CASE STUDY

INTRODUCTION-

My client Mrs. rekha Sahu, she is 34 year old, W/O Mr Madan mohan admitted in J. L. N.
Hospital, Bhilai, with the compliant of per vaginall bleeding for 2months and odema in leg
25/06/2018 at 9 A.M.

BASELINE DATA OF THE PATIENT-

1. Name - Mrs. rekha Sahu

2. Husband’s Name - Mr. Madan mohan
3. Age - 34 years
4. Sex - Female
5. Address - BHILAI, C.G.
6. Date of Admission - 20/06/2018
7. Unit - I
8. Ward no - H1
9. Bed no - 02
10. Religion - Hindu
11. Marital status - Married
12. Educational status - 11th Passed
13. Occupation - House wife
14. Diagnosis - carcinoma cervix I B2.

CLIENT COMPLAINTS-(document in patient’s own word)

Pain in lower abdomen, Dizziness, Weakness-

Other complains-  Dizziness and weakness

 Decreased appetite
 Odema on leg

HISTORY OF THE CLIENT

FAMILY HISTORY-

1. Type of family-Nuclear

2. No. of family members- 03

3. Any disease- No history of any disease condition in the family.

 S.No Name of the Age/sex Relationship with Health Specify
persons client status disease(if
any)
1. Madan mohan 41yr/M Husband Good No

2. Rekha sahu 35yr/F Self Average No

3. Hari ram 8yr/M Son Good No

FAMILY TREE-(symbolic representation)

Male femalefemale female client

41yrs 34yrs

8yrs

SOCIO ECONOMIC HISTORY-

Family income -Rs. 15,000/month

No of earning member - one

Education - Wife / 10th passed, Husband / B.A passed

Social support - Satisfactory

Relationship with neighbours - Good

1. PERSONNAL HEALTH HISTORY

 Oral hygiene:-Good
 Bathing habit:-Daily-
 Grooming :-Maintained-
 Health facility nearby home:-Present-
 Sleep pattern:-Regular-
 Bladder and bowel habits:-Regular-REMAKS- reduced urine output.
 Allergies :- No significant history of allergies

 Health habits:-
 Smoking
 Tobacco None of these
 Alcohol
 Drugs

Religious history:-

Religion Hindu

Exercise:- No exercise done

2. SANITARY HISTORY-Good

3. ENVIRONMENTAL HISTORY-

 Type of house:-Pucca
 Ventilation:-Adequate
 Electricity:-Available
 Water supply:-Tape water
 Drainage system:-Closed

4. NUTRITIONAL HISTORY
 Type of diet. Non vegetarian

5. MEDICAL HISTORY OF THE CLIENT

PRESENT MEDICAL HISTORY-My client with the compliant of p/v bleeding for
2months and odema in leg

PAST MEDICAL HISTORY-

 Childhood illness - Not significant

 Adult illness - Not significant
 Hospitalization - No
 Accident - No
 Hyperlipidemia - No
 Hypertension - yes
 Diabetes mellitus - No
 Thrombo embolism - No
 Any other disease - No

6. SURGICAL HISTORY OF THE CLIENT--

 PRESENT SURGICAL HISTORY

My client has undergone through hystrectomy.

PAST SURGICAL HISTORY

No any significant past surgical history.

7. MENSTRUAL HISTORY-
 Type of Cycle - irregular
 Duration of menstrual cycle - -
 Duration ofmenstruation - 3-4days
 Amount of Blood Loss -
 No of Pads Used -3-4/day

8. OBSTETRICAL HISTORY-
 No of living children- Nil
 Health status of the baby- Nil
 Last issues child age- Nil
 Gravida- 1
 Para- 1
 Abortion- Nil
 Stillbirth- Nil

9. PAST OBSTETRICAL HISTORY-

S.no Gravida Abort. Preterm Fullterm Type of Sex Alive Wt. Stillbirth Remarks
Delivery
1. 2 - - - Normal M 1 - -
delivery

10. ANTENATAL ATTENDANCE-

Date Wt. Urine, B.P. F.H.R. Weeks Of Fundal T/t and

Albumin, Gestation Height Remarks
Sugar
 11. PHYSICAL EXAMINATION OF CLIENT

GENERAL APPEARANCE-

Body positions:-Normal

Nourishment:-Under nourishment

Health:-Unhealthy

Activity :-Dull

MENTAL STATUS-

Consciousness-Conscious

Look:-Anxious,Worried,Depressed

SKIN CONDITION-

Color-Pallor

Texture-Dryness,Wrinkling

Skin turgor-Present

Scars- Absent

Hair distribution-Normal

Hair color-Black

HEAD AND FACE

a) Scalp - Normal and Clean

b) Hair distribution -Normal
c) Hair Color - Black
d) Face - Pale

EYES-Depressed

Eye brow:-Normal-

Eye lashes:-Equal distribution

Conjunctiva-Pale

Sclera:-White

Pupils:-Reacted to light

Vision:-Normal

EARS:-
External ear:-Normal

Hearing:-Normal

NOSE:-

External nose:-Normal

Nostril:-Normal

MOUTH AND PHARYNX-

Lips:-Pale

Mouth:-Foul smell

Teeth :-Discoloration

Tongue:-Pale

Gums:- Normal

Uvula:-Symmetrical

Tonsils:-Normal

Voice:-Normal

NECK

 Lymph nodes - No Enlargement

 Thyroid gland- No Enlargement
 Masses - Absent
 Swelling - Absent
 Neck Range of Motion- Normal

THORAX AND LUNGS

a) Shape - Normal
b) Expansion - Adequate
c) Tenderness - Not Present
d) Breath sound - No any abnormal sound

HEART

a) Rate - 80 beats/min.
b) Rhythm - Regular
c) Size - Normal
d) Location - Appropriate
 e) Apical pulse - Palpable
f) Heart sound - S1 and S2 audible

ABDOMEN-

a) Shape - Normal
b) Bowel sound - Present
c) Liver - Palpable
d) Spleen - Palpable
e) Tenderness - Present
Lower Abdominal pain is present

EXTREMITIES-

a) Upper limb - Normal

b) Lower limb - Normal
c) Movement - Present
d) Tremors - Absent
e) Edema - Present
f) Varicose vein - Absent
g) Reflexes - Present

GENITALIA(FEMALE)

a) Hair distribution - Equal

b) Discharge - Scanty
c) Bleeding - Nil
d) Urethral meatus - Normal
e) Vaginal Opening - Normal
f) Clitoris - Normal
g) Foul smell - Absent
h) Mass - Not present

RECTUM

a) Inflammation - Normal
b) Scars - Not Present
c) Lesions - Not Present
d) Ulceration - Not Present
e) Rashes - Not Present
f) Pain - Not Significant
g) Bleeding - Nil
h) Sphincter control - Present

VITAL SIGNS
 a) Pulse
 Monitoring site - Radial.
 Rate - 80beats/min
 Rhyth - Regular

Remarks – No any significant abnormality seen

b) Respiration
 Rate - 22 breaths/min
 Rhythm - Regular

Remarks- No any significant abnormality observed

c) Blood pressure
 Lying down position - 140/90 mm of Hg
 Orthostatic hypotension - Absent

HEIGHT - 5’

WEIGHT - 76kg

12.OBSTETRICAL EXAMINATION-

 BREAST EXAMINATION
I. Consistency - No Tenderness, palpable without mass
II. Engorgement - Not engorged
III. Lactation - -
IV. Nipple - Normal without any cracks

 ABDOMINAL EXAMINATION

1. Abdomen -lower abdominal pain

 PERINEAL EXAMINATION
1. Perineal area - Normal
2. Any bleeding/ discharge - present slight bleeding
3. Episiotomy suture - Nil
4. Any wound gaping - Ni

 VAGINAL EXAMINATION
1. Bleeding - present / occur by touch and friction on the lesion.
2. Cervix – nodular mass is observed
  EXTREMITIES
1. Edema - leg present
2. Varicosities -absent

INVESTIGATION

S.NO. PARAMETER PATIENTS NORMAL REMARK

VALUE VALUE

1. Hematology
Hb 8gm% 11.5-13.5 gm% Low
Blood group A+ve - No Abnormality
HIV I & II -ve - No Abnormality
HbsAg -ve - No Abnormality
HCV -ve - No Abnormality
VDRL -ve - No Abnormality
Malaria Parasite -ve - No Abnormality
Sicking test -ve - No Abnormality

2. Urinalysis

Albumin nil Normal

Sugar -ve Normal
Pus cell 2-3 cells Normal
3. Creatinine o.6mg/dl 0.7-1.5 Low
4. Prothrombine time 14sec 14 normal
5. INR 1.45 2-3 LOW

ULTRASONOGRAPHY- FINDINGS 14week.

Clinically visible lesion of 3.5cm in greater dimension.

DIAGNOSIS: Carcinoma cervix I B2

DEFINITION

“Cervical cancer is a type of cancer that occurs in the cells of the cervix — the lower part of
the uterus that connects to the vagina.”

INCIDENCE- In most of the developing countries carcinoma of the breast and cervix are
the leading sites of malignancies in female and are major public issues.

ANATOMY

Gross anatomy

 The cervix is a firm, cylindrical structure situated at the lower pole of the uterine
corpus.
 The length of a normal adult non-pregnant cervix is approximately 25 mm, with an
anteroposterior diameter ranging between 20 and 25 mm and a transverse diameter of
25–30 mm,
 The cervix is divided into two portions that lie above and below the vaginal reflection,
the portiosupravaginalis and portiovaginalis respectively.
 . It ensures communication between the cavity of the corpus and the lumen of the
vagina, and is bounded by the internal and external os.
PHYSIOLOGY

 It is the lower most part of the uterus and is made up of strong muscles.
 The function of the cervix is to allow flow of menstrual blood from the uterus into the
vagina,
 Direct the sperms into the uterus during intercourse.
 The opening of the cervical canal is normally very narrow.

I Cervical carcinoma confined to the cervix (disregard extension to the corpus)

IA Invasive carcinoma diagnosed only by microscopy; stromal invasion with a

maximum depth of 5.0 mm measured from the base of the epithelium and a
horizontal spread of 7.0 mm or less; vascular space involvement, venous or
lymphatic, does not affect classification

IA1 Measured stromal invasion ≤ 3.0 mm in depth and ≤ 7.0 mm in horizontal spread

IA2 Measured stromal invasion > 3.0 mm and ≤ 5.0 mm with a horizontal spread ≤ 7.0
mm

IB Clinically visible lesion confined to the cervix or microscopic lesion greater than
T1a/IA2

IB1 Clinically visible lesion ≤ 4.0 cm in greatest dimension

IB2 Clinically visible lesion > 4.0 cm in greatest dimension

II Cervical carcinoma invades beyond uterus but not to pelvic wall or to lower third of
vagina

IIA Tumor without parametrial invasion

IIA1 Clinically visible lesion ≤ 4.0 cm in greatest dimension

IIA2 Clinically visible lesion > 4.0 cm in greatest dimension

IIB Tumor with parametrial invasion

III Tumor extends to pelvic wall and/or involves lower third of vagina and/or causes
hydronephrosis or nonfunctional kidney

IIIA Tumor involves lower third of vagina, no extension to pelvic wall

IIIB Tumor extends to pelvic wall and/or causes hydronephrosis or nonfunctional kidney

IV Tumor invades mucosa of bladder or rectum and/or extends beyond true pelvis
(bullous edema is not sufficient to classify a tumor as T4)

IVA Tumor invades mucosa of bladder or rectum (bullous edema is not sufficient to
classify a tumor as T4)

IVB Tumor extends beyond true pelvis

ETIOLOGY-

IN GENERAL IN PATIENT

Family history Absent

Consumption of alcohol/smoking Absent

Uterine infection Present

Obesity Present

HPV Absent

Genetic factor Present

PATHOPHYSIOLOGY-:

Tumors cells resemble normal cells

(elongated , spindle shaped with a cigar shaped nucleus)

From bundles with different directions.

These cells are inform in shape and size with scarce mitoses.

These appear a prominent nucleus with perinuclear halos

Fibroid uterus

CLINICAL FEATURES-

IN GENERAL IN PATIENT

Irregular vaginal bleeding Present

Offensive vaginal discharge Present

Pelvic pain Present

Leg oedema Present

Dysuria Absent

Bleeding per rectum Absent

MANAGEMENT:

Medical management-

IN GENERAL IN PATIENT
 1. Ciprofloxacin Given

2. Flagyl Given

3. Voveron Given

4. Calcium Given

5. Esylate Given

Surgical management –

IN GENERAL IN PATIENT

1. Hysterectomy Done

MEDICATION.

S. Drug name Dose/ Time Action Side Nurses

no route effect Responsibility
1. ciprofloxacin I/V 8hrly The bactericidal action of Nausea , ->To check the
1 200mg ciprofloxacin results from vomiting 5rights of
1 inhibition of the enzymes ,dizzines medication.
topoisomerase II (DNA s, ->To tell the
gyrase) and topoisomerase IV constipat patient to
(both Type II ion. report for side
topoisomerases), which are effect.
required for bacterial DNA
replication, transcription,
repair, and recombination.

2. Inj. Voveron I/V 8hrly Diclofenac sodium works by Nausea,v ->check the
blocking the production of omiting, 5rights of
some of the body chemicals dizziness medication.
that cause inflammation, pain, ->Check the
stiffness, tenderness, swelling vital signs.
and increased temperature.

3. I/V flagyl 100cc BD Inhibits DNA synthesis in Vertigo,h ->Check the 5

specific (obligate) anaerobes, eadeche, rights of the
causing cell death anorexia, medication.
dry ->Inform the
mouth. patient that
drug cause and
side effect.
NURSING CARE PLAN ACCORDING TO OREM’S THEORY-:

NURSING OUT COME AND IMPLEMENTATION EVALUATION

DIAGNOSIS PLAN
1.Self care deficit -> Improved self -> Provide all the articles needed -> Patient
related to restricted care. for self care near to patient. perform some of
movement due to -> To maintain the -> Provide assistance whenever activities with
operative procedure. ability to self care in needed. minimal
optimal level. -> Provide passive excercises. assistance.

2.Ineffective pain Achieve and ->Provide hot and cold -> Patient
control related to maintain a reduction applications. demonstrated
lack of utilization of in pain. -> Administer analgesics as reduction in the
pain relief measures. prescribed pain behaviour.
-> Provide diversonal and
psychological support to the
patient.
3. Potential for fall -> Absence of falls -> Never leave the client alone in -> Patient
and fracture related and injury to the the unit. remains free
to movements. patient. -> Assess patients gait, activities from injury and
and mental status for disorientation. falls.
-> Income family members to
provide support to the patient
whenever needed.

4.Potential for -> Absence of -> Verbalize the various Patient got
complication related complication and complication and their prevention. adequate
to operative improved awareness -> Verbalize the changes occurring information
procedure secondary about present with treatment. regarding her
to knowledge deficit. conclusion. -> Describe actions and side effects condition and its
-> Improve the of medications used. management.
knowledge of
patient.
5.Alteration in To maintain  Assess the nutritional status. Patient achieved
nutrition less than nutritional status.  Provide balance diet . the optimal level
body requirement.  Provide nutritional therapy. of nutrition.

6.Knowledge deficit To provide adequate  Provide health education She has
regarding diseased information regarding participate in
condition and regarding treatment  Rest health care
treatment modalities.  Diet . activities.
 Medicine
 Personal hygiene
 Family planning .
 Provide psychological
support.

ONE DAY MENU PLANNING-:

TIME FOOD ITEMS AMOUNT

8:00 AM Suji 1plate

Banana 2Nos
 Milk 1Glass
Egg 1Nos
1:00PM Rice 1plate
Chicken 1katorie
Curd 1katorie
Papad 2nos
Salad 1plate
Dhal 1katorie
4:00PM Tea 1cup
Bread 2nos
DINNER Chappati 2nos
Egg curry 1katorie
Rice ½ plate
Dhal ½ katorie
AT BED TIME Milk 250ml

DAY TO DAY PROGNOSIS-:

1st DAY-:
General condition:- normal
Consciousness-:conscious
B.P.-> 130/80mmhg
Pulse->78/min
Resp-:20/min
Temp-:98.6o f

2nd DAY-:
General condition:- Better
Consciousness-:conscious
Orientation-:oriented
B.P.-> 120/80mmhg
Pulse->76/min
Resp-:22/min
Temp-:99o f

3rd DAY-:
General condition:- Stable
Consciousness-:conscious
B.P.-> 110/80mmhg
Pulse->72/min
Resp-:20/min
Temp-:98.6o f

4th DAY-:
General condition:- Stable
Consciousness-:conscious
Orientation-:oriented
B.P.-> 120/80mmhg
Pulse->80/min
Resp-:22/min
Temp-:98.6o f
HEALTH EDUCATION-:

1.Diet-:
->Advised to take balanced diet rich in protein.
-> To improve the dailycalories and protein.
->Advised to improve fluid intake and fruit juice
.
2. Personal hygiene-:
-> Advised to take regular bath.
->Advised to maintain hygiene level of genital area.
->Advised to keep genital area dry after defecation and urination.

3. Rest and sleep-:

->Advised to take rest and sleep.
->Advised to doexercise .
->Advised to avoid doing heavy work.

4. Follow up->
->Advised to come for follow up.
->Advised to take medicine on time

5. Surgery is a common treatment for cervical cancer, and patients often need help controlling their
sugars post-operatively because stress can raise sugar levels.

Biography:
1) D.C .Dutta “Textbook of gynecology”

6th edition, New central agency, 2006, Page no.321.

2) NimaBhaskar “Midwifery and Obstetrical Nursing”

Second edition 2013, EMMESS Medical Publication, Pp-.

3) Myles “Textbook for Midwives”

Fifteenth edition2009, ELSEVIER Publication, Pg-

4) “preeclampsia”. Bivin Jose. Retrived on-13/jan/2012.

<http://www.emedicinehealth.com/postpartum_preeclampsia/page6_em.htm>

5) “multiple pregnancy”. Wikimedia Foundation, Inc 12 October 2013

<www.en.wikipedia.org/wiki/preeclampsia>