterectomy rectomy
According to the family genogram, her grandparents, paternal side, are deceased and she
does not know her grandfather’s cause of death but her grandmother died due to old age. Patient’s
grandparents on the maternal side are already deceased and the patient does not recall the
causes of death. The patient’s father died due to a lung problem (patient does not know the exact
lung illness). Her mother has rheumatoid arthritis and also has hypertension. The genogram also
shows that two of her sisters also undergone hysterectomy before. The client is the fifth child of her
parents.
G. SOCIO-ECONOMIC
The client is a plain housewife and currently living with her husband and two daughters and
both of them are still students. The family’s source of income is from her husband who is a
supervisor in a resort. She claimed that her husband’s income is enough for them.
H. DEVELOPMENTAL HISTORY
Middle Adulthood: 35 to 55 or 65
Ego Development Outcome: Generativity vs. Self absorption or Stagnation
Basic Strengths: Production and Care
Now work is most crucial. Erikson observed that middle-age is when we tend to be
occupied with creative and meaningful work and with issues surrounding our family. Also, middle
adulthood is when we can expect to "be in charge," the role we've longer envied.
The significant task is to perpetuate culture and transmit values of the culture through the
family (taming the kids) and working to establish a stable environment. Strength comes through
care of others and production of something that contributes to the betterment of society, which
Erikson calls generativity, so when we're in this stage we often fear inactivity and
meaninglessness.
As our children leave home, or our relationships or goals change, we may be faced with
