39075313 Ectopic Pregnancy

STI College of Nursing Sta. Cruz, Laguna

Submitted to:

Ms. Aurea Celino, RN, MAN

Clinical Instructor

Submitted by:

GROUP II

Members:

Bernardino, Michelle S.

Bernas, Nikki Lou

Ching, Judith U.

De Ramos, Robert Immanuel

Ingalla, Charmaine

Matienzo, Evangeline N.

Monteseña, Roselle Ann

Sotomayor, Karen

July 2010

TABLE OF CONTENTS

0

I. Introduction ------------------------------------------------------------------------------------

2

A. Objectives -------------------------------------------------------------------------------3

B. Background of the Study ------------------------------------------------------------3

C. Rationale for Choosing the Case --------------------------------------------------4

D. Significance of the Study ------------------------------------------------------------4

E. Scope and Limitations ----------------------------------------------------------------4

II. Clinical Study

------------------------------------------------------------------------------------5

A. Demographic Data ----------------------------------------------------------------------5

B. Physical Assessment -------------------------------------------------------------------7

C. System Affected --------------------------------------------------------------------------9

D. Laboratory and Diagnostic Exam ----------------------------------------------------9

III. Clinical Discussion

----------------------------------------------------------------------------11

A. Anatomy and Physiology -------------------------------------------------------------11

B. Pathophysiology ------------------------------------------------------------------------14

C. Nursing Care Plan ----------------------------------------------------------------------15

D. Drug Study -------------------------------------------------------------------------------20

E. Course in the Ward --------------------------------------------------------------------29

F. Discharge Plan --------------------------------------------------------------------------30

G. Evaluation --------------------------------------------------------------------------------32

H. Summary ----------------------------------------------------------------------------------

33

I. Recommendation -----------------------------------------------------------------------34

J. Bibliography ------------------------------------------------------------------------------35

1

I. Introduction

ECTOPIC PREGNANCY

The BSN level III students were given the opportunity to have a hospital

exposure at Laguna Provincial Hospital – Delivery Room; and on that day found a

commendable case reasonable to be presented for case study. The patient, to be

mentioned in this paper as J.S, housewife, G2P1 (T1-P0-A0-L1), was one of the

patients admitted to the Delivery Room. She was 33 years of age. Her LMP is June 10,

2010 and her EDC is March 17, 2011. She was admitted due to ectopic pregnancy.

An ectopic pregnancy occurs when the baby starts to develop outside the womb

(uterus). The most common site for an ectopic pregnancy is within one of the tubes

through which the egg passes from the ovary to the uterus (fallopian tube). However, in

rare cases, ectopic pregnancies can occur in the ovary, stomach area, or cervix. Ectopic

Pregnancy occurs in about 1 in 250 pregnancies amounting to approximately 70 000

cases annually, 5,833 per month, 1,346 per week, 191 per day, 7 per hour. In the

Philippines, unpublished reports have estimated the incidence to be just about 22, 194

each year.

An ectopic pregnancy is commonly referred to as a tubal pregnancy because 95

percent occur in a fallopian tube. An ectopic pregnancy needs to be treated immediately

to avoid fallopian tube damage or life threatening blood loss. When identified early,

ectopic pregnancies are treatable with medication that stops the pregnancy. If the

pregnancy is further along, laparoscopy is usually performed to remove the ectopic

tissue and repair the fallopian tube.

If the ectopic pregnancy has ruptured or bleeding persists, salpingectomy is a

very common option. This procedure involves excision of segment of the Fallopian tube

involved in the ectopic pregnancy. The tubal segment to be removed is coagulated and

2

cut off with bipolar forceps. The group chose J.S. as our subject primarily because her

case posed as a very intricate case requiring due understanding and knowledge. The

group recognizes their partial knowledge about ectopic pregnancy and the surgical

procedures involved in such condition, thus making this case a good avenue to broaden

the proponents’ knowledge about the disease and the surgical procedures involved.

A. OBJECTIVES

To define what ectopic pregnancy is, trace the pathophysiology and

enumerate the signs and symptoms of ectopic pregnancy.

To identify and understand different types of medical treatment necessary

for the treatment of ectopic pregnancy.

To formulate and apply nursing care plan utilizing nursing process.

To learn new clinical skills, as well as sharpen our current clinical skills

required in the management of the patient with ectopic pregnancy.

To develop our sense of unselfish love and empathy rendering nursing

care to our patient so that we may be able to serve future clients with

higher level of holistic understanding, as well as individualized care.

B. BACK GROUND OF THE STUDY

This is a case of a patient, named J.S, 33 years old from Binan Laguna, who has

been diagnosed with Ectopic Pregnancy. The patient has a maternal history of

G2P1T1P0A0L1. The patient was complaining from pain in right lower quadrant of her

abdomen. The patient has been admitted at the Delivery Room then transferred to OB –

Gyne Ward last July 22, 2010 at 5:30am. Upon internal examination there was a

tenderness also the patient experienced scanty vaginal bleeding. The result of her

ultrasound indicates Ectopic Pregnancy. She has undergone series of diagnostic tests

and undergone operation for Exploratory Laparatomy (EXLAP) and right

salphingectomy.

3

We decided to present this case due to our eagerness to learn and explore new

knowledge and information about this type of condition. Our group wants to

formulate a correlation among the conditions that manifests in patient JS. We

believe that this can be of great help in performing appropriate nursing interventions

to the patient. Our group also wants to focus on ectopic pregnancy, which is

uncommon among pregnant mothers. It is a significant topic for the mothers

especially those who are in their pregnancy stage. It is of great advantage that they

have knowledge on this condition.

C. RATIONALE OF CHOOSING THE CASE

This case has been chosen by the group due to the following reasons:

A. To conduct further studies about Ectopic Pregnancy.

B. To have a further knowledge about this complication and how it can occur.

C. To know the possible risk of the one who has this kind of complication and how it

can be treated.

D. To be able to present the case study of our chosen client that would provide a

comprehensive discussion of the pathological mechanism of the complication to

yield significant information for the case study.

D. SIGNIFICANCE OF THE STUDY

This study is done for the benefits of the following:

To the relatives and client – to help them to understand the present condition

and its complication.

Student Nurse – to enhance the level of our knowledge and appropriate nursing

care about Ectopic Pregnancy

Reader – acquire more understanding about Ectopic Pregnancy and its sign and

symptoms.

E. SCOPE AND LIMITATION

This study covers and focuses on the following:

A brief discussion of the disease and its pathophysiology

4

A drug study of medications prescribed to patient

Nursing Care Plans which would present nursing analysis, diagnosis, plan, and

appropriate interventions that would aid in patients recovery.

Discharge plan which presents follow-up care and treatment after confinement.

II. Clinical Study

A.DEMOGRAPHIC DATA

Patient Name: Ms. JS

Age: 33 years old

Birth Date: April 9, 1977

Civil Status: Single

Occupation: None

Address: Binan, Laguna

Maternal history:

LMP: June 10, 2010

EDC: March 17, 2011

G2P1 T1P0A0L1

Clinical/ Admitting Data:

CC: Abdominal pain

Internal Examination: with tenderness, with scanty vaginal bleeding

Date of Admission: July 22, 2010

Time of Admission: 5:30am

Attending Physician: Dra. Estela Galvez

Admitting Diagnosis: Ectopic pregnancy G2P1 T1P0A0L1

Proposed Surgical procedure: EXLAP and Right Salpingectomy

Vital Signs on admission:

5

T= 37.2 °C

PR= 105bpm

RR= 22cpm

BP= 90/60mmHg

Family Background:

2nd among 5 children

With 2 year old baby girl

Partner: Mr. EP

Partner is a smoker

History of Past Illness

She seldom get sick but experiences fever sometimes due to weather conditions

No information about her immunizations.

No known allergy

History of Present Illness

The patient is not aware of her pregnancy.

During the 6th week of pregnancy, the patient experienced scanty vaginal

bleeding and abdominal pain which made her seek for medical help.

She went to one of the hospital in Binan, Laguna, she was advised to have an

ultrasound.

The findings of the ultrasound indicate that the patient has ectopic pregnancy

and they were referred in LPH.

6

B. PHYSICAL ASSESSMENT

General Appearance

- with facial grimace

- with guarding behavior

- weak and pale looking

- with foul breath

- conscious and coherent

- with IVF hooked on right hand

- on NPO

Head

- normocephalic

- symmetrical in shape

- no masses, no lesions

Hair

- evenly distributed over the scalp

- with black, straight and thick hair

- dandruff is present

Eyelids- lids close symmetrically

- no edema, and no discharges

Sclera - whitish

Iris- symmetrical in size

- round and dark brown

Pupils

- Symmetrical in movement

- round and dark brown in color

- PERRLA (Pupils Equally Round And React To

Light and Accommodation)

Ears - equal in size

- auricles are smooth and symmetrical

- pinna recoils after it is folded

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- with dry cerumen

Nose

- the external nose is symmetrical and straight

- color is the same with the entire face

- lesions and tenderness were both absent

- nasal mucosa was pinkish

- both left and right nares were patent

- the nasal septum is intact and in midline without

deviations

- cilia present in internal nares

- absence of nasal discharge

Mouth

- appear dry and pale

- tongue was located at the midline, pink in color,

slightly dry and furry with whitish coating

- tounge moves freely

- uvula is in midline

Neck

- neck movement was coordinated and difficulty in

moving was not noted

- free from lumps and no tenderness

Thorax

- no masses and tenderness upon palpation

- no adventitious breath sounds upon auscultation on

both left and right lung fields

Breast

- round in shape, no lumps, no masses

- areola dark brown in color

- nipples round, equal in size

Abdomen

- same color of the body

- with presence of stretch marks

- with throbbing pain in RLQ

Upper extremities

- good range of motion was noted

- no lesions, no presence of abnormalities, no

tenderness

- can extend arms without difficulty

8

Lower extremities

- skin uniform in color

- no varicose

- with limited movement

Genitalia - With scanty vaginal bleeding

C. SYSTEM AFFECTED

Reproductive System

D. LABORATORY AND DIAGNOSTIC EXAM

Complete Blood Count

July 22, 2010

BLOOD COMPONENTS

RESULT NORMAL VALUE

INTERPRETATION SIGNIFICANCE

Hemoglobin 11.0 g/dl 13-19g/dl Decrease Decrease hemoglobin will result to bleeding

White Blood Cells (WBC)

11.8 K/uL 4.1 – 10.9 k/uL

Increase Increase WBC signifies infection in the body.

Hematocrit 32.8% 35 – 45% Decrease Decrease hematocrit indicates that the mass of RBC is decrease

July 24, 2010

BLOOD COMPONENTS

RESULT NORMAL VALUE

INTERPRETATION SIGNIFICANCE

Hemoglobin 11.5 g/dl 13-19g/dl Decrease Decrease hemoglobin will result to bleeding

White Blood 11.3 K/uL 4.1 – 10.9 Increase Increase WBC

9

Cells (WBC) k/uL signifies infection in the body.

Hematocrit 35% 35 – 45% Normal

Ultrasonography

DATE

DIAGNOSTIC EXAM

NORMAL RESULT

RESULT IMPRESSION

July

21,

2010

Obstetric ultrasono-graphy

No anatomic or functional abnormalities exist. The organs are normal in shape, size, contour and position. The internal structures of the organs and nearby tissues are within normal limits.

The uterus is anteverted measuring about 8.01 cm in length x 7.0 cm in width x 5.3 cm in thickness. The endometrial stripe is about 1.4 cm in thickness.

A complex mass measuring about 5.12 cm x 5.12 cm is seen at the right adnexae.

ENLARGED UTERUS.THICKENED ENDOMETRIAL STRIPE

COMPLEX MASS RIGHT ADNEXAE CONSIDERATIONS ARE:TUBO-OVARIAN OATHOLOGY RIGHTEXTRA-UTERINE CONCEPTION RIGHT

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III. CLINICAL DISCUSSION

A. ANATOMY AND PHYSIOLOGY

The female reproductive organs consist of the ovaries, uterine tubes (or fallopian

tubes), uterus, vagina, external genitalia, and mammary glands.

11

Ovaries – the two ovaries are small organs suspended in the pelvic in the pelvic

cavity by ligaments. Ovaries are the female reproductive glands where the 400,000 ova

or egg cells are stored. The outer part of the ovary is made up of dense connective

tissue and contains ovarian follicles.

Fallopian tubes – the uterine tubes extend from the area of the ovaries to the

uterus. They open directly into the peritoneal cavity near each ovary and receive the

oocyte. The opening of each uterine tube is surrounded by long, thin processes called

fimbrae. It is a 4 inches long from each side of the uterus (fundus). It transports the

mature ova form the ovaries to the uterus and provide a place for fertilization of the ova

by the sperm in it’s outer 3rd or outer half. Parts:

Isthmus – portion that is cut or sealed in a tubal ligation.

Ampulla – widest, longest portion that spreads into fingerlike projections/fimbriae

and it is where fertilization usually occurs.

Infundibulum - rim of the funnel covered by fimbriated cells (hair covered

fingerlike projections) that help to guide the ova into the fallopian tube.

Uterus - is as big as a medium-sized pear. The part of the uterus superior to the

entrance of the uterine tubes is called fundus. The uterine wall is composed of three

layers:

The outer layer called the serous layer or perimetrium of the uterus

The middle layer called the muscular layer or myometrium

The innermost layer of the uterus is the endometrium.

The uterus is supported by the broad ligament and the round ligament

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Vagina – is a female organ of copulation and functions to receive the penis

during intercourse. It also allows menstrual flow and childbirth. The superior portion of

the vagina is attached to the sides of the cervix so that a part of the cervix extends into

the vagina.

External Genitalia – also called vulva or pudendum of the vestibule and its

surrounding structures. The vestibule is the space into which the vagina and urethra

open. The vestibule is bordered by a pair of thin, longitudinal skin folds called the labia

minora. A small erectile structure called clitoris. The two labia minora unite over the

clitoris to form a fold skin called the prepuce. Lateral to the labia minora are two

prominent, rounded folds skin called labia majora. The space between the labia majora

is called the pudendal.

Fertilization is the meeting of sperm cell and the fertilized ovum. It can only occur

if intercourse takes place before the time of ovulation that usually occurs mid-cycle or

about 14 days before the woman's next menstrual period. At the time of ovulation, the

ovum is released from the ovary and transported in the fallopian tube where it remains

for about 24-48 hours. Sperm cells remain viable within the female reproductive tract for

about 72 hours. Only a single sperm cell is needed to fertilize the ovum, even though

the average ejaculation contains approximately 300 million sperm.

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14

Predisposing Factor:Female, 33 years of age

Matured ovum release from ovary ready for fertilization

Sperm cells enter to uterine cavity and migrate to fallopian tube

Matured egg pick-up by fallopian tube

Only one best & healthiest sperm will reach the ovum

Sperm cell and egg cell fused

Single cell become zygote

Fision

Division of cells

Cluster of cell

Morula

Blocks movement of fertilized egg to the uterus

Fertilized egg attaches and implants in the fallopian tube

Distention and irritation of fallopian tube Abdominal pain

Moderate amount, dark red vaginal

bleeding

B. Pathophysiology

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Ectopic Pregnancy

Subjective Objective Analysis Planning Intervention Rationale Evaluation

“Sumasakit ang puson ko” as verbalized by the patient.

- with pain scale of 8 out of 10-with facial grimace-irritable-with weak and pale looking - with guarding behavior - with limited movement

V/S:BP-90/60 mmHgRR- 22 bpmT- 37.2 C

Acute pain related to distention of the fallopian tube as evidenced by verbal reports of discomfort and pain

After 8 hours of nursing intervention, the patient will verbalize and show relief of pain lessened from 8/ 10 to 6/ 10 in pain scale

Used pain rating scale appropriate for age/ condition .

Obtained client’s assessment of pain to include location, characteristics, onset/duration, frequency, quality, intensity, and precipitating factors. Reassessed each time pain occurs/is reported.

Provided comfort measures such as touch, repositioning, use of cold packs, nurse’s presence and quiet environment and calm activities.

To assess the rate of the intensity, quality and frequency of pain.

To rule out worsening of underlying condition/development of complications.

To promote nonpharmacological pain management.

Goal met.After 8 hours of nursing interventions, the patient able to verbalized and showed relief of discomfort, pain lessened from 8/10 to 6/10 in pain scale

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A. Nursing Care Plan

Instructed and encouraged use of relaxation techniques such as focused breathing, imaging.

Administered analgesics, as ordered.

To distract attention and reduce tension.

To decrease pain at tolerable level. Notify physician if regimen is inadequate to meet pain control goal.

DAY 1: JULY 22, 2010

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Subjective Objtive Analysis Planning Intervention Rationale Evaluation

“Namumula ang tahi ko”, as verbalized by the patient.

- with reddish 4 inches surgical incision due to exploratory lapatoromy.- with unhealthy environment for postoperative patient wound- with pale and weak looking- incision site is warm to touch-no swelling

V/S:-RR= 22 bpm-Temp.= 37.2 C-Hgb= 11.3g/dL

Risk for infection related to inadequate primary and secondary defenses secondary to exploratory laparotomy as evidenced by reddish incision site.

After 8 hours of nursing interventions, the patient will be able to identify interventions to prevent or reduce risk of infection.

Noted risk factors for infection including skin integrity, environmental exposure and laboratory results.

Observed for localized signs of infection as the surgical wound.

Maintained clean technique when doing wound dressing.

Cleansed incision sites daily and as needed with appropriate cleaning solution.

To serve as basis in providing preventing actions.

To assess physical signs that manifest infection.

To prevent bacterial colonization.

To maintain a clean surgical wound and reduce the risk of infection.

After 8 hours of nursing interventions the patient was able to identified the health teachings given to prevent or reduce risk of infection.

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Changed dressings as ordered

Encouraged the client to take nutritious foods and increase fluid intake such as meat and fish.

Maintained a clean and healthy environment.

Administered antibiotics as ordered.

To maintain adequate protection and prevent contamination.

To strengthen the patient’s immune system this decreasing the patient’s susceptibility to infection.

To promote an environment for faster wound healing.

To prevent infection and fast healing of wounds.

DAY 2: JULY 23, 2010

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Subjective Objective Analysis Planning Intervention Rationale Evaluation“Hindi ko alam kung mabubuntis pa ako uli” as verbalized by the patient.

-asking questions about her condition-anxious

Knowledge deficit related to the treatment and effect on future pregnancies as evidenced by verbal reports of the patient.

After 8 hours of nursing interventions, the patient will be able to increase knowledge about Ectopic pregnancy and treatment.

Determined client’s ability/readiness and barriers to learning.

Provided information relevant only to the situation.

Listened to client’s perception of need. Relate information to client’s personal desires/needs and values/beliefs.

Begun with information the client already knows and move to what the client does not know, progressing from simple to complex.

Client’s readiness will help the barriers to learning.

To prevent overload of information

So that client feels competent and respected.

Can arouse interest/limit sense of being overwhelmed.

After 8 hours of nursing interventions the patient was able to verbalizedunderstanding of her condition.

DAY 3: JULY 24, 2010

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B. DRUG STUDY

Drug Name Dosage Classification Mechanism of Action

Indication Contraindication Adverse Effects

Nursing Responsibilities

Generic Name:CEFUROXIME SODIUM

Brand Name:Zinacef

45mg IV q 8 hours x 4 doses (-) ANST (After Negative Skin Test)

Second-generation Cephalosphorin

Bactericidal: inhibits synthesis of bacterial cell wall, causing cell death

Peri-operative prophylaxis

with allergy to cephalosporins or penicillins

Headache, dizziness, lethargy, abdominal pain, flatulence, decreased WBC and hematocrit inflammation at IV site

Advise patient receiving IV drug to report any discomfort in the injection site to check if there is a problem on the site.

Inform the patient that this drug is given to treat infection.

Follow the ten rights of the medication and administration.

Skin test of IV drug before administration.

Advice patient to report signs of hypersensitivity such as itchiness and rashes.

21




Generic Name:CEFTRIAXONE SODIUM

Brand Name:Rocephin

1g IV q 12 hours (-) ANST

Third-generation Cephalosphorin

Bactericidal: inhibits synthesis of bacterial cell wall, causing cell death

Peri-operative prophylaxis for patients undergoing potentially contaminated surgical procedures

with allergy to cephalosporins or penicillins

Headache, dizziness, diarrhea, lethargy, abdominal pain, flatulence, decreased WBC and hematocrit inflammation at IV site

Advise patient receiving IV drug to report any discomfort in the injection site to check if there is a problem on the site.

Do not mix ceftriaxone with any other antimicrobial drug.

Skin test of IV drug before administration.

22




Generic Name:TRAMADOL HYDROCHLORIDE

Brand Name:Ultram

50mg IV q 6 hours

Analgesic Binds to mu-opioid receptors and inhibits the reuptake of norepinephrine and serotonin; causes many effects similar to the opioids – dizziness, somnolence, nausea, constipation – but does not have the respiratory depressant effects

Relief of moderate to moderately severe pain

With allergy to tramadol or opioids or acute intoxication with alcohol, opioids, or psychoactive drugs

Vertigo, headache, confusion, sweating, tachycardia, bradycardia, pallor, constipation

Control environment (temperature, lighting) if sweating or CNS effects occur.

Advise patient to report severe nausea, dizziness, severe constipation.

Withdrawal symptoms may occur if drug is stopped abruptly. Reduce dosage gradually.

Inform patient the side effects that he may fall asleep/ lethargic

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Generic Name:CO-AMOXICLAV

Brand Name:AmoclavAugmentinAugmex

625mg cap BID per orem

Combination with beta-lactamase inhibitor

Combination of amoxicillin, a β-lactam antibiotic; with clavulanic acid, β lactamase inhibitors results in an antibiotic with an increased spectrum of action and restored efficacy against β lactamase producing amoxicillin-resistant bacteria

For post-surgical infections, prophylaxis against infectious associated with major surgical procedures

Hypersensitivity to penicillin, possible cross sensitivity with other β-lactams

Indigestion, rash, Stevens-Johnson syndrome, erythema

Obtain patient’s history of allergy.

Inform patient that amoxicillin may cause side effects.

Assess patient for previous sensitivity reaction to penicillin or other cephalosporin to determine any allergic reactions.

Assess for allergic reaction during treatment: rash, urticaria, pruritus, chills and fever.

Assess bowel pattern and sign of dehydration. If severe diarrhea occurs drug should be discontinued.

Advise patient to discontinue drug if hypersensitivity reaction occurs.

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Generic Name:IBUPROFEN

Brand Name:AdvilGenprinIbutabMenadolMidolMotrin

500mg cap BID per orem

AnalgesicNSAIDPropionic acid derivative

Anti-inflammatory, analgesic, and antipyretic activities largely related to inhibition of prostaglandin synthesis; exact mechanisms of action are not known. Inhibits both cyclooxygenase (COX) 1 and 2. Ibuprofen is slightly more selective for COX-1

Relief of mild to moderate pain

with allergy to ibuprofen, salicylates, or other NSAIDs

Somnolence, fatigue, tiredness, palpitations, arrhythmia, pruritus, rash, sweating

Be aware that patient may be at increased risk of GI bleeding.

Advise patient to administer drug with food or after meals if GI upset occurs.

Advise patient to discontinue drug if hypersensitivity reaction occurs.

Assess for allergic reaction during treatment: rash, urticaria, pruritus, chills and fever.

25


Indication Contra-indication

Adverse Effects


Generic Name:FERROUS SULFATE

Brand Name:FeozolFer-gen-solFer-in-sol

500mg 1 cap OD per orem

Iron Preparation

Elevates the serum iron concentration, which then helps to form Hgb or trapped in the reticuloendothelial cells for storage and eventual conversion to a usable form of iron

Prevention and treatment of iron-deficiency anemias

Dietary supplement for iron

With allergy to any ingredient; hemolytic anemias

With normal iron balance

Acidosis, anorexia

Confirm that patient does have iron deficiency anemia before treatment.

Advise patient to give drug with meals (avoiding milk, eggs, coffee, and tea) if GI discomfort is severe.

Inform patient that stool may be dark or green.

Advice patient to arrange for periodic monitoring of Hct and Hgb levels.

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DrugName

Dosage Classification Mechanism of Action



Generic Name:Promethazine Hydrochloride

Brand Name:PhenadozPhenergan

25mg IM

(Pre-Op Meds.)

AntiemeticAntihistamineAnti-motion-sickness drugDopaminergic blockerPhenothiazineSedative-hypnotic

Blocks cholinergic receptors in the vomiting center that are believed to mediate the nausea and vomiting caused by gastric irritation, by input from the vestibular apparatus (motion sickness, nausea associated with vestibular neuritis), and by input from the chemoreceptor trigger zone (drug- and radiation-induced emesis)

Prevention and control of nausea and vomiting associated with anesthesia and surgery

Preoperative, postoperative, or obstetric sedation

with hypersensitivity to antihistamines or phenothiazines

Dizziness,headache, vertigo, dry mouth

Give IM injections deep into muscle.

Do not administer subcutaneously; tissue necrosis may occur.

Do not administer intra-arterially; arteriospasm and gangrene of the limb may result.

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Generic Name:Nalbuphine Hydrochloride

Brand Name:Nubain

10mg IM

(Pre-Op Meds.)

Opioid agonist-antagonist analgesic

Acts as an agonist at specific opioid receptors in the CNS to produce analgesia and sedation but also acts to cause hallucinations and is an antagonist at mu receptors

Pre-operative analgesia, as a supplement to surgical anesthesia

with hypersensitivity to nalbuphine

Sweating, headache, confusion, vertigo, floating feeling, numbness

Keep opioid antagonist and facilities for assisted or controlled respiration available in case of respiratory depression.

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Generic Name:SIMETHICONE

Brand Name:DisflatylDegasFlatulexMylanta GasMyliconPhazyme

40mg 2 tabs after meal now per orem BID

Antiflatulent Defoaming action disperses and prevents the formation of mucus-surrounded gas pockets in the GI tract; changes the surface tension of gas bubbles in the stomach and small intestine, enabling the bubbles to coalesce, allowing gas to be more easily freed by belching or flatus

Relief of symptoms and pressure of excess gas in the digestive tract; postoperative gaseous distention and pain

With allergy to components of the product

Nausea, vomiting, belching, passing of flatus, constipation

Give after each meal and at bedtime.

Advise patient that she may experience increases belching and passing of flatus as gas disperses.

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C.COURSE IN THE WARD

Date Time Vital Sign Observation

July 22, 2010 6:30am

7:30am

8:30am

9:30am

10:30am

T – 37.2 oCP – 105 bpmR – 22 cpmBP– 90/60

mmHg

T – 37.3 oCP – 80 bpmR – 20 cpmBP– 110/70

mmHg

T – 36.5 oCP – 89 bpmR – 22 cpmBP– 100/70

mmHg

T – 37 oCP – 88 bpmR – 23 cpmBP– 110/60

mmHg

T – 36 oCP – 85 bpmR – 25 cpmBP– 100/70

mmHg

- with pain scale of 8 out of

10

-with facial grimace

-irritable

-with weak and pale looking

- with guarding behavior

- with limited movement

- with foul breath

- conscious and coherent

- with IVF hooked on right

hand

- on NPO

30

11:30am

12:30nn

1:30pm

T – 37.2 oCP – 91 bpmR – 22 cpmBP– 110/70

mmHg

T – 37.2 oCP – 91 bpmR – 22 cpmBP– 110/70

mmHg

T – 36.8 oCP – 87 bpmR – 24 cpmBP– 110/60

mmHg

DISCHARGE PLAN

Medications:

Take ferrous sulfate 500mg 1 tablet each day for 6 months preferably before bed

time; Co-amoxiclav 500mg 2 times a day for seven days every 12 hours, 1 tablet

7AM and 1 tab in 7PM, do not take with empty stomach; Ibuprofen 500mg 1tab

for 3 days for pain only

Exercise and Environment:

Do light exercises like stretching or walking slowly and carefully; seek assistance

for safety measure

Encouraged the mother to keep an environment clean and conducive to health

for her rapid recovery and to avoid infection and keep environment quiet to make

the patient comfortable

Treatment:

Explain to the client that becoming pregnant again may be difficult because

fertilization takes place only on the side of the remaining tube after ovulation of

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the remaining tube of the ovary on the same side and at higher risk for a

subsequent ectopic pregnancy as well as infertility.

Emphasized to the mother the importance of regular follow-up check-ups and as

instructed by physician

Advised the mother to seek medical advice if any strange arises

Encouraged the mother to let her be monitored by the health care provider until

complete recovery is met

Health Teachings:

Emphasized to the mother the importance of proper hand washing and proper

hygiene

Educate the client to recognize some signs and symptoms of pregnancy if

occurs, aside from the absence of menstrual period and morning sickness she

should visit her OB or nearest health center for proper assessment & check-ups.

Advice the client to engage in safe sexual practices like proper hygiene before

intercourse to prevent from STDs and pelvic infections that could cause further

damage to the fallopian tubes.

Refrain from sexual intercourse for at least 6 weeks until the follow-up

appointment with the physician.

Out Patient:

Reminded the mother that even though she feels better, it is important to have

the doctor monitor her progress. The patient is scheduled for her follow up check

up one week after her discharge from the hospital in Out-Patient Department in

Laguna Provincial Hospital (LPH) to evaluate her recovery.

Diet:

Encourage to eat nutritious food and drink natural fruit juices for fast recovery.

Get plenty of rest. Increase fluid intake. Keep the incision clean.

Spirituality:

Encouraged the mother to continue to seek God’s guidance and to continue to

have a positive outlook in life

Emphasized the importance of prayers in healing

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Encouraged the mother to pray for her fast recovery and gave words of

encouragement

EVALUATION

A pregnant woman with vaginal bleeding must be evaluated promptly. Once a

diagnostic of ectopic pregnancy is made and surgery is scheduled, start an IV as

ordered and begin preoperative teaching. Immediately report the signs of developing

shock. If the patient experiences severe abdominal pain administer analgesics and

evaluate the effectiveness and patient’s response.

Regardless of the treatment used, the prescribed therapy for the post operative

procedure such underwent Salphingectomy operation, the patient should be at complete

bed rest, abstinence from sex, religious intake of medication and emotional support

from the family.

However, though the group had rendered not enough time to handle the case

completely because of conflicting schedule, the nursing intervention we had during the

confinement for the patient like aseptic wound cleansing of the incision site, mild

assistance in ambulation and health teaching with regards to continuous prescribed

meds, proper hygiene, eat well and strengthens faith in God provided the client with

much ease and comfort that the client exhibits early recovery and may go home order.

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SUMMARY

Our patient Ms. JS, 33, a G2P1, plain housewife, was admitted on July 22, 2010

@ 8:00 in the morning with the chief complaint of abdominal pain. She obtained medical

consultation in Binan Hospital, Binan, Laguna and then was advised/referred to Laguna

Provincial Hospital, Sta. Cruz, Laguna for prompt surgery. Upon assessment Ms. JS

happened to have scanty vaginal bleeding, pale and weak. She presented an UTZ

result which came out to her to undergo Salphingectomy (excision of segment of the

Fallopian tube) that is involved in the ectopic pregnancy. Ms. JS has no family or past

history of present illness, no known history of illness, no known allergies and reportedly

without recognizing that she was 6th weeks pregnant. Her husband is a driver and they

were blessed with a 2-year old female child. Her husband known to be a responsible

and good provider but a chain smoker, they were not married.

At the course of the ward, necessary surgical procedure was done, consent letter

was signed, IVF hooked such as 1L D5LR; Voluven 500ml (side drips); 1L D5 NSS;

prescribed medication such as antibacterial (Co-amoxiclav, Cefuroxime, Ceftriaxone);

Analgesic (Tramadol & Ibuprofen); Pre-Op anesthesia (Promethazine & Nalbuphine);

For iron supplement (Ferrous sulfate); Anti-flatulence (Disflatyl); For laboratory study:

CBC, urinalysis and “For Exlap”. Post-Op: sponge bath, apply abdominal binder and

clear liquid tee and crackers for diet then diet as tolerated once bowel movement occur;

Ambulate; change of dressing or wound care.

Upon interviewing the client, other concerns we gather, she was not a stressful

housewife and only do light household chores. Though their budget is limited they still

manage to eat a balanced diet and able to provide their child’s needs.

The etiology of ectopic is unknown but then our case has revealed that an aging

woman is prone for this kind of condition and if not prompted damage of fallopian tube

will occur or life threatening blood loss is at risk.

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RECOMMENDATION

This case study has provided us with important information about the patient’s

ectopic pregnancy condition and its proper nursing care intervention prior to pre-and-

post surgical procedure. In order to ensure that optimal health is restored and

maintained, the group would like to recommend the following:

To the patient:

Whenever there is, the onset of a certain condition it implies one to contribute her

cooperation and willingness to be responsible for her own health, such as:

The patient must be sensitive of her own needs and be able to expect liability for

her actions.

She is also encouraged to verbalize her own thoughts and feelings concerning

how she perceives her condition affect her life and her expected duration of her

recovery.

She is advised to take part in complying with therapeutic regimen designed for

her recovery.

She should realize the importance of complying with her medication and the

benefits this practice would bring to the improvement of her well-being.

Moreover, she must not hesitate on seeking medical assistance whenever she

feels signs and symptoms, which may be due to other health illness.

To the patient’s family:

The patient’s family plays an important role in the patient’s recovery.

The family should make themselves physically present so that the patient would

somehow feel their support and concern.

They are encouraged to be the patient’s source of strength and inspiration as she

undergoes painful, traumatic and harrowing procedures. In addition, it is of prime

importance that they are oriented and educated basic facts regarding the

patient’s condition so that they will understand her even better and assist him in

his daily activities.

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To our fellow nursing students:

It is encourage as much as possible to have a complete nursing care in the span

of confinement of your client, it starts from the assessment, admission and up to the full

recovery of the client that includes the discharge or may go order and follow-up check-

ups so that every actual scenario can be studied and experienced of the given

appropriate nursing intervention done. Since the goal of giving nursing care is promote

wellness, prevent from or further illness and restore health, thorough handling for this

kind of case must be given prior attention, time and effort.

For Future Researcher:

It is recommend that you must have an actual case handle because every patient

has a case-to-case basis nevertheless this case may guide you to have comparison

although case-to-case basis but then depending on how and what kind of person is

giving care to a certain patient to have a fulfilled nursing care.

BIBLIOGRAPHY

Medical-Surgical Nursing, Brunner and Suddarth’s, 12th ed., Vol. 1, p. 299

Medical-Surgical Nursing, Brunner and Suddarth’s, 12th ed., Vol. 2, p. 1432

Fundamental of Nursing, Kozier and Erb’s, 8th ed., Vol. 2, p. 1455

Nursing Drug Guide, Lippincott’s, 2009, pp. 259, 257, 998, 832, 1170, 607, 508, 1074

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39075313 Ectopic Pregnancy

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