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
7
- 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
10
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
12
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.
13
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
15
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
16
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
17
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.
18
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
19
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
20
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
Drug Name Dosage Classification Mechanism of Action
Indication Contraindication Adverse Effects
Nursing Responsibilities
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
Drug Name Dosage Classification Mechanism of Action
Indication Contraindication Adverse Effects
Nursing Responsibilities
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
23
Drug Name Dosage Classification Mechanism of Action
Indication Contraindication Adverse Effects
Nursing Responsibilities
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.
24
Drug Name Dosage Classification Mechanism of Action
Indication Contraindication Adverse Effects
Nursing Responsibilities
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
Drug Name Dosage Classification Mechanism of Action
Indication Contra-indication
Adverse Effects
Nursing Responsibilities
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.
26
DrugName
Dosage Classification Mechanism of Action
Indication Contraindication Adverse Effects
Nursing Responsibilities
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.
27
Drug Name Dosage Classification Mechanism of Action
Indication Contraindication Adverse Effects
Nursing Responsibilities
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.
28
Drug Name Dosage Classification Mechanism of Action
Indication Contraindication Adverse Effects
Nursing Responsibilities
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.
29
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
31
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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