I. INTRODUCTION

Ectopic Pregnancy is a complication of pregnancy in which the pregnancy implants outside the uterine cavity. With rare exceptions, ectopic pregnancies are not viable. Furthermore, they are dangerous for the mother, internal bleeding being a common complication. Most ectopic pregnancies occur in the Fallopian tube , but implantation can also occur in the cervix, ovaries, and abdomen. An ectopic pregnancy is a potential medical emergency, and, if not treated properly, can lead to death.

II. OBJECTIVES

General: To have a comprehensive study and knowledge about ectopic pregnancy.

Specific

1.) We will have better understanding of ectopic pregnancy by reading books, articles and journals that are related with the disease;

2.) Understand clearly the pathophysiology of the disease, risk factors, manifestations and treatment and modalities of the disease; and

3.) Equip ourselves with skills and health teachings that are appropriate for the care of patients with ectopic pregnancy.

III. SOCIO-DEMOGRAPHIC PROFILE

a. Name of Patient: Mrs. A.b. Age: 33 years oldc. Gender: Femaled. Religion: Roman Catholice. Civil Status: Marriedf. Admitting Diagnosis: G3P1 (1011) Threatened Abortion 9 weeksg. Final Diagnosis: G3P1 (1021) Ectopic, 9 Weeks Left Fallopian Tube, Ampullary Ruptured, Endometriotic

Cyst Lefth. Operation Performed: Exploratory Laparotomy + Salpingectomy + Left Oophorocystectomyi. Surgeon: Dr. Bj. Date of Operation: October 23, 2010 / 135501-2010k. Type of Anesthesia: Spinal Anesthesial. Anesthesiologist: Dr. C.

IV. NURSING HISTORY

A. Past Health History

Mrs. A. has no previous medical problem and never hospitalized due to serious illness. Mrs. A. had her first pregnancy last 2000 and delivered a live full term baby girl via normal spontaneous delivery. On her second pregnancy last 2001, she had an incomplete abortion and undergo Dilation and Curettage.

B. History of Present Illness

Mrs. A. is a G3P1 (1011) 9 3/7 weeks AOG with chief complaint of hypogastric pain and vaginal bleeding.

On October 14, Mrs. A experienced vaginal spotting that lasted for 3 days so she decided to went to her doctor for a consult and advised her to undergo trans-vaginal ultrasound. The UTZ revealed no intrauterine, no extrauterine pregnancy with thin endometrium. She had her pregnancy test and revealed positive with increase HCG level and advised her to take Duphaston three times a day.

One day prior to hospitalization, the patient experienced hypogastric pain and cramping and non-radiating with increase amount of vaginal bleeding that consumed 2 pads per day with minimal to moderately soaked.

C. Family History

Mrs. A. had a familial history of hypertension on her father side. No known history of cancer, asthma, diabetes mellitus and thyroid disease.

V. PHYSICAL ASSESSMENT

General Appearance Normal Standards Actual Findings Interpretation and Analysis1. Posture/Gait >Straight posture, have

balance gait>Complete bed rest without bathroom privileges.

>Limitations in usual role activities>The patient needs guidance from the nurse because of pain.>Pain tolerance is the maximum amount and duration of pain that an individual is willing to endure. Some clients are unable to tolerate even the slightest pain.

(Kozier, B., Erb, G., Berman, A.J, & Snyder, S. (2004). Fundamentals of Nursing: Concepts, Process and Practice. 7th Edition. Page 1135.Upper Saddle River, New Jersey: Pearson Education Inc.)

2. Skin >Varies from light to deep brown; from ruddy pink to light pink; generally uniform except in areas exposed to sun>Moisture in skin fold

>The patient’s skin is dry. Skin color is brown which is uniform in all areas except for areas that are not usually exposed to sun such as the axillae, the legs and soles of the feet.

>Normal

3. Personal hygiene/ Grooming

>Clean and neat, No body and breath odor

>Clean and neat, No body and breath odor

>Normal

4. Nutritional Status >Eat three meals a day and snacks that consist of a balance diet (go, grow, glow food).

>NPO with IVF

BMI: Height= 5’4" Weight= 49.5 kgs.

Computation:BMI = Wt (kg)/Ht (m)2

= 49.5kg/(1.626 m)2 = 49.5 kgs./2.644 = 18.72 BMI = Normal

BMI Weight Status CategoriesBelow 18.5= Underweight18.5 - 24.9 = Normal25- 29.9= OverweightAbove 30= Obese

>The diet given to her is to comprise her post-operative condition

BMI Weight Status CategoriesBelow 18.5= Underweight18.5 - 24.9 = Normal25- 29.9= OverweightAbove 30= Obese

>Normal

5. Verbal Behavior >Can communicate well and express her feelings.

>Can communicate well and express her feelings.

>Normal

6. Non-verbal Behavior >Actions coordinate with the mood of the client.

>Seen to be always on deep thought; Flat affect; Biting of lower lips; Diaphoresis; Sighing; Facial grimace

>There are wider variations in non verbal response to pain. For many patients, nonverbal expressions may be the only means of communicating pain. Facial expressions are often the

first indication of pain.7. Physiologic Cues T = 35.8°C - 37°C

PR = 60 -100bpmRR = 12 - 20bpmBP = SP (100 – 140mmHg) DP (60 – 90mmHg)

T: 36.8 ˚C P: 87R: 19BP: 120 / 80

>Physiologic responses vary with the origin and duration of the pain. Early in the onset of acute pain, the sympathetic nervous system is stimulated resulting in increase BP, PR, and RR.

Body Parts (Technique Used)

Normal Standards Actual Findings Interpretation and Analysis

Head Skull >Rounded and smooth

skull contour>Smooth, uniform consistency and absence of nodules

>The patient’s skull is proportional to the size of her body, round, with prominences in the frontal area anteriorly and the occipital area posteriorly, symmetrical in all planes, gently curved.

Normal

Scalp >White and uniform in color>Absences of flakes and lesion

>The scalp is white, no lice, no nits and dandruff, no lesions, no infection or infestation. No areas of tenderness.

Normal

Hair >Evenly distributed; thick hair

>Hair is black in color, evenly distributed and covers the whole scalp, thin and free from split ends.

Normal

Face >Symmetrical facial features; symmetrical facial movements>No erythema

>Oblong, symmetrical, facial expression is dependent on the mood and her true feelings, smooth and free from wrinkles. There are no involuntary muscle movements.

Normal

Eyes Eyebrows >Hair evenly distributed

and symmetrical>Black, plucked eyebrows, hairs are not evenly distributed, raise and lower symmetrically and inline, with equal movement

>Plucking eyebrows indicates that the patient is conscious of her physical appearance and body image.>A person with a healthy body image will normally show concern for both health and appearance.(Kozier, B., Erb, G., Berman, A.J, & Snyder, S. (2004). Fundamentals of Nursing: Concepts, Process and Practice. 7th Edition. Page 960. Upper Saddle River, New Jersey: Pearson Education Inc.)

Eyelashes >Hair equally distributed and curved slightly outward

>Eyelashes are black in color, evenly distributed and turned outward.

Normal

Eyelids >Skin intact; no discharged; no discoloration

>Upper lids cover a small portion of the iris and the cornea and the sclera when the eyes are open. When the eyes are closed, the lids meet completely. Symmetrical. No palpable mass.

Normal

Conjunctiva >Shiny, smooth and pink or red in color; no presence of lesions

>Shiny, smooth and pale conjunctiva; no presence of lesions

Normal

Sclera >White in color, clear >White in color, clear Normal

Iris >Flat and round, black or brown in color

>Iris is proportional to the size of the eye, round, brown, and symmetrical.

Normal

Pupils >Black in color, equal in size; normally 3-7mm in diameter; round

>Pupils are symmetrical, 3-5 mm in diameter, equally reactive to light and accommodation

Normal

Pupil test >Illuminated pupil constricts (direct response), Non-illuminated pupil constricts (consensual response)

>Pupils equally round and react to light and accommodation

Normal

Extraocular muscle

>Both eyes coordinated, move in unison, with parallel alignment

>Both eyes coordinated, move in unison, with parallel alignment

Normal

Lacrimal gland >No edema or tearing >No edema or tearing over the lacrimal gland

Normal

Ears Auricles >Color same as facial skin,

symmetrical auricle aligned with the outer canthus of eye, about 10 from vertical>Mobile, firm, and not tender, pinna recoils after it is folded

>Color same as facial skin, symmetrical auricle aligned with the outer canthus of eye, about 10 from vertical>Mobile, firm, and not tender, pinna recoils after it is folded

Normal

Hearing acuity test

>Normal voice tones audible (Done by standing 2 feet away from the client and ask her to repeat the 3 words what the nurse will say).

>Normal voice tones audible Normal

Nose >Symmetrical in shape; no discharge or flaring; uniform in color>Mucosa pink; no lesions>Nasal septum intact and in midline>No tenderness or lesion>No rashes

>Symmetrical in shape; no discharge or flaring; uniform in color>Mucosa pink; no lesions>Nasal septum intact and in midline>No tenderness or lesion>No rashes

Normal

Mouth Lips >Uniform pink/red color;

soft moist, smooth texture

>Uniform pinkish color; symmetrical, lip margin well defined, smooth and moist

Normal

Buccal mucosa >Uniform pink color; moist, smooth, glistening and elastic texture

>Uniform pink color; moist, smooth, glistening and elastic texture

Normal

Gums >Pink gums and moist, no bleeding

>Pink gums, moist and firm texture. No bleeding.

Normal

Tongue >Pink color, moist; slightly rough; thin whitish coating; smooth lateral margins; no lesions raised papillae>Central position, moves freely, no tenderness smooth tongue base with prominent veins

>Pink color, moist; slightly rough; thin whitish coating; smooth lateral margins; no lesions raised papillae>Central position, moves freely, no tenderness smooth tongue base with prominent veins

Normal

Teeth >32 permanent teeth, well-aligned, free from caries or filling, no halitosis

>15 upper teeth, 14 lower teeth.>Free from caries. No halitosis.

>29 permanent teeth present.>Some older adults may have few permanent teeth left. Loss of teeth occurs mainly because of periodontal disease which increases during pregnancy because the rise in female hormones affects gingival tissue and increases its reaction to bacterial plaque.

(Kozier, B., Erb, G., Berman, A.J, & Snyder, S. (2004). Fundamentals of Nursing: Concepts, Process and Practice. 7th Edition. Page 398. Upper Saddle River, New Jersey: Pearson Education Inc.)

Neck >Proportional to the size of the body and head, symmetrical, and straight.>No palpable lumps, masses, or areas of tenderness. >Coordinated, smooth movements with no discomfort. Head flexes 45°, laterally flexes 40°, and laterally rotates 70°. >Neck muscles have equal strength and the same as the shoulders.

>Proportional to the size of the body and head, symmetrical, and straight.>No palpable masses. >Coordinated, smooth movements with no discomfort. Head flexes 45°, laterally flexes 40°, and laterally rotates 70°. >Neck muscles have equal strength and the same as the shoulders.

Normal

Thorax and Lungs Posterior Thorax Shape and

Symmetry>Anteroposterior to transverse diameter in a ratio of 1:2>Chest symmetric

>Anteroposterior to transverse diameter ratio is 1:2

>Chest is symmetric.

Normal

Spinal Alignment >Vertically aligned >Spine is vertically aligned when inspected and palpated.

Normal

Palpation >Skin intact, uniform temperature>Chest wall intact, no tenderness no masses

>Skin is intact and of uniform temperature>Chest wall intact, with no tenderness no masses

Normal

Respiratory /Thoracic Excursion

>Full symmetric chest expansion

>Full symmetric chest expansion Normal

Auscultation of thorax

>Vesicular and bronchovesicular breath sounds

>Vesicular and bronchovesicular breath sounds

Normal

Heart Aortic valve – no pulsationsPulmonic valve – no pulsationsTricuspid area – no pulsationsApical area – pulsations visible and palpable.Epigastric area –

Aortic valve – no pulsations

Pulmonic valve – no pulsationsTricuspid area – no pulsations

Apical area – pulsations visible and palpable.

Normal

abdominal aortic pulsations visible and palpable.The two heart sounds are audible in all areas but loudest at apical area.Cardiac rate ranges from 60-100 beats/minute.

Epigastric area – no pulsations The two heart sounds are audible in all areas but loudest at apical area, 4th ICS, LMCLCardiac rate has normal ranges with a regular rhythm.

Abdomen >Skin is unblemished, no scars, color is uniform, flat, rounded (convex), or scaphoid (concave), slightly protuberant for infants, symmetrical movements caused by respiration, umbilicus is flat or concave, positions midway between the xiphoid process and the symphysis pubis, color is the same as the surrounding skin.

>Skin is unblemished, no scars, color is uniform, flat, rounded (convex), or scaphoid (concave), slightly protuberant for infants, symmetrical movements caused by respiration, umbilicus is flat or concave, positions midway between the xiphoid process and the symphysis pubis, color is the same as the surrounding skin.

Normal

Arms >Skin color varies (pinkish, tan, dark brown), symmetrical, fine hair evenly distributed, presence/absence of visible veins.>Warm, dry and elastic; no areas of tenderness. Muscle appears equal with good muscle tone.

>Skin color is light brown, symmetrical, absence of visible veins and scars.>Warm, dry and elastic; no areas of tenderness.

Normal

Palms and dorsal surfaces

>Palms pinkish (dorsal surface), warm

>Palms pinkish, warm and softer Normal

Nails >Nails are transparent, smooth, and convex with pink nail beds and white translucent tips.>Five fingers in each hand.>As pressure is applied to the nail bed, appears white or blanched, and pink color returns immediately as pressure is released.

>Nails are short, transparent, smooth, and convex with pink nail beds and white translucent tips.>Five fingers in each hand.>As pressure was applied to the nail bed, it appears white and pink color returns less than 2 seconds.

Normal

Shoulders Raise both arms to vertical position – Performs with relative easePlace head behind the neck – Performs with relative easePlace hands behind the small of the back – Performs with relative ease

>Able to raise both arms to vertical position, and place hands behind the small of the back with relative ease.

Normal

Arms Abduct – Performs with >The patient can perform abduct, Normal

relative easeAdduct – Performs with relative easeRotate – Performs with relative ease

adduct and rotate with relative ease.

Elbows Bend and straighten elbow – Performs with relative ease

>Able to bend and straighten elbow with relative ease

Normal

Hands and wrists Extend and spread the fingers – Performs with relative easeMake a fist, thumb across the knuckles – Performs with relative ease

>Can extend and spread the fingers and make a fist, thumb across the knuckles with relative ease.

Normal

Lower extremities Legs >Skin color varies

(pinkish, tan, dark brown), skin is smooth, fine hair evenly distributed, absence of varicose veins.>Muscles appear equal, warm and with good muscle tone.>With full range of motion, full and equal pulses.

>Skin color was light brown; skin is smooth, absence of varicose veins. >Muscles appear equal, warm.>With full range of motion, full and equal pulses.

Normal

Toes >Five toes in each foot; sole and dorsal surface is smooth; with pink nailbeds and white translucent tips.>As pressure is applied, the nailbed appears white or blanched; pink color returns when pressure is released.>With full range of motion, full and equal pulses.

>Five toes in each foot; sole and dorsal surface is smooth; with pink nailbeds and white translucent tips.

>As pressure is applied, the nailbed appears white; pink color returns when pressure is released.

>With full range of motion.

Normal

Pain Assessment

PQRST MnemonicP – Provocation and Palliation

Q – Quality and Quantity

R – Region and Radiation

S – Severity and Scale

NT: “Ano’ng nagpapagaan at nagpapalala nito?”

NT: “Maaari nyo po bang idescribe iyong pain na nararamdaman ninyo?”

NT: “San po masakit?”

NT: “Gaano po kasakit? from the rate po of 1-10, 1 po as no pain and 10 as the most painful.”

P: “Pag humihinga ako ng malalim medyo nawawala.”P: “Lalong sumasakit kapag gumagalaw ako”P: “Una nagsimuLa ditto sa may bandang taas tapos pababa sa may tagiliran”

P: “Dito.” (Pointing at left lower quadrant)P: “Mga 7”.

Effective pain management requires careful assessment and regular review of pain. Pain is a subjective symptom. Pain assessment tools are therefore based on the patient’s own perception of their pain and its severity. Pain assessment involves initial, detailed evaluation of each type of pain, and regular reassessment of severity and response to treatment.

T – Timing and Type of Onset

NP:”Kelan po sya sumasakit?” P: “Sumasakit kapag gumagalaw ako.”

Reference:http://www.caresearch.com.au/caresearch/ClinicalPractice/Physical/Pain/AssessmentTools/tabid/748/Default.aspx

VI. ANATOMY ANG PHYSIOLOGY

INTERNAL GENITALIAa. Fallopian tube/Oviduct – 4 inches long from each side of the uterus (fundus). Ittransports the mature ova form the ovaries

to the uterus and provide a place for fertilization of the ova by the sperm in its outer 3rd or outer half.Parts:

Interstitial – lies within the uterine wall 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.

b. Ovaries – Oval, almond sized, dull white sex glands on either side of the uterus that measures 4 by 2 cm in diameter and 1.5 cm thick. It is responsible for the production, maturation and discharge of ova and secretion of estrogen and progesterone.

c. Uterus – hollow, pear-shaped muscular organ, 3 inches long, 2 inches wide, weighing 50-60 grams held in place by broad and round ligaments, and abundant blood supply from the uterine and ovarian arteries. It is located in the lower pelvis, posterior to the bladder and anterior to the rectum. Organ of menstruation, site of implantation and provide nourishment to the products of conception.

Layers:1. Perimetrium – outermost layer of the uterus comprised of connective tissue, it offers added strength and support to the structure.2. Myometrium – middle layer, comprised of smooth muscles running in 3 directions; expels fetus during birth process then contracts around blood vessels to prevent hemorrhage.3. Endometrium – Inner layer which is visibly vascular and is shed during menstruation and following delivery.

Divisions of the Uterus:1. Fundus – upper rounded, dome-shaped portion that can be palpated to determine uterine growth during pregnancy and the force of contractions and for the assessment that the uterus is returning to its non-pregnant state following child birth.2. Corpus – body of the uterus.

3. Isthmus – area between corpus and cervix which forms part of the lower uterine segment. It enlarges greatly to aid in accommodating the fetus. The portion that is cut when a fetus is delivered by a caesarian section.4. Cervix – lower cylindrical portion that represents 1/3 of the total uterus. Half of it lies above the vagina; half of it extends to the vagina. The cavity is termed the cervical canal. It has 2 openings/Os: internal os that open to the uterine cavity and the external os that opens to the vagina.5. Vagina – a 3-4 inch long dilatable canal located between the bladder and the rectum, it contains rugnae which permit considerable stretching without tearing. It acts as an organ of intercourse/copulation and passageway for menstrual discharges and fetus. Doderlein’s bacillus is the normal flora of the vagina which makes the pH of vagina acidic, detrimental to the growth of pathologic bacteria.

EXTERNAL GENITALIA

a. Mons Veneris/Pubis – Pad of fat which lies over the symphysis pubis where dark and curly hair grows in triangular shape that begins 1-2 years before the onset of menstruation. It protects the surrounding delicate tissues from trauma.

b. Labia Majora – Two (2) lengthwise fatty folds of skin extending from mons veneris to the perineum that protects the labia minora, urinary meatus and vaginal orifice.

c. Labia Minora – 2 thinner, lengthwise folds of hairless skin extending from clitoris to fourchette. Glands in the labia minora lubricates the vulva Very sensitive because of rich nerve supply Space between the labia is called the Vestibule

d. Clitoris – small, erectile structure at the anterior junction of the labia minora that contains more nerve endings. It is very sensitive to temperature and touch, and secretes a fatty substance called Smegma. It is comparable to the penis in its being extremely sensitive.

e. Vestibule – the flattened smooth surface inside the labia. It encloses the openings of the urethra and vagina.f. Skene’s Glands/Paraurethral Glands – located just lateral to the urinary meatus on both sides. Secretion helps lubricate the

external genital during coitus.g. Bartholin’s Gland/Vulvovaginal Glands – located lateral to the vaginal opening on both sides. It lubricates the external

vulva during coitus and the alkaline pH of their secretion helps to improve sperm survival in the vagina.h. Fourchette – thin fold of tissue formed by the merging of the labia majora and labia minora below the vaginal orifice.i. Perineum – muscular, skin-covered space between the vaginal opening and the anus. It is easily stretched during childbirth

to allow enlargement of vagina and passage of the fetal head. It contains the muscles (pubococcygeal and levator ani) which support the pelvic organs, the arteries that supply blood and the pudendal nerves which are important during delivery under anesthesia.

j. Urethral meatus – external opening of the urethra. It contains the openings of the Skene’s glands which are often involved in the infections of the external genitalia.

k. Vaginal Orifice/Introitus – external opening of the vagina, covered by a thin membrane called Hymen.

VII. PATHOPHYSIOLOGY

VIII. DIAGNOSTICS AND LABORATORIES

Fertilized EggEtiology- Age- Sex

Blastocyst burrows into the epithelium of the tubal wall

Tapping of blood vessels by the same process as normal implantation

Implantation on the tubal mucosa

Erosive action of villous trophoblast causes penetration of the tubal wall which may extent to the peritoneal

Sudden Abdominal Pain Abdominal ultrasound findings- No intrauterine findings- β – HCG > 6500mIU/mL

Vaginal spotting

Uninterrupted invasion of trophoblastic tissue or tearing of extremely stretched tissue

Products of conception completely/ incompletely expelled into the abdominal cavity or in between the folds of broad ligaments

Sharp abdominal pain.

Rupture/Tubal Rupture Treatment/Management:* Salphingectomy to remove affected tube and control bleeding* Salphingoophorectomy (removal of tube with adjacent ovary)* Management of shock* Methotrexate* Constant hCG monitoring* Micro-surgical repair of tube

Invasion of blood vessels causes bleeding into the lumen, tubal wall or peritoneal cavity

CBCTest Oct. 23 Oct. 24 Reference Values

Hemoglobin 10.8 12.3 12:00 – 15.00 g/dLHematocrit 33.0 38 36.00 – 46.00 %RBC Count 3.68 4.23 4.00 – 4.50 x 10^ 6/L

MCV 89.7 89 80.00 – 100.00 flMCH 29.3 29 27.00 – 31.00 pg

MCHC 32.7 33 32.00 – 36.00 %Platelets 212 217 150.00 – 400.00 x 10^ 3/L

WBC Count 6.63 9.7 4.50 – 11.00 x 10^ 3/LEosinophil 1 1 1.00 – 4.00 %Neutrophil 60 66 36.00 – 66.00 %

Lymphocyte 32 23 22.00 – 40.00 %Monocyte 8 10 4.00 – 8.00 %

RDW 12.7 12.8 8.50 – 15.00

ULTRASOUND (Oct. 23, 2010)Trans-vaginal scan shows a normal sized cervix with intact endocervical lining. The uterus is normal in size, retroverted woth

no myometrial lesions. The endometrium is thickened at 1.2 cm with an achogenic structure within measuring 1.9 x 1.7 x 0.5 cm suggestive of blood clot. The right ovary contains a cystic cob web structure measuring 3.2 x 1.3 cm suggestive of corpus luteum. Inferior to the uterine corpus and more on the left adnexa is a complex structure measuring 5.0 x 3.5 x 4.4 cm could be extrauterine pregnancy surrounded by a hypoechoic structure total volume 25.3 ml could be hemoperitoneum.Findings:

NORMAL SIZED RETROVERTED UTERUSTHICKENED ENDOMETRIUM WITH BLOOD CLOTSCORPUS LUTEUM, RIGHT OVARYCOMPLEX MASS, LEFT ADNEXA COULD BE EXTRAUTERINEGESTATION PROBABLY RUPTUREDHEMOPERITONEUM AS DESBRIBED

IX. MEDICAL-SURGICAL MANAGEMENT

MedicalEarly treatment of an ectopic pregnancy with methotrexate is a viable alternative to surgical treatment. If

administered early in the pregnancy, methotrexate terminates the growth of the developing embryo; this may cause an abortion, or the tissue may then be either resorbed by the woman's body or pass with a menstrual period. Surgical

If hemorrhage has already occurred, surgical intervention may be necessary. However, whether to pursue surgical intervention is an often difficult decision in a stable patient with minimal evidence of blood clot on ultrasound.

Surgeons use laparoscopy or laparotomy to gain access to the pelvis and can either incise the affected Fallopian and remove only the pregnancy (salpingostomy) or remove the affected tube with the pregnancy (salpingectomy).

Exploratory laparotomy is a method of abdominal exploration, a diagnostic tool that allows physicians to examine the abdominal organs. The procedure may be recommended for a patient who has abdominal pain of unknown origin or who has sustained an injury to the abdomen. Because of the nature of the abdominal organs, there is a high risk of infection if organs rupture or are perforated. In addition, bleeding into the abdominal cavity is considered a medical emergency. Exploratory laparotomy is used to determine the source of pain or the extent of injury and perform repairs if needed. Exploratory laparotomy may be used to examine the abdominal and pelvic organs (such as the ovaries, fallopian tubes, bladder, and rectum) for evidence of endometriosis. Any growths found may then be removed.

X. NURSING CARE PLAN

Pre-operatively

Nursing Diagnosis Rank JustificationAcute pain related to rupture fallopian tube 1 An actual problem that needs intervention because it can aggravate abdominal

pressureRisk for ineffective tissue perfusion related to

hemorrhage2 A potential problem that needs intervention to prevent risk for hypovolemic shock and

may lead to maternal mortality

Intra-operatively

Nursing Diagnosis Rank JustificationRisk for infection r/t surgical incision 1 It is a potential problem that needs immediate intervention because if it is not

prevented, it can lead to certain complications.Risk for falls r/t effects of anesthesia 3 It is a potential problem that needs an immediate intervention because it can cause

physical harm.

Post-operatively

Nursing Diagnosis Rank JustificationGrieving, dysfunctional related to perceived loss of a child

1 An actual problem that needs attention because it may lead to psychological problem( major depression, anxiety and suicide)

Impaired adjustment related to incomplete grieving (severe emotional loss)

2 The state in which the individual is unable to modify her behavior in a manner consistent with a change in health status.

Pain related to post-op surgery 3 A state in which an individual experiences and reports the presence of severe discomfort or an uncomfortable sensation

Pre-operatively

CUES NURSING DIAGNOSIS

GOAL and OBJECTIVE NURSING INTERVENTION RATIONALE EVALUATION

Subjective“Masakit ang tiyan ko as verbalized by the patient”

Objective Facial mask

of pain Guarding

behavior Pain scale

of 7 (1 as no pain 10 as worst pain)

Acute pain related to rupture of fallopian tube

GoalAfter 8 hours of nursing intervention the patient will be able to report pain relief/control as evidenced by no guarding behavior and absence of facial mask of pain.

ObjectiveAfter 30 minutes of nursing intervention, the patient will report reduction of pain from 7 to 4 of pain scale.

Independent Perform assessment of pain to

include location, characteristics, onset, duration, frequency, quality and severity.

Monitor maternal vital signs.

Monitor for presence and amount of vaginal bleeding

Monitor for increase pain and abdominal distention and rigidity

Monitor CBC

Encourage verbalization of feeling about pain.

Provide comfort measure like backrubs, deep breathing. Instruct in visualization exercises.

Provide diversional activities.

Dependent Administer medications as

indicated.

Collaborative Laboratory as indicated.

To assess factors that precipitates and contributes to the pain sensation and to indicate the appropriate choice of treatment.

To determine presence of hypotension and tachycardia caused by rupture of hemorrhage.

To further assess the present situation indicating hemorrhage

Indicates rupture and possible intra-abdominal hemorrhage.

To determine the amount of blood loss.

It can reduce anxiety and fear thereby reduces perception of intensity of pain.

It may enhance patient’s coping abilities by refocusing attention.

Aids in refocusing attention and enhancing coping with limitation.

To maintain acceptable level of pain.

To determine blood loss

After 8 hours of nursing intervention, the patient was able to report pain relief/control as evidenced by no guarding behavior and absence of facial mask of pain.

After 30 minutes of nursing intervention, the patient was able to report reduction of pain from 7 to 4 of pain scale as evidenced by less facial grimace.

Intra-operatively

CUES NURSING DIAGNOSIS

GOAL and OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

Risk for Infection related to invasive procedure, break in the skin and exposure to pathogens.

> Impaired primary defenses and inadequate secondary defense that resulted from the operation contributes to the patient’s wound being invaded by pathogenic micro organism. (NANDA)

Goal:After using intervention, the patient will have no signs of infection during and after the procedure

Objective:After 1.5 hours of invasive procedure the patient will have a safe aseptic environment by maintaining the sterility of the instruments and the field.

Independent: Review history for preexisting

conditions/risk factors. Note time of rupture of membranes.

Assess for signs/symptoms of infection (e.g., elevated temperature, pulse, WBC; abnormal odor/ color of vaginal discharge, or fetal tachycardia).

Provide perineal care per protocol, especially once membranes have ruptured.

Carry out preoperative skin preparation; scrub according to protocol.

Verify sterility and integrity of all items used in the procedure.

Verify that preoperative skin preparation was done aseptically.

Examine skin for breaks or irritation, signs of infection.

Identify breaks in aseptic technique and resolve immediately on occurrence.

Collaborative: Administer antibiotics, as ordered.

Risk of chorioamnionitis increases with the passage of time, placing mother and fetus at risk. Presence of infectious process may increase fetal risk of contamination

Rupture of membranes occurring 24 hr prior to surgery may result in chorioamnionitis prior to surgical intervention and may impair wound healing.

Reduces risk of ascending infection.

Reduces risk of skin contaminants entering the incision, reducing risk of postoperative infection.

Prepackaged items may appear to be sterile; however each item must be scrutinized for sterile indicators and package integrity.

Cleansing reduces bacterial count on the incision site.

Disruptions of skin integrity at or near the operative site are sources of contamination to the incision.

An unsterile item that touches sterile items is considered unsterile.

May be given prophylactically for suspected infection or contamination

Does the patient have safe aseptic environment?

√ yes?_ no?

Post-operativelyCUES NURSING

DIAGNOSISOBJECTIVE and GOAL NURSING INTERVENTIONS RATIONALE EVALUATION

Subjective:“Nawala ulit ang baby ko.”“Excited pa naman ang anak ko na magkaroon ng kapatid.”

Objective: Crying Difficulty in

expressing loss

Labile affect

Grieving, dysfunctional related to perceived loss of a child

Goal:After the end of nursing care the patient will be able to demonstrate progress in dealing with stages of grief at own pace.

After 8 hours of nursing intervention the patient will be able to verbalize a sense of progress toward resolution of the grief and hope for the future.

Independent Identify(be aware of) stage of

grief being expressed: Bargaining, Anger, Denial, Depression, Acceptance

Be aware of avoidance behaviors (anger, withdrawal)

Identify factors and ways individual has dealt with previous loss(es)

Encourage verbalization without confrontation about realities

Encourage patient to talk about what the patient chooses and do not try to force the patient to face the fact

Active listen feelings and be available for support/ assistance(speak in soft, caring voice)

Acknowledge reality of feelings of guilt and assist patient to take steps toward resolution

Respect the patient’s needs and wishes for quiet privacy and/or talking

Discuss health ways of dealing with difficult situation

Provide information about normalcy of feelings/ actions in relation to stages of grief

To assess contributing /causative factors that precipitates/contributes grief and to indicate the appropriate choice of therapeutic communication

To further assess the present situation

Assist patient to deal appropriately with loss. Helpful in beginning resolution and acceptance

To promote wellness (teaching)

After 8 hours of nursing intervention the patient is able to verbalizes a sense of progress toward resolution of the grief and hope for the future

XI. DRUG ANALYSIS

Generic Name Dosage Action Indication Contraindication Adverse Effect Nursing Consideration

Paracetamol 600 mg IV PRN Analgesic and Antipyretic

Fever reduction. Temporary relief of mild to moderate pain

Paracetamol should not be used in hypersensitivity to the preparation and in severe liver diseases.

GI: hepatic failureGU: renal failureSkin: rash, urticaria

1. Do not use this medication without medical direction for fever.2. Do not self medicate adults for pain more than 10 days without consulting a physician.3. Do not take other medications containing acetaminophen without medical advice, overdosing and chronic use can cause liver damage and other toxic effects

Cefuroxime 750 mg IV q8 Semi- synthetic cephalosporin antibiotic similar to penicillin

Treat wide variety of infection

Contraindicated in patients hypersensitivity to drug or other cephalosporin.Use cautiously in breastfeeding women and in patients with history of colitis or renal insufficiency.

Diarrhea, nausea and vomiting, abdominal pain. Headache, rash, vaginitis, and mouth ulcers.

1. Inform the physician if you have liver or kidney disease.2. Instruct the patient to follow the prescribed frequency of the drug even if he feels better.3. Instruct the patient to take it with meals.4. Instruct the patient to report any adverse reaction of the drug.

Demerol 25 mg IV Analgesic, Narcotic Medical: Management of moderate to severe pain; adjunct to anesthesia and preoperative sedation

Hypersensitivity to meperidine or any component; patients receiving MAO inhibitors presently or in the past 14 days

Cardiovascular: Hypotension Central nervous system: Fatigue, drowsiness, dizziness Gastrointestinal: Nausea, vomiting, constipation Neuromuscular & skeletal: Weakness

1. If I.V. administration is required, inject very slowly using a diluted solution; administer over at least 5 minutes; intermittent infusion.2. May cause hypotension, dizziness, drowsiness, impaired coordination, or blurred vision; loss of appetite, nausea, or vomiting; constipation. 3. Report chest pain, slow or rapid heartbeat, acute dizziness or persistent headache; changes in mental status; swelling of extremities or unusual weight gain; changes in urinary elimination; acute headache; back or flank pain or muscle spasms; blurred vision; skin rash; or shortness of breath

Diphenhydramine 50 mg IV Antihistamine Can be used for mild nighttime sedation; has anesthetic properties

Hypersensitivity to Diphenhydramine or any component; should not be used in acute attacks of asthma; use in neonates is contraindicated

Cardiovascular: Hypotension, palpitations, tachycardia Central nervous system: Sedation, sleepiness, dizziness, disturbed coordination, headache, fatigueGastrointestinal: Nausea, vomiting, diarrhea, abdominal pain

1. May experience drowsiness or dizziness; or dry mouth, nausea, or vomiting. 2. Report persistent sedation, confusion, or agitation; changes in urinary pattern; blurred vision; sore throat, difficulty breathing, or expectorating (thick secretions)3. Raise bed rails, institute safety measures, assist with ambulation

Celebrex 200mg Non-steroidal anti-inflammatory

Relief of signs and symptoms of osteoarthritis and rheumatoid arthritis. Treatment of acute pain.

Severe hepatic impairment; hypersensitivity to celecoxib; asthmatic patients with aspirin triad; advance renal disease; concurrent use of diuretics and ACE inhibitors.

Back pain, peripheral edema, abdominal pain, diarrhea, dyspepsia, flatulence, nausea, dizziness, headache, insomnia, pharyngitis, sinusitis, URI, and skin rash.

1. Periodically monitor Hct and Hgb, liver functions, BUN and creatinine, and serum electrolytes.2. Monitor closely lithium levels when the two drugs are given concurrently.3. Monitor closely PT/INR when used concurrently with warfarin.4. Monitor for fluid retention and edema especially in those with a history of hypertention or CHF.

Ketorolac 30mg IV NSAID, Antipyretic, Analgesic, CNS agent

Exhibits analgesic, anti-inflammatory, and antipyretic activity

Individuals with complete or partial syndrome of nasal polyps, angioedema and bronchospastic reaction to aspirin, during labor and delivery; patients with severe renal impairment or at risk for renal failure due to volume depletion, patien with risk for bleeding.

Drowsiness, dizziness, headache, nausea, dyspepsia, GI pain, hemorrhage, edema

1. Correct hypovolemia prior to administration of ketorolac.2. Periodic serum electrolytes and liver functions3. Monitor urine output in older patients with the history of cardiac decompensation, renal impairment, and heart failure.3. Monitor for signs and symptoms of GI distress or bleeding4.Monitor for fluid retention

Nalbuphine 5mg CNS agent, analgesic; narcotic agonis-antagonist

Analgesic action that relieves moderate to severe pain with apparently low

History of emotional instability or drug abuse; head injury, increased intracranial

Hypotenton, bradycardia, tachycardia, flushing; Abdominal

1. Assess respiratory rate before drug administration. Withhold drug and notify physician if respiratory rate falls below 12.

potential for dependence

pressure, impaired respirations, impaired kidney or liver function; MI; biliary tract surgery.

cramps, bitter taste, nausea and vomiting, dry mouth; sedation, dizziness, nervousness, depression, restlessness, crying, euphoria; Dyspnea, asthma, respiratory depression; pruritus, burning sensation

2. Watch for allergic response in person with sulfite sensitivity.3. Administer with caution to patients hepatic or renal impairment.4. Monitor ambulatory patients, because it may produce drowsiness.Watch for respiratory depression in newborn if drug is used during labor and delivery.

Infusion Classification Indication Contraindication Nursing ResponsibilityD5NM 1L Hypertonic solution Maintenance of fluid

and electrolytesHypersensitivity to any of the components

Check doctor’s orderObserve 10 R’s when preparing and administering IVF.Check the sterility and integrity of the IV solution, IV set and other devices.Place IV label on the IV bottle.Calibrate the IV bottle and regulate flow infusion according to prescribed duration. Expel air bubbles if any.Make sure IV line is patent and infusing well.Assess patient’s fluid status. Monitor I/O of the patientMonitor other electrolyte levelsClean rubber port aseptically Observe patient and report any untoward effect.

PNSS 1L Isotonic solution Fluid replacement in patient with dhn or fluid deficit. Used solution in BT.

No known contraindication Check doctor’s orderObserve 10 R’s when preparing and administering IVF.Check the sterility and integrity of the IV solution, IV set and other devices.Place IV label on the IV bottle.Calibrate the IV bottle and regulate flow infusion according to prescribed duration. Expel air bubbles if any.Make sure IV line is patent and infusing well.Assess patient’s fluid status. Monitor I/O of the patientMonitor other electrolyte levelsClean rubber port aseptically Observe patient and report any untoward effect.

D5LR Hypertonic solution Source of water, electrolytes and calorics as an alkanizing agent

Contraindicated with known allergy to corn and corn product.

Check doctor’s orderObserve 10 R’s when preparing and administering IVF.Check the sterility and integrity of the IV solution, IV set and other devices.Place IV label on the IV bottle.Calibrate the IV bottle and regulate flow infusion according to prescribed

duration. Expel air bubbles if any.Make sure IV line is patent and infusing well.Assess patient’s fluid status. Monitor I/O of the patientMonitor other electrolyte levelsClean rubber port aseptically Observe patient and report any untoward effect.

D5NR Hypertonic solution Maintenance of fluid and electrolytes

Hypersensitivity to any of the components

Check doctor’s orderObserve 10 R’s when preparing and administering IVF.Check the sterility and integrity of the IV solution, IV set and other devices.Place IV label on the IV bottle.Calibrate the IV bottle and regulate flow infusion according to prescribed duration. Expel air bubbles if any.Make sure IV line is patent and infusing well.Assess patient’s fluid status. Monitor I/O of the patientMonitor other electrolyte levelsClean rubber port aseptically Observe patient and report any untoward effect.

PRBC Blood Components Used in patients with acute anemia whose symptoms were related to blood loss and were refractory to crystalloid infusions, as well as in patients with chronic anemia in whom nontransfusion therapies (eg, iron replacement, erythropoietin) had not been effective.

Contraindicated to patient with severe congestive heart failure and to those unable to obtain appropriately matched blood

Check doctor’s orderObserve 10 R’s. Explain the procedure for giving blood transfusion. Get the pt’s history regarding previous transfusion.Countercheck the compatible blood to be transfused against X-matching sheet noting ABO grouping RH, serial no. of each blood unit, and expiry date with the blood bag label and other lab blood exam done.Get the baseline vital signs before transfusion.Give pre-med 30 minutes before transfusion as prescribed.Do hand hygiene before and after the procedure.Observe patient for 10-15 minutes for any immediate reaction.Observe patient on an on-going basis for any untoward s/sx such as flushed skin, chills, elevated temp, itchiness, urticaria, and dyspnea.Continue to observe and monitor patient post transfusion for delayed reaction.Recheck Hgb and Hct, bleeding time, serial platelet count within specified hours.Discard blood bag and BT set and sharps.

XII. HEALTH TEACHING

Diet and Bowel:

Patients who have received spinal anesthesia may experience nausea and occasionally, vomiting. It is therefore preferable to instruct the patient to eat a bland light meal or a liquid diet once fully awake after surgery. Regular diet may be resumed the next day. Also, pain medication may cause nausea if taken on an empty stomach. It would be better to take that medication with a piece of toast or some food.

To help to avoid constipation and promote healing eat fruits and vegetables and drink 6 to 8 glasses of water each day, stool softeners or mild laxative may be needed if no positive bowel movement within 3 days after surgery as prescribed by the doctor.

Patient should void spontaneously within 6 to 8 hours after catheter is removed. Normal bowel function should return by third or fourth post op day.

Instruct the patient:

Instructed the patient of no heavy lifting while in recovery from surgery, must not lift weights over 15 pounds, heavy lifting puts too much strain on lower abdomen and abdominal muscle may rupture, heavy lifting may pop the stitches in incision site.

Walk or move legs as much as possible, to prevent blood clots and gradually resume normal activity. Support abdomen when coughing, turning and deep breathing. Place a pillow over abdomen and apply pressure on it to support

and minimize pain. Medications compliance was instructed, teach patient and family to care for the wound and perform dressing changes and

irrigations as prescribed. Antibiotic is usually prescribed for seven to ten days following surgery. Instruct to take them as ordered. Remind to keep the incision clean and dry during first week after surgery to prevent infection. Instruct the patient that she may shower after removal of dressing; wash it with soap and water then pat dry and instruct not to

use oils and lotion over incision area. Instruct the patient to have slowly increase activities. Begin with light chores, short walks. Instruct the patient to avoid excessive stair climbing for two weeks after the surgery. Refer for home care nursing as indicated to assist with care and continued monitoring of complications and wound healing. Reinforce need for follow-up appointment with the surgeon one week after the discharge Instruct the patient not to engage in strenuous exercise or resume sexual intercourse until check up with the doctor.

XIII. BIBLIOGRAPHY

http://en.wikipedia.org/wiki/Ectopic_pregnancy http://www.ispub.com/ostia/index.php?xmlFilePath=journals/ijgo/vol6n2/ectopic.xml http://www.google.com.ph/

#hl=tl&source=hp&biw=1264&bih=541&q=medical+and+surgical+management+on+patient+with Fundamentals of Nursing: Concepts, Process and Practice. 7th Edition.. Upper Saddle River, New Jersey: Pearson Education

Inc.) http://international.drugstore.com/default.asp Maternal and Child Health Nursing: Care of the Childbearing and Childrearing Family volume 1 5 th edition. By Adele Pilliteri Foundation of Maternal- Newborn Nursing 4 th edition. By Sharon Smith Murray, Emily Stone Mc Kinney Maternal and Child Nursing Care 2 nd edition. By Marcia L London, Patricia W. Ladewig, Jane W. Ball, Ruth Bindler. Progress in Obstetric and Gynecology. Edited by John Studd, Seang Lin Tan, Frank D. Chervenak Fundamentals of Nursing, Concepts, Process, and Practice updated 5 th edition By Barbara Kozier, Glenora Erb,

Kathleenn Blais, Judith M. Wilkinson