Nursing Care Plan Ectopic Pregnancy
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ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION Subjective: “Masakit ang tiyan ko” (My tummy hurts) as verbalized by patient. Objective: Facial mask of pain. Guarding behavior. Acute pain related to distention or rupture of fallopian tube Ectopic pregnancy is gestation located outside the uterine cavity. The fertilized ovum implants outside of the uterus, usually in the fallopian tube. Predisposin g factors include adhesions of the tube , salpingitis , After 8 hours of nursing intervention s , the patient will be relieved or controlled Independent: Monitor maternal vital signs. Monitor for presence and amount of vaginal bleeding. Monitor for increase and pain and abdominal distention and rigidity. Monitor complete blood count To determine presence of hypotension and tachycardia caused by rupture or hemorrhage. To further assess the present situation indicating hemorrhage. Increased pain and abdominal distention indicates rupture and possible intraabdomin al After 8 hours of nursing intervention s, the patient was relieved or controlled
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Transcript of Nursing Care Plan Ectopic Pregnancy
ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION Subjective:“Masakit angtiyan ko” (My
tummy hurts) asverbalized bypatient.
Objective:Facial maskof pain.Guardingbehavior.
Acute painrelated todistention orrupture offallopian tube
Ectopicpregnancyis gestationlocatedoutside theuterinecavity. Thefertilizedovumimplantsoutside ofthe uterus,usually inthe fallopiantube.Predisposing factorsincludeadhesionsof the tube ,salpingitis,congenitalanddevelopmentalanomaliesof thefallopiantube,previous
After 8 hoursof nursinginterventions, the patientwill berelieved orcontrolled
Independent:Monitor maternalvital signs.
Monitor forpresence andamount of vaginalbleeding.
Monitor forincrease and painand abdominaldistention andrigidity.
Monitor completeblood count(CBC).
Provide comfortmeasure likeback rubs, deep
To determinepresence ofhypotensionand tachycardiacaused byrupture orhemorrhage.
To furtherassess thepresentsituationindicatinghemorrhage.
Increased painand abdominaldistentionindicatesrupture andpossible intraabdominalhemorrhage.
To determinethe amount ofblood loss.
Promotesrelaxation andmay enhance
After 8hours ofnursinginterventions, thepatient wasrelieved orcontrolled
ectopicpregnancy, use of anintrauterinedevice formore than 2years,multipleinducedabortions,menstrualreflux , anddecreasedtubalmotility.
breathing.Instruct inrelaxation orvisualizationexercises.Providediversionalactivities.
Providediversional activities.
Collaborative:
Administeranalgesics asindicated.
patient’s copingabilities byrefocusingattention.
Diversionalactivities aids in refocusingattention andenhancingcoping withlimitations.
To maintainacceptablelevel of pain
