University of San Jose –Recoletos
COLLEGE OF NURSING
Cebu City, Philippines
A Study on the Case of
Obstetric Client F.B.M., Female, 25
Years Old,
Diagnosed with Ruptured Ectopic
Pregnancy, Right Uterine Tube,
undergone Exploratory Laparotomy,
Right Salpingo-oophorectomy
Removal of the fallopian tube/ removal of the ovary
In Partial Fulfillment of the Requirements in NCM
102 –RLE
Perpetual Succour Hospital
Station 3B, Sto. Niño & St. Elizabeth Wards
Third Rotation
(Feb 15-19, March 1-5, 2010)
Presented to the Faculty of
the University of San Jose –Recoletos College of
Nursing
5 March 2010
A Study on the Case of
Obstetric Client F.B.M., Female, 25 Years Old,
Diagnosed with Ruptured Ectopic Pregnancy,
Right Uterine Tube, undergone Exploratory
Laparotomy, Right Salpingo-oophorectomy
TABLE OF CONTENTS Contents i Introduction 1 Objectives 3 Nursing Assessment Client’s Profile 4 Physical Assessment 5 Gordon’s Functional Health Patterns 6
Laboratory Findings 8
Anatomy and Physiology of the Female Reproductive System 10 Pathogenesis of Ectopic Pregnancy 12
Nursing Care Plans 13
Discharge Plan 16
Drug Study 17
Bibliography 21
Appendix 22
I. INTRODUCTION (lacking of statistical data/ epidemiology –Philippines-/ literature)
An ectopic pregnancy is one in which implantation occurs outside the uterine cavity. The implantation may occur on the surface of the ovary or in the cervix. The most common site (in approximately 95% of such pregnancies) is in the uterine tube. Of these uterine tube sites, approximately 80% occur in the ampullar portion, 12% occur in the isthmus, and 8% are interstitial or fimbrial.
With ectopic pregnancy, fertilization occurs as usual in the distal third of the uterine tube. Immediately after the union of the ovum and the spermatozoon, the zygote begins to divide and grow normally. Unfortunately, because an obstruction is present, such as adhesion of the uterine tube from a previous infection (chronic salpingitis or pelvic inflammatory disease), congenital malformations, scars from tubal surgery, or a uterine tumor pressing the proximal end of the tube, the zygote cannot travel the length of the tube. It lodges at the strictured site along the uterine tube and implants there instead of in the uterus.
Approximately 2% of pregnancies are ectopic; ectopic pregnancy is the second most frequent cause of bleeding in early pregnancy. The incidence is increasing because of the increasing rate of pelvic inflammatory disease, which leads to tubal scarring. Ectopic pregnancy occurs more frequently in women who smoke compared to those who do not. There is some evidence that intrauterine devices (IUDs) used for contraception may slow the transport of the zygote and lead to an increased of tubal or ovarian implantation. The incidence also increases following an in vitro fertilization. Women who have one ectopic pregnancy have a 10% to 20% chance that a subsequent pregnancy will also be ectopic. This is because salpingitis that leaves scarring is usually bilateral. Congenital anomalies such as webbing (fibrous bands) may also be bilateral. Surprisingly, oral contraceptives may reduce the possibility of ectopic pregnancy. (3 classification of ectopic pregnancy – pain, bleeding and abd tenderness)
Assessment
With ectopic pregnancy, there are no unusual symptoms at the time of implantation. The corpus luteum of the ovary continues to function as if the implantation were in the uterus. No menstrual flow occurs. A woman may experience the nausea and vomiting of early pregnancy, and pregnancy test for human chorionic gonadotrophin (hCG) will be positive. At weeks 6 to 12 of pregnancy (2 to 8 weeks after a missed menstrual period), the zygote grows large enough to rupture the slender uterine tube or the trophoblast cells break through the narrow base. Tearing and destruction of the blood vessels in the tube result. The extent of the bleeding that occurs depends on the number and size of the ruptured vessels. If implantation is in the interstitial portion of the tube (where the tube joins the uterus), the rupture can cause severe intraperitoneal bleeding. Fortunately, the incidence of tubal pregnancies is highest in the ampullar area (the distal third), where the blood vessels are smaller and profuse hemorrhage is less likely. However, continued bleeding from this area may in time result in a large amount of blood loss. Therefore, a ruptured ectopic pregnancy is serious regardless of the site of implantation.
A woman usually expediencies a sharp, stabbing pain in one of her lower abdominal quadrants at the time of the rupture, followed by scan vaginal spotting. With placental dislodgement, progesterone secretion stops and the uterine decidua begins to slough, causing additional bleeding. The amount of bleeding evident with a ruptured ectopic pregnancy often does not reveal the actual amount present, however, because the products o conception from the ruptured tube and the accompanying blood may be expelled into the pelvic cavity rather than into the uterus. Therefore, this blood does not reach the vagina to become evident. If internal bleeding progresses to acute hemorrhage, a woman may experience lightheadedness and rapid pulse, signs of shock.
When helping determine the possibility of an ectopic pregnancy, ask a woman whether she has pain or vaginal bleeding. Any woman with sharp abdominal pain and vaginal
spotting needs to be evaluated by her health care provider to rule out the possibility of ectopic pregnancy. Occasionally, a woman will move suddenly and move and pull one of her round ligaments, the anterior uterine supports. This can cause a sharp, but momentarily and innocent, lower quadrant pain. However, it would be rare for this phenomenon to be reported in connection with vaginal spotting.
By the time a woman with a ruptured ectopic pregnancy arrives at the hospital of physician’s office, she may already be in severe shock, as evidenced by rapid, thready pulse, rapid respirations, and falling blood pressure. Leukocytosis may be present, not from infection but from trauma. Temperature is usually normal. A transvaginal sonogram will demonstrate the ruptured tube and blood collecting in the peritoneum. Either a falling hCG or serum progesterone suggests that pregnancy has ended. If the diagnosis of ectopic pregnancy is in doubt, a physician may insert a needle through the postvaginal fornix into the cul-de-sac under sterile conditions to see whether blood can be aspirated. A laparoscopy or culdoscopy can be used to visualize the uterine tube if the symptoms alone do not reveal a clear picture of what has happened. However, sonography alone usually reveals a clear-cut diagnostic picture.
If a woman waits before seeking help, gradually her abdomen becomes rigid from peritoneal irritation. Her umbilicus may develop a bluish tinge (Cullen’s Sign). A woman may have continuing extensive or dull vaginal and abdominal pain; movement on the cervix on pelvic examination my cause excruciating pain. There may be pain in her shoulders from blood in the peritoneal cavity causing irritation to the phrenic nerve. A tender mass is usually palpable in Douglas’ cul-de-sac on vaginal examination.
Therapeutic Management
Although some ectopic pregnancies spontaneously end and then reabsorbed, requiring no treatment, it is difficult to predict when this will happen, so when an ectopic pregnancy is revealed by an early sonogram, some action is taken. If an ectopic pregnancy can be diagnosed before the tube has ruptured, it can be treated medically by oral administration of methotrexate and leucovorin. Methotrexate, a folic acid antagonist chemotherapeutic agent that attacks and destroys fast-growing cells. Because trophoblast and zygote growth is rapid, the drug is drawn to the site of ectopic pregnancy. Women are treated until a negative hCG titer is achieved. A hestrosalpingogram or sonogram is usually performed after the chemotherapy to assess whether the tube is fully patent. Mifepristone, an abortifacient, is also effective at causing sloughing of the tubal implantation site. The advantage of these therapies is that the tube is left intact, with no surgical scarring that could cause second ectopic implantation.
If an ectopic pregnancy ruptures, it is an emergency situation. Keep in mind that the amount of blood evident is a poor estimate of the actual blood loss. A blood sample needs to be drawn immediately for hemoglobin level, tying, and cross-matching, and possibly hCG level for immediate pregnancy testing, if pregnancy has not yet been confirmed. Intravenous fluid using a large-gauge catheter to restore intravascular volume is begun. Blood then can be administered through this same line when matched.
The therapy for ruptured ectopic pregnancy is laparoscopy to ligate the bleeding vessels and to remove or repair the damaged uterine tube. A rough suture line on the uterine tube may lead to another tubal pregnancy, so either the tube will be removed or suturing on the tube is done with microsurgical technique.
If a tube is removed, a woman is theoretically only 50% fertile, because every other month, when she ovulates next to the removed tube, sperm cannot reach the ovum on that side. However, this is not reliable contraceptive measure. Research in rabbits has shown that translocation of ova can occur –that is, an ovum released from the right ovary can pass through the pelvic cavity to the opposite (left) uterine tube and become fertilized and vice versa.(salphigictomy-removal of the fallopian tube.)
As with miscarriage, women with Rh-negative blood should receive Rh (D) immune globulin (RhIG) after an ectopic pregnancy fro isoimmunization protection in future childbearing.
(See Appendix for illustrations)
II. OBJECTIVES
Generally, later than three weeks of orientation and exposure at the Perpetual Succour Hospital –Station 3B, the proponents should contribute to the practice of managing ectopic pregnancy cases in any clinical setting by utilizing the acceptable notions, skills, and outlooks that they will be achieving from this study.
Specifically, later than three weeks, the proponents should:
1) devise a complete output on the specified client and condition through obtaining apt orientation and clear instructions from the clinical instructor on how to devise the study.
2) pool all data for printing and binding and finish the study before March 5, 2010, Friday, the scheduled date of presentation.
3) submit the final hard and soft copies of the output to the clinical instructor. 4) gather as a group for brainstorming of ideas making use of individual
researches about the disease condition.
5) present the case study on the scheduled date.
6) defend the case study in front the panelists by answering the relevant questions thrown by them.
7) identify and describe the signs and symptoms of ectopic pregnancy. 8) map out and explain the disease process of ectopic pregnancy.
9) identify and describe the various managements –especially nursing management –for ectopic pregnancy.
10)gather again as a group for pointers and reactions from each member and from the clinical instructor after the case presentation.
III. NURSING ASSESSMENT Client in Context
Client F.B.M., 25 years old, female, 5 weeks age of gestation; admitted to Perpetual Succour Hospital for the first time on March 02, 2010 at 8:58 A.M., accompanied by her husband; in for complaints of right, lower abdominal pain; pre-operative diagnosis – ectopic pregnancy; operative diagnosis –ruptured ectopic pregnancy, right uterine tube; undergone major operation on March 02, 2010 at 10:00 A.M. –exploratory laparostomy, right salpingo-oophorectomy; under the services of Dr. Lyn Alana Busa of the Department of Obstetrics; with hospital number 219923.
Biographical Data
Name of Client: F.B.M. Sex: Female Age: 25
years old
Civil Status: Married Nationality: Filipino
Religion: Kristohanon
Address: Holy Name, Mabolo, Cebu City Contact No: 0926…
Birthdate: October 6, 1984 Birthplace: Ipil, Zamboanga Sibugay
Education: College Graduate Occupation: Stocks In-charge
,
Ever CareHealth Insurance: PhilHealth
Date and Time of Admission: March 02, 2010 at 8:58 A.M.
Informant / Relation to Client: U.R.M. / Husband
Reliability: Reliable
Chief Complaints and History of Present Illness
Client not aware of pregnancy, LMP on January 22, 2010; experienced vaginal spotting with minimal bleeding on February 24, 2010, regarded as usual menstruation, drank beer; experienced abdominal pain on afternoon of February 27, 2010, 3 days PTA, started at RLQ, squeezing in quality, tolerable, radiated downwards to right thigh, no other associated symptoms such as fever, nausea and vomiting; no medications taken, no consultation; pain persisted and increased in quality on March 02, 2010, thus prompted admission; ER blotter: T 36.4°C, HR 92 bpm, RR 24 cpm, BP 90/60 mmHg.
Past Health History
Childhood Illness: Fever, Cough, Cold
Surgeries: None
Serious Injuries: None
Immunizations: Can’t recall
Allergies: No known food, drug, dust allergies
Blood Transfusions: None
CONDITION INSTITUTION DATE
None
Medications before Admission
Medication
Name Dose/Frequency
Time of Last
Dose Medication Name Dose/Frequency
Time of Last Dose None PHYSICAL ASSESSMENT General appearance
Client F.M, 25 years old married and resident of holyname mabolo cebu city. She was seen grimacing once in awhile. She can now move minimally with assistant and was able to turn sides occasionally. She was still pale and weak.
Vital signs Temperature: 36.8°C Pulse: 79 bpm Respiration: 20 cpm Blood Pressure: 90/60 mmHg Height: 5 feet Weight: 47kg Integumentary
Skin is fair colored, warm, soft, and smooth, with moles at the right lower face, left upper face behind the left nares and freckles around the left upper forehead; trauma in the right dorsal part of the hand; hairs is thick, long, wavy, without parasites nor flakes on the scalp; no clubbing present, negative capillary test (3 sec)
HEENT
Head/face normocephalic; no tenderness or masses; facial features symmetrical. Vision was not assessed, extraocular muscles intact, visual fields normal by confrontation, cornea and iris are intact, sclera is white, conjunctivae clear and pale pink, PERRLA, positive constriction and convergence. External ear canals clear without redness, swelling, lesions, and tympanic membrane intact, gray. Nares patent, no sinus tenderness present; nasal mucosa pink, cilia noted; septum intact, no deviation. Lips dry; oral mucosa and gingivae pink and moist without lesions; 32 ivory colored teeth, dental cary noted at the upper left canine; tonsils are not assessed; tongue is smooth pink, symmetrical, no lesions.
Neck and Axillae
Positive swallow reflex
Thorax
Breasts symmetrical; light brown areolas and nipples with no masses or discharges; normal spinal curvatures
Abdomen
Sutures seen in the abdomen, Wasn’t able to auscultate abdomen due to abdominal binder present and the client felt the pain when binder was loose
Musculoskeletal System and Extremities
Full ROM of lower extremities (patient was sitting with her legs dangling), upper extremities are not fully movable because of the IVF at the right arm and the left arm is still in trauma; skin is warm, hairs are visible in both legs; wasn’t able to assess gait, heel-to-toe walk and the likes because client is still lethargic and still needs assistance in moving.
Neuro-sensory
NO DATA
Genitalia-Rectum
Menarche at 13 years old, regular for 3 days, consumes 1 napkin in a day; positive dysmenorrheal;
GORDON’S FUNCTIONAL HEALTH PATTERNS
Health Perception –Health Management
“Health is wealth. Importante ni aron mabuhi, so that we could do everything we want” as verbalized by the patient. She scaled her health as 7/10. Patient said that if ever she or a member of her family is sick, they usually buy OTC drugs. They don’t really go to health center because they are renting an apartment far from a health center. They sometimes use herbal medicine such as “kalabo” w/c can be used for treatment of cough.
Nutritional –Metabolic
Patient eats 3 meals a day. For breakfast, she eats fish, rice and drinks milk. For lunch she eats 1cup of rice, fish and drinks orange juice and for dinner she usually eats vegetables, a cup of rice and milk. Patient eats snack between meals. When she was admitted she said that her eating pattern is not the same before, she can only eat 2-2 ½ cup of rice for the 3meals compared to 3-4 cups of rice for the 3 meals before she was admitted
Elimination
Prior to admission and during admission, patient’s elimination pattern is still the same. She urinates 4-5x a day with approximately 240- 250 ml per void. She defecates 4-5x a week. She said that she is constipated. Patient said that she noticed if she eats apple in the morning she can defecate an hour or two after. Activity –Exercise
She wakes up early every morning. Before going to work she strolls outside their apartment as her exercise. She spends 30mins- 1hr walking. At work, she usually rest during her break. She takes a nap every break time. Now that she is admitted her activity is limited because she needs rest due to her surgery.
Sleep –Rest
Patient usually wakes up at 6-7 in the morning and sleep at around 10:30 in the evening. She can only take a nap sometimes. So far she doesn’t talk while sleeping but ‘’hagok’’ if she’s very stress from work. She also mentioned that previously she treat her insomnia by means of taking ‘’4G’’ but as of now she takes ferrous sulfate to treat her insomnia. During her admission, patient sleeping pattern was different because patient doesn’t have enough sleep due to some noise in the ward.
Cognitive –Perceptual
The client can understand well. She responds calmly to the interviewers. She has no difficulties in all her senses. When she was admitted, she said she was exhausted. Role –Relationship
Patient aware that her responsibilities in the family is to be a good, loving, caring, understanding wife to her husband and to their future children. As a wife, she said that she takes care of her husband’s needs like cooking him for breakfast, preparing his food for work. She is very close to her husband, she even ask advices from her husband. She is not very close to her siblings because it’s been long time since
they’ve seen each other. In work, she believes that she’s almost responsible to all. She defines roles and responsibilities in life as a law and is to be followed accordingly. The client felt sadness after knowing that her baby has already gone. Her husband is always at her side to comfort her
.
Value –Belief
Patient doesn’t believe on horoscope as well as fortune/palm reading because she believes that we are the one making our future by means of self-decision making. She also believes that God has already planned our individual life. Patient is a protestant but considered herself as a catholic in general because she is one of the Christ believers but in terms of religious beliefs, she doesn’t worship saints and do the sign of the cross. During assessment, we observed that patient is religiously active.
Self-perception –Self-concept
Patient describes herself as emotional, hard working and of course loving wife to her husband. She’s emotional, because according to her, she’s very sensitive (emotionally); hardworking, because she really focuses on her work; lastly, she’s loving wife, because she still have time for her husband although she’s workaholic. Coping –Stress
Patient stated that, ‘’A problem is part of our lives. It molds us to become stronger.’’ For her, problem is like a challenge that if without it; a person won’t fully enjoy and feel life’s accomplishments and satisfaction. She also mentioned during assessment that problems gives stress and makes a person very depress unless that certain person knows how to handle it. Her ways in coping up with problems/stressors are to always pray and ask God’s guidance; Work on it in order to solve it whether by herself or with the help of others.
Sexuality –Reproductive
Patient stated that she had her first menstruation at the age of 13. Her menstruation is regular, usually lasts for 3 days, and she consumes at least 1 sanitary pad per day. She rated her sexual satisfaction as 9/10. .. … …. ….. …… ……
IV. LABORATORY FINDINGS
Exam date: March 02, 2010
URINALYSIS MACROSCOPIC Color (Urine) Appearance Glucose Protein pH Specific gravity Bilirubin Urobilinogen Urine ketone Nitrite Leukocytes Blood MICROSCOPIC RBC/ hpf WBC/ hpf Epithelial cells Mucus threads Amorphous material Bacteria Umol/ L Mg/ dl /hpf /hpf LEGEND
NEG= Negative BLOOD PROTEIN POS= Positive + = 0.03mg/dl
+ = 30mg/dl
TNTC= Too numerous to count ++ = 0.2mg/dl ++ = 100mg/dl OCC= Occational +++ = 1.0mg/dl +++ = 300mg/dl ++++ = 2000mg/dl BILIRUBIN GLUCOSE UROBILINOGEN + = 1mg/ dl + =50mg/dl + = 2mg/dl ++ = 2mg/ dl ++ = 150mg/dl ++ = 4mg/dl +++ = 4mg/ dl +++ = 500mg/dl +++ = 8mg/dl ++++ = 1000mg/dl ++++ = 12mg/dl
SCLOUD= Slightly Cloudy KETONE LEUKOCYTES
LTYLW= Lightly yellow + = 25mg/dl + = 25wbcs/ ul
DKYLW= Dark yellow ++ = 100mg/dl ++ = 75 wbcs/ul
LTORNG= Light orange +++ = 300mg/dl +++ = 500wbcs/ul
Exam date: March 02, 2010
COMPLETE BLOOD COUNT
RESULT UNITS REFERENCE RANGE White Blood Cells
Neutrophils Lymphocytes Monocytes Eosinophils Basophils Hemoglobin Hematocrit
Mean Corpuscular vol. Mean Corpuscular Hgb Red Blood Cells Dist. Width Platelet Count X10^9/L % % % % % g/ dL % 10^12/ L Fl Pg ( % ) x 10^9/ L 4.50- 13.0 25.0- 70.0 20.0- 65.0 0.00- 9.00 0.00- 8.00 0.00-3.00 12.0- 16.0 36.0- 49.0 78.0- 102.0 25.0- 35.0 31.0- 36.0 140.0- 440.0 MANUAL PLATELET COUNT: 50,000/ cumm
Exam date: March 02, 2010
HEMATOLOGY
Test Name Result Units Reference Range
Clotting Time –LW 13’30’’ min sec 7.0-15
Bleeding Time –
IVY 4’30’’ min sec 2.0-8.0
Exam date: March 02, 2010
CHEMISTRY Test
Name Results Units Reference Range Results Units Reference Range
Creatinin
e 0.86 mg/dL 0.60-1.50 76.02 mg/dL 132.6
53.4-Sodium 134 mmol/L 133-146 134 mmol/L 133-146
Potassiu
m 3.46 mmol/L 2.4-5.2 3.46 mmol/L 3.4-5.2
PREGNANCY
Result POSITIVE
V. ANATOMY AND PHYSIOLOGY (Female Reproductive System)
The system consists of external and internal genitalia, which develop and function according to hormonal influences that affect fertility and childbearing. It also consists of urinary structures.
External genitilia include the mons pubis, clitoris, vestibule, labia majora, labia minora, vaginal introitus, hymen, Bartholin’s gland, Skene’s gland, and the urethral meatus. Internal genitalia include the vagina, cervix, uterus, adjacent structures (adnexa), ovaries, and uterine tubes. Internal urinary structures include the ureters, bladder, and urethra. The functions of the female reproductive system are:
Manufacturing and protective ova for fertilization
Transporting the fertilized ovum for implantation and embryonic/fetal development Housing and nourishing the developing fetus.
Regulating hormonal production and secretion of several sex hormones. Providing sexual stimulation and pleasure
Providing a drainage route for the excretion of urine (urinary structures)
Structures and Functions of the Female Reproductive System
STRUCTURE DESCRIPTION/PRIMARY FUNCTION
Mons Pubis - Pad of subcutaneous fatty tissue lying over anterior symphysis pubis
- Protects pelvic bones during coitus
Labia Majora - Two longitudinal folds of adipose and connective tissue - Extended from clitoris anteriorly and gradually narrow to merge and form posterior commissure of perineum
- Outer surface of the labia majora becomes pigmented, wrinkled and hairy at puberty
- Inner surface is smoother, softer, and contains subcutaneous glands
- Protects vulva components that it surrounds - Protects urethra and vagina from infections
Labia Minora - Consists of two thin folds of skin that extend to form prepuce of clitoris anteriorly and a transverse fold of skin forming fourchette posteriorly
- Contains sebaceous glands, erectile tissue, blood vessels, and involuntary muscle tissue
- Secretions are bactericidal and aid in lubricating vulval skin and protecting it from urine
Clitoris - Erectile body about 2.5 cm in length and 0.5 cm in diameter
- Contains erectile tissue and has significant supply of nerve endings
- Serves as primary organ for sexual stimulation Vestibule - Area between two folds of labia minora
- Boat-shaped area containing the urethral meatus, openings of the Skene’s glands, hymen, openings of the Batholin’s glands and vaginal introitus
Skene’s Gland - Surround urethral meatus
- Provide lubrication to protect skin
Vaginal Introitus - Entrance to vagina; size and shape may vary
Hymen - Avascular thin fold of connective tissue surrounding vaginal introitus in women who have not had sexual experiences
Bartholin’s Glands - Small, pea-shaped glands deep in perineal structures
- Ducts are not visible
- Secrete clear, viscid, odorless, alkaline mucus that improves viability and motility of sperm along the reproductive tract
Perineum - Space between fourchette and anus
- Composed of muscle, elastic fibers, fascia, and connective tissue
Vagina - Muscular tube from cervix to vulva
- Located posteriorly to bladder and anteriorly to rectum
- serves a female organ of copulation, birth canal, and channel through which menstrual flow exists
Cervix - End of uterus that projects into vagina
Uterus - Pear-shaped, hollow, muscular organ between bladder neck and rectal wall
- Mucous membrane lining is the endometrium. Muscular layer is the mesometrium. Inferior aspect is cervix, superior aspect is fundus
- Major functions include serving as implantation site of fertilized ovum as protective sac for developing embryo and fetus
Uterine Tubes - Two 7-10cm long ducts on either side of fundus of uterus
- Extend from uterus almost to ovaries
- Major functions include serving as fertilization site and providing passage way for unfertilized ova to travel to uterus
Ovaries - Almond-shaped glandular structures that produce ova
- Located laterally to uterine tubes
- Major functions include producing ova for fertilization by sperm and producing estrogen and progesterone
(See Appendix for illustrations)
V. PATHOGENESIS
Ectopic Pregnancy in the Uterine Tube
HOST AGENT
ENVIRONMENT
-Female, 25 y/o Unknown -rides on
motor--unaware of pregnancy cycle with
band
Fertilization
Zygote travels along the uterine tube (UT)
Possible Causes
- adhesion of UT from Zygote trapped on stinctured site previous infection
(chronic salpingitis, PID) Implantation on site
- congenital malformations - (+) pregnancy
- scars from tubal surgery - uterine tumor
- IUD
Reabsorbed If diagnosed early
If undiagnosed
- no Tx - oral meds
- (-) pregnacy (methotrexate, leucovorin,
Conceptus grows Mifepristone) Recovery UT ruptures Destruction of conceptus - (-) pregnancy Recovery
Uterine deciduas sloughs off scant vaginal spotting Pain (RLQ) Bleeding Additional bleeding Hemoperitoneum (1500 cc) - shoulder pain Hypovolemia
- tachycardia, thready pulse - tachypnea
- hyptotension
Total circulatory collapse Coma
VI. NURSING CARE PLANS
NAME OF CLIENT: F.B.M ATTENDING PHYSICIAN: Dr. Lyn Alana Busa
AGE: 25 years old SEX: Female STATUS: Married
RELIGION: Kristohanon CHIEF COMPLAINT: RLQ abdominal pain
ADDRESS: Holy Name, Mabolo, Cebu City DIAGNOSIS: Ruptured Ectopic Pregnancy, Right Uterine Tube
DATE AND TIME OF ADMISSION: March 02, 2010 08:58 A.M CLIENT PROFILE: Received client on bed,
. asleep, with husband, afebrile, without IVF
NEED/NUR SING DIAGNOSI S/CUES SCIEN TIFIC ANALY SIS OBJECTIV ES NURSING OBJECTIVES/ NURSING INTERVENTIO NS
RATIONALE EVALUATION EVALUATION
Acute pain related to post operative surgery as manifested by verbalized reports. Subjective: Sakit jud kayo akong tinahi dong as verbalized by the patient. Objective: facial grimacing, difficulty in moving Unplea sant sensor y and emotio nal experie nce arising from actual or potenti al tissue damag e or describ ed in terms of such damag e After 3 days of nursing interventio n the patient will be able to: -report pain -follow prescribed pharmacol ogical regimen -verbalized methods that provide relief -demonstra te use of relaxation skills 1. Perform a comprehensiv e assessment of pain to include location, characteristics , onset/duration , frequency, quality, severity, and aggreviating factors. 2. Perform pain assessment each time pain occurs. 3. Monitor vital signs 4.Provide quiet environment 5. Encourage adequate rest periods -to assess etiology
-to rule out worsening of underlying condition/devel opment of complications. -to have baseline data of the client. -to be successful in alleviating pain -to promote wellness and to prevent fatigue. After 3 days of nursing interven tion/ teaching the goal will be met, actions perform ed and attain
NEED/ NURSING DIAGNOSI S/ CUES SCIENTIFI C ANALYSIS OBJECTIVES NURSING OBJECTIVES / NURSING INTERVENTI ONS RATIO
NALE EVALUATION VALUE INTEGR ATION Physiologi c needs: Risk for infection related to tissue destructio n and increase in environme ntal exposure/ vertical incision O: Received pt. on bed with vertical incision at lower abdomen w/binder Intact skin and mucous membran e are the body’s first line of defense against microorg anisms. Unless the skin and mucosa became crack and broken, they are an effective barrier against bacteria/ infectious agents. Source: Fundame ntals of nursing 8th edition page 673 After 8 hours of nursing interventions the patient will be able to: a) Verbaliz e understa nding of individu al causativ e risk factors. b) Identify interven tion to prevent/ reduce risk f infection . c) Demons trate techniqu e, lifetime changes to promote safe environ ment. 1. Note risk factor s occur rence of infect ion. 2. Clean incisi on with betad ine or appro priate soluti on. 3. Chan ge dress ing as need ed or indic ated. 4. Provi de perin eal care. 5. Monit or for signs and symp toms of sepsi s. Proces s the causat ive factors of infecti on. To reduce spread of infecti on and to promo te optima l healin g. To mainta in skin integri ty at optima l level. To promo te wellne ss. To assess patien t or in order to preven t further infecti ons. After 8 hours of nursing interventions the patient was able to:
a) Verbaliz e understa nding of individu al causativ e risk factors. b) Identify interven tions to prevent or reduce risk of infection . c) Demons trate techniqu e, lifetime changes to promote safe environ ment. I learned the value of service towards my patient on how to take care of them, the best that I can. NEED/ NURSIN G DIAGNO SIS/ CUES SCIENTIF IC ANALYSI S OBJECTIVES NURSING OBJECTIVES/ NURSING INTERVENTI ONS RATIONA
LE EVALUATION VALUE INTEGRA TION
Powerle ssness related to early loss of pregnan cy seconda ry to ectopic pregnan cy. S: Client states she feels sad at pregnan cy loss but is able to deal with situatio n; has returne d to work and has forward-thinking plans. O: Receive d pt. on bed with grimace face, weak , conscio us and has the followin g vital signs: T: P: R: BP: Depressio n is an illness that causes a person to feel sad and hopeless much of the time. It is different from normal feelings of sadness, grief, or low energy. Anyone can have depression . It often runs in families. But it can also happen to someone who doesn't have a family history of depression . You can have depression one time or many times. If you think you may be depressed, tell your doctor. There are After 8 hours of nursing interventions the patient will be able to: a) Express feelings of physical safety. b) Use effective coping mechani sms to reduce depressi on. c) Mobilize support systems and professio nal resource s as necessar y. d) Reestabli sh and maintain adaptive interpers onal relations hips. 1. Provid e the patien t with psych ologic al suppo rt. Visit freque ntly. 2. Be availa ble to listen. 3. Accept the patien t’s feeling s and behavi ors. 4. Instru ct the patien t in at least one fear-reduci ng behavi or, such as seekin g suppo rt from others when frighte ned. 5. Help her under stand the phase s of crisis and the patien t’s reacti ons to the family memb ers. To decreas e the patient’ s fear of being left alone and to encoura ge a trusting relation ship. To express empath y with the patient’ s feelings. To reassur e the patient that they’re appropri ate and valid. To help the patient gain a sense of mastery over the current situatio n. These measur es help reduce anxiety. After 8 hours of nursing interventions the patient was be able to: a) Express feelings of physical safety. b) Use effective coping mechani sm to reduce depressi on. c) Mobilize support systems and professio nal resource s as necessar y. d) Reestabli sh and maintain adaptive interpers onal relations hips. I learned to have an understa nding and a caring heart to the patient, to be able to understa nd her feelings and to help her get through her problems .
good treatments that can help you enjoy life again. The sooner you get treatment, the sooner you will feel better.
VIII. DISCHARGE PLAN NAME OF CLIENT: F.B.M. WARD & BED NO: 3B-SE7
AGE: 25 years old SEX: Female STATUS: Married RELIGION: Kristohanon CHIEF COMPLAINT: RLQ abdominal pain
ADDRESS: Holy Name, Mabolo, Cebu City OCCUPATION: Stocks In-charge, Ever Care
DIAGNOSIS: Ruptured Ectopic Pregnancy, Right Uterine Tube
DATE AND TIME OF ADMISSION: March 02, 2010 08:58 A.M. TYPE &
DATE OF SURGERY: Exploratory Laparotomy, Right Spingo-oophoretomy 03/02/10
OBJECTIVES NURSING INTERVENTIONS
By the time the client will be discharged, she should:
Medications
- take his prescribed drugs unfailingly.
Environment
- live in an environment conducive to faster recovery and health maintenance.
- explain why the drug is prescribed
including side effects and immediate measure in case these occur (refer to drug study)
- explain the relation of a well environment to health
Treatment
- recognize the necessity to comply with his treatment.
Health Teaching
- learn about ectopic pregnancy
Observable Signs & Symptoms
- recognize the signs and symptoms of ectopic pregnancy
Diet
- identify due diet for faster recovery
Spirituality
- improve spiritual wellness
- site ways on how to provide a well environment
- advise to follow scheduled checkups (if there are any)
- advise to give maintenance drugs such as vitamin supplements (if there are any) - health teaching session
- advise for admission when these occur -encourage prenatal care
- encourage to drink fluids as tolerated (water, fruit juices)
- encourage to eat fruits and vegetables, and other nutrient-dense foods
- allow to verbalize about personal matters about faith
IX. DRUG STUDY
NAME OF CLIENT: F.B.M.
CHIEF COMPLAINT: RLQ abdominal pain
AGE: 25 years old SEX: Female STATUS: Married RELIGION: Kristohanon DIAGNOSIS: Ruptured Ectopic Pregnancy, Right Uterine Tube
ADDRESS: Nivel Hills, Brgy. Lahug, Cebu City OCCUPATION: Stocks In-charge,
Ever Care GOAL:
To lower down fever from 37.8°C to at least 37.5°C
DATE AND TIME OF ADMISSION: March 2, 2010 08:58 A.M. CLIENT
PROFILE: Received
client on bed, asleep, with husband, afebrile, without IVF
DRUG CLASSIFIC ATION AND MECHANI SM OF ACTIONS INDICATION S AND DOSAGE CONTRAINDIC
ATIONS EFFECTSSIDE
NURSING RESPONSIB
mefenamic acid (Dolfenal) Tramadol (TDL) parecoxib (Dynastat) cefazolin (Stancef) ranitidine(E ntac) Mefenamic acid is a nonsteroid al anti-inflammato ry drug (NSAID) which is an anthranilic acid derivative. It exhibits anti-inflammato ry, analgesic and antipyretic activity by inhibiting prostaglan din synthesis in body tissues. Unlike most other nonsteroid al anti-inflammato ry drugs, mefenamic acid appears to compete with prostaglan dins for binding at the prostaglan din receptor site and thus, potentially affect prostaglan dins that have already been formed. Binds to mu-opoid receptors. Inhibits reuptake of serotonin and norepineph rine in the CNS. Therapeuti 500mg/tab Q6 RTC/ prn for pain Relief of mild to moderately severe somatic and neuritic pain; headache, migraine,trau matic pain, post-partum pain, postop pain, dental pain and in pain and fever following various inflammatory conditions; dysmenorrhe al, menorrhagia accompanied by spasm of hypogastric pain 50mg Q6 prn for painModerat e to severe acute and chronic pain, painful diagnostic procedures and surgery Short term treatment of acute pain & post-op pain. May be used pre-op to prevent or reduce post-op pain; can reduce opioid requirements when used concomitantl y. GI ulceration of inflammation. Kidney or liver impairment. Resp depression, especially in presence of cyanosis and excessive bronchial secretion, and after op on biliary tract. Acute alcoholism, head injuries, conditions in which intracranial pressure is raised. Attack of bronchospasm. Heart failure secondary to chronic lung disease
.
Hypersensitivit y to parecoxib or to any other ingredient of Dynastat. Patients who have demonstrated allergic-type reactions to sulfonamides, acetylsalicylic acid (aspirin) or nonsteroidal anti-inflammatory drugs (NSAIDS) including other cyclooxygenas e-2 (COX-2) specific inhibitors; asthma and urticaria Gi disturbances and hemorrhage, blood dyscrasias. Drowsiness, dizziness, headache, visual disturbances. Skin reactions and nephropathy. Nausea, vomiting, fatigue, headache, constipation, drowsiness, confusion, skin reactions, dry mouth, facial flushing, sweating, vertigo, bradychardia , palpitation, orthostatic hypotension, hypothermia, restleness, changes in modod, miosis. Rarely, muscle weakness,ap petite changes, difficulty in passing urine, biliary spasm. Body as a Whole: Back pain. Central and Peripheral Nervous System: Dizziness. GI System: Alveolar osteitis (dry Instruct patient to avoid alcohol (includes wine, beer, and liquor) when taking this medicine since it can cause increases in stomach irritation. Avoid aspirin, aspirin-containing products, other pain medicines, other blood thinners (warfarin, ticlopidine, clopidogrel), garlic, ginseng, ginkgo, and vitamin E while taking. Talk with healthcare provider ®assess type, location and intensity of pain before 2-3 hr after administration. ®assess BP and RR. Respi depression has not occurred with recommended doses. ®advise patient to change position slowlyc effect: decreased pain Parecoxib is a prodrug of valdecoxib. The mechanism of action of valdecoxib is by inhibition of cyclooxyge nase-2 (COX-2)-mediated prostaglan din synthesis. Cyclooxyge nase is responsible for generation of prostaglan dins. Two isoforms, COX-1 and COX-2, have been identified. COX-2 is the isoform of the enzyme that has been shown to be induced by pro-inflammato ry stimuli and has been postulated to be primarily responsible for the synthesis of prostanoid mediators of pain, inflammati on and fever. At therapeutic doses, 500mg IVTT Q8H Infections of the resp, GIT & GUT, otic & bone; skin, soft tissue & post-op infections; bacteremia, septicemia, endocarditis & other infections due to susceptible organisms; surgical prophylaxis Treatment of peptic ulcer disease, GERD, selected cases of persistent dyspepsia, pathological hypersecreto ry states eg Zollinger-Ellison syndrome, stress ulceration & in patient at risk of acid aspiration during general History of shock by cefazolin. Hypersensitivit y; some products that contain alcohol and should be avoided in patient with known intolerance; some products that contain aspartame and patient with phenylketonuri a. socket), constipation and flatulence. Platelet, Bleeding and Clotting: Ecchymosis. Psychiatric: Agitation and insomnia. Skin and Appendages: Increased sweating and pruritus. Events Occurring ≥0.5% and <1%: Application Site: Injection site pain. Autonomic Nervous System: Dry mouth. Body as a Whole: Asthenia and peripheral edema. Hearing and Vestibular: Earache. Heart Rate and Rhythm: Bradycardia. Metabolic and Nutritional: Hyperglycem ia. Musculoskele tal System: Arthralgia. Respiratory System: Pharyngitis. Skin and Appendages: Rash and skin postoperativ e complication s. Urinary System: Oliguria. Shock; hypersensitiv ity reactions; hematologic to minimize orthostatic hypotension. ®do not confuse tramadol from toradol. Give the medication around the clock at evenly spaced times and to finish the medication completely at directed, even if feeling better. Check for
valdecoxib is a COX-2 selective inhibitor of both peripheral and central prostaglan dins and does not inhibit COX-1, thereby sparing COX-1-dependent physiologic al processes in tissues, particularly the stomach, intestine and platelets. COX-2 is also thought to be involved in ovulation, implantatio n and closure of the ductus arteriosus and CNS functions (fever induction, pain perception and cognitive function). Bind to bacterial cell wall membrane causing cell death. Therapeuti c effect: bactericidal action against susceptible bacteria. Inhibits the anesthesia. eg granulocytop enia, eosinophilia or thrombocyto penia; hepatic, renal impairment; GIT disease eg colitis; CNS signs including convulsions; alteration in bacterial flora; vit deficiencies & others eg headache, dizziness or malaise Confusion, dizziness, drowsiness, hallucination, headache. Arrythmiasis, constipation and nausea. signs of super infection (vaginal itching/ discharges) and allergy. Assess patient for epigastric or abdominal pain and frank or occult blood in the stool, emesis, of gastric aspirate. Administer with meals or immediately afterward and at bedtime to prolong effect.
action of histamine at the h2-receptor site located primarily in gastric parietal cells, resulting in inhibition of gastric acid secretion. X. BIBLIOGRAPHY
Dillon, Patricia M. 2007. Nursing Health Assessment, ed. 2. Bangkok, Thailand: iGroup Press Co., Ltd.
Maried, Elaine N. 2006. Essentials of Human Anatomy & Physiology, ed. 8. Philippines: Peason Education South Asia Pte Ltd.
Pillitteri, Adele. 2007. Maternal and Child Health Nursing: Care for the Childbearing and Childbearing Family, ed. 5. Philippines: Lippincott Williams and Wilkins.
