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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 old
c. Gender: Female
d. Religion: Roman Catholic
e. Civil Status: Married
f. Admitting Diagnosis: G3P1 (1011) Threatened Abortion 9 weeks
g. Final Diagnosis: G3P1 (1021) Ectopic, 9 Weeks Left Fallopian Tube, Ampullary
Ruptured, Endometriotic
Cyst Left
h. Operation Performed: Exploratory Laparotomy + Salpingectomy + Left
Oophorocystectomy
i. Surgeon: Dr. B
j. Date of Operation: October 23, 2010 / 135501-2010
k. Type of Anesthesia: Spinal Anesthesia
l. 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 Normal Standards Actual Findings Interpretation and


Appearance Analysis
1. Posture/Gait >Straight posture, have >Complete bed rest without >Limitations in usual role
balance gait bathroom privileges. 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 >The patient’s skin is dry. >Normal
deep brown; from ruddy Skin color is brown which is
pink to light pink; uniform in all areas except
generally uniform for areas that are not usually
except in areas exposed to sun such as the
exposed to sun axillae, the legs and soles of
>Moisture in skin fold the feet.
3. Personal >Clean and neat, No >Clean and neat, No body >Normal
hygiene/ Grooming body and breath odor and breath odor
4. Nutritional >Eat three meals a day >NPO with IVF >The diet given to her is
Status and snacks that consist to comprise her post-
of a balance diet (go, BMI: Height= 5’4" operative condition
grow, glow food). Weight= 49.5 kgs.
BMI Weight Status
Computation: Categories
BMI = Wt (kg)/Ht (m)2 Below 18.5= Underweight
= 49.5kg/(1.626 m)2 18.5 - 24.9 = Normal
= 49.5 kgs./2.644 25- 29.9= Overweight
= 18.72 BMI Above 30= Obese
= Normal
>Normal
BMI Weight Status Categories
Below 18.5= Underweight
18.5 - 24.9 = Normal
25- 29.9= Overweight
Above 30= Obese

5. Verbal Behavior >Can communicate well >Can communicate well and >Normal
and express her express her feelings.
feelings.
6. Non-verbal >Actions coordinate >Seen to be always on deep >There are wider
Behavior with the mood of the thought; Flat affect; Biting of variations in non verbal
client. lower lips; Diaphoresis; response to pain. For
Sighing; Facial grimace 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 T: 36.8 ˚C >Physiologic responses
PR = 60 -100bpm P: 87 vary with the origin and
RR = 12 - 20bpm R: 19 duration of the pain. Early
BP = SP (100 – BP: 120 / 80 in the onset of acute pain,
140mmHg) the sympathetic nervous
DP (60 – 90mmHg) system is stimulated
resulting in increase BP,
PR, and RR.

Body Parts Normal Standards Actual Findings Interpretation and


(Technique Analysis
Used)
Head
 Skull >Rounded and >The patient’s skull is Normal
smooth skull contour proportional to the size of her
>Smooth, uniform body, round, with
consistency and prominences in the frontal
absence of nodules area anteriorly and the
occipital area posteriorly,
symmetrical in all planes,
gently curved.
 Scalp >White and uniform >The scalp is white, no lice, Normal
in color no nits and dandruff, no
>Absences of flakes lesions, no infection or
and lesion infestation. No areas of
tenderness.
 Hair >Evenly distributed; >Hair is black in color, evenly Normal
thick hair distributed and covers the
whole scalp, thin and free
from split ends.
 Face >Symmetrical facial >Oblong, symmetrical, facial Normal
features; expression is dependent on
symmetrical facial the mood and her true
movements feelings, smooth and free
>No erythema from wrinkles. There are no
involuntary muscle
movements.
Eyes
 Eyebrows >Hair evenly >Black, plucked eyebrows, >Plucking eyebrows
distributed and hairs are not evenly indicates that the patient is
symmetrical distributed, raise and lower conscious of her physical
symmetrically and inline, with appearance and body image.
equal movement >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 >Eyelashes are black in color, Normal


distributed and evenly distributed and turned
curved slightly outward.
outward
 Eyelids >Skin intact; no >Upper lids cover a small Normal
discharged; no portion of the iris and the
discoloration cornea and the sclera when
the eyes are open. When the
eyes are closed, the lids meet
completely. Symmetrical. No
palpable mass.
 Conjunctiv >Shiny, smooth and >Shiny, smooth and pale Normal
a pink or red in color; conjunctiva; no presence of
no presence of lesions
lesions
 Sclera >White in color, clear >White in color, clear Normal
 Iris >Flat and round, >Iris is proportional to the Normal
black or brown in size of the eye, round, brown,
color and symmetrical.
 Pupils >Black in color, >Pupils are symmetrical, 3-5 Normal
equal in size; mm in diameter, equally
normally 3-7mm in reactive to light and
diameter; round accommodation
Pupil test >Illuminated pupil >Pupils equally round and Normal
constricts (direct react to light and
response), Non- accommodation
illuminated pupil
constricts
(consensual
response)
Extraocular >Both eyes >Both eyes coordinated, Normal
muscle coordinated, move in move in unison, with parallel
unison, with parallel alignment
alignment
 Lacrimal >No edema or >No edema or tearing over Normal
gland tearing the lacrimal gland
Ears
 Auricles >Color same as >Color same as facial skin, Normal
facial skin, symmetrical auricle aligned
symmetrical auricle with the outer canthus of eye,
aligned with the about 10° from vertical
outer canthus of eye, >Mobile, firm, and not tender,
about 10° from pinna recoils after it is folded
vertical
>Mobile, firm, and
not tender, pinna
recoils after it is
folded
 Hearing >Normal voice tones >Normal voice tones audible Normal
acuity test audible (Done by
standing 2 feet away
from the client and
ask her to repeat the
3 words what the
nurse will say).
Nose >Symmetrical in >Symmetrical in shape; no Normal
shape; no discharge discharge or flaring; uniform
or flaring; uniform in in color
color >Mucosa pink; no lesions
>Mucosa pink; no >Nasal septum intact and in
lesions midline
>Nasal septum intact >No tenderness or lesion
and in midline >No rashes
>No tenderness or
lesion
>No rashes
Mouth
 Lips >Uniform pink/red >Uniform pinkish color; Normal
color; soft moist, symmetrical, lip margin well
smooth texture defined, smooth and moist
 Buccal >Uniform pink color; >Uniform pink color; moist, Normal
mucosa moist, smooth, smooth, glistening and elastic
glistening and elastic texture
texture
 Gums >Pink gums and >Pink gums, moist and firm Normal
moist, no bleeding texture. No bleeding.
 Tongue >Pink color, moist; >Pink color, moist; slightly Normal
slightly rough; thin rough; thin whitish coating;
whitish coating; smooth lateral margins; no
smooth lateral lesions raised papillae
margins; no lesions >Central position, moves
raised papillae freely, no tenderness smooth
>Central position, tongue base with prominent
moves freely, no veins
tenderness smooth
tongue base with
prominent veins
 Teeth >32 permanent >15 upper teeth, 14 lower >29 permanent teeth
teeth, well-aligned, teeth. present.
free from caries or >Free from caries. No >Some older adults may
filling, no halitosis halitosis. 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 >Proportional to the size of Normal
size of the body and the body and head,
head, symmetrical, symmetrical, and straight.
and straight. >No palpable masses.
>No palpable lumps, >Coordinated, smooth
masses, or areas of movements with no
tenderness. discomfort. Head flexes 45°,
>Coordinated, laterally flexes 40°, and
smooth movements laterally rotates 70°.
with no discomfort. >Neck muscles have equal
Head flexes 45°, strength and the same as the
laterally flexes 40°, shoulders.
and laterally rotates
70°.
>Neck muscles have
equal strength and
the same as the
shoulders.
Thorax and
Lungs
Posterior >Anteroposterior to >Anteroposterior to Normal
Thorax transverse diameter transverse diameter ratio is
Shape and in a ratio of 1:2 1:2
Symmetry >Chest symmetric
>Chest is symmetric.
Spinal >Vertically aligned >Spine is vertically aligned Normal
Alignment when inspected and palpated.
Palpation >Skin intact, uniform >Skin is intact and of uniform Normal
temperature temperature
>Chest wall intact, >Chest wall intact, with no
no tenderness no tenderness no masses
masses
Respiratory >Full symmetric >Full symmetric chest Normal
/Thoracic chest expansion expansion
Excursion
Auscultation >Vesicular and >Vesicular and Normal
of thorax bronchovesicular bronchovesicular breath
breath sounds sounds
Heart Aortic valve – no Aortic valve – no pulsations Normal
pulsations
Pulmonic valve – no Pulmonic valve – no
pulsations pulsations
Tricuspid area – no Tricuspid area – no pulsations
pulsations
Apical area –
pulsations visible and Apical area – pulsations
palpable. visible and palpable.
Epigastric area –
abdominal aortic Epigastric area – no
pulsations visible and pulsations
palpable. The two heart sounds are
The two heart sounds audible in all areas but
are audible in all loudest at apical area, 4th
areas but loudest at ICS, LMCL
apical area. Cardiac rate has normal
Cardiac rate ranges ranges with a regular rhythm.
from 60-100
beats/minute.
Abdomen >Skin is >Skin is unblemished, no Normal
unblemished, no scars, color is uniform, flat,
scars, color is rounded (convex), or
uniform, flat, scaphoid (concave), slightly
rounded (convex), or protuberant for infants,
scaphoid (concave), symmetrical movements
slightly protuberant caused by respiration,
for infants, umbilicus is flat or concave,
symmetrical positions midway between
movements caused the xiphoid process and the
by respiration, symphysis pubis, color is the
umbilicus is flat or same as the surrounding skin.
concave, positions
midway between the
xiphoid process and
the symphysis pubis,
color is the same as
the surrounding skin.
Arms >Skin color varies >Skin color is light brown, Normal
(pinkish, tan, dark symmetrical, absence of
brown), symmetrical, visible veins and scars.
fine hair evenly >Warm, dry and elastic; no
distributed, areas of tenderness.
presence/absence of
visible veins.
>Warm, dry and
elastic; no areas of
tenderness. Muscle
appears equal with
good muscle tone.
Palms and >Palms pinkish >Palms pinkish, warm and Normal
dorsal (dorsal surface), softer
surfaces warm
Nails >Nails are >Nails are short, transparent, Normal
transparent, smooth, smooth, and convex with pink
and convex with pink nail beds and white
nail beds and white translucent tips.
translucent tips. >Five fingers in each hand.
>Five fingers in each >As pressure was applied to
hand. the nail bed, it appears white
>As pressure is and pink color returns less
applied to the nail than 2 seconds.
bed, appears white
or blanched, and pink
color returns
immediately as
pressure is released.
Shoulders Raise both arms to >Able to raise both arms to Normal
vertical position – vertical position, and place
Performs with hands behind the small of the
relative ease back with relative ease.
Place head behind
the neck – Performs
with relative ease
Place hands behind
the small of the back
– Performs with
relative ease
Arms Abduct – Performs >The patient can perform Normal
with relative ease abduct, adduct and rotate
Adduct – Performs with relative ease.
with relative ease
Rotate – Performs
with relative ease
Elbows Bend and straighten >Able to bend and straighten Normal
elbow – Performs elbow with relative ease
with relative ease
Hands and Extend and spread >Can extend and spread the Normal
wrists the fingers – fingers and make a fist,
Performs with thumb across the knuckles
relative ease with relative ease.
Make a fist, thumb
across the knuckles –
Performs with
relative ease
Lower extremities
Legs >Skin color varies >Skin color was light brown; Normal
(pinkish, tan, dark skin is smooth, absence of
brown), skin is varicose veins.
smooth, fine hair >Muscles appear equal,
evenly distributed, warm.
absence of varicose >With full range of motion,
veins. full and equal pulses.
>Muscles appear
equal, warm and with
good muscle tone.
>With full range of
motion, full and
equal pulses.
Toes >Five toes in each >Five toes in each foot; sole Normal
foot; sole and dorsal and dorsal surface is smooth;
surface is smooth; with pink nailbeds and white
with pink nailbeds translucent tips.
and white translucent
tips. >As pressure is applied, the
>As pressure is nailbed appears white; pink
applied, the nailbed color returns when pressure is
appears white or released.
blanched; pink color
returns when
pressure is released. >With full range of motion.
>With full range of
motion, full and
equal pulses.

Pain Assessment

PQRST Mnemonic
P – Provocation and NT: “Ano’ng nagpapagaan P: “Pag humihinga ako Effective pain
Palliation at nagpapalala nito?” ng malalim medyo management requires
nawawala.” careful assessment and
P: “Lalong sumasakit regular review of pain.
kapag gumagalaw ako” Pain is a subjective
Q – Quality and NT: “Maaari nyo po bang P: “Una nagsimuLa ditto symptom. Pain
Quantity idescribe iyong pain na sa may bandang taas assessment tools are
nararamdaman ninyo?” tapos pababa sa may therefore based on the
tagiliran” patient’s own perception
NT: “San po masakit?” of their pain and its
R – Region and P: “Dito.” (Pointing at severity. Pain
Radiation NT: “Gaano po kasakit? left lower quadrant) assessment involves
from the rate po of 1-10, 1 P: “Mga 7”. initial, detailed
S – Severity and Scale po as no pain and 10 as the evaluation of each type
most painful.” of pain, and regular
reassessment of severity
NP:”Kelan po sya P: “Sumasakit kapag and response to
T – Timing and Type sumasakit?” gumagalaw ako.” treatment.
of Onset
Reference:
http://www.caresearch.c
om.au/caresearch/Clinica
lPractice/Physical/Pain/As
sessmentTools/tabid/748
/Default.aspx

VI. ANATOMY ANG PHYSIOLOGY

INTERNAL GENITALIA
a. 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
Fertilized Egg
Etiology
- Age
- Sex

Blastocyst burrows into the epithelium of the

Tapping of blood vessels by the same process as

Implantation on the tubal

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

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

Sudden Abdominal Abdominal ultrasound


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

Uninterrupted invasion of
trophoblastic tissue or
tearing
of extremely stretched

Products of conception completely/


incompletely expelled into the abdominal
cavity or in between the folds of broad

Treatment/Management:
Rupture/Tubal
* Salphingectomy to remove
Rupture
affected
Vaginal tube and control bleeding
spotting * Salphingoophorectomy
(removal of
tube with adjacent ovary)
* Management of shock
Sharp abdominal * Methotrexate
pain. * Constant hCG monitoring
VIII. DIAGNOSTICS AND LABORATORIES

CBC
Test Oct. 23 Oct. 24 Reference Values
Hemoglobin 10.8 12.3 12:00 – 15.00 g/dL
Hematocrit 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 fl
MCH 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/L
Eosinophil 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 UTERUS
THICKENED ENDOMETRIUM WITH BLOOD CLOTS
CORPUS LUTEUM, RIGHT OVARY
COMPLEX MASS, LEFT ADNEXA COULD BE EXTRAUTERINE
GESTATION PROBABLY RUPTURED
HEMOPERITONEUM AS DESBRIBED

IX. MEDICAL-SURGICAL MANAGEMENT

 Medical
Early 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 Justification


Acute pain related to rupture fallopian 1 An actual problem that needs intervention because it can aggravate
tube abdominal pressure
Risk for ineffective tissue perfusion related 2 A potential problem that needs intervention to prevent risk for
to hemorrhage hypovolemic shock and may lead to maternal mortality

Intra-operatively

Nursing Diagnosis Rank Justification


Risk 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 Justification


Grieving, dysfunctional related to 1 An actual problem that needs attention because it may lead to
perceived loss of a child psychological problem( major depression, anxiety and suicide)
Impaired adjustment related to incomplete 2 The state in which the individual is unable to modify her behavior in a
grieving (severe emotional loss) 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 GOAL and NURSING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS OBJECTIVE
Subjective Acute pain Goal Independent
“Masakit ang related to After 8 hours of  Perform assessment of pain  To assess factors that After 8 hours of
tiyan ko as rupture of nursing to include location, precipitates and contributes to nursing intervention,
verbalized fallopian intervention the characteristics, onset, the pain sensation and to the patient was able
by the tube patient will be duration, frequency, quality indicate the appropriate choice to report pain
patient” able to report and severity. of treatment. relief/control as
pain relief/control evidenced by no
Objective as evidenced by  Monitor maternal vital  To determine presence of guarding behavior
• Facial no guarding signs. hypotension and tachycardia and absence of facial
mask of behavior and caused by rupture of mask of pain.
pain absence of facial hemorrhage.
• Guarding mask of pain. After 30 minutes of
behavior  Monitor for presence and  To further assess the present nursing intervention,
• Pain Objective amount of vaginal bleeding situation indicating the patient was able
scale of 7 After 30 minutes hemorrhage to report reduction of
(1 as no of nursing pain from 7 to 4 of
 Monitor for increase pain
pain 10 intervention, the Indicates rupture and possible pain scale as
and abdominal distention 
as worst patient will report intra-abdominal hemorrhage. evidenced by less
and rigidity
pain) reduction of pain facial grimace.
from 7 to 4 of
 Monitor CBC  To determine the amount of
pain scale. blood loss.

 Encourage verbalization of  It can reduce anxiety and fear


feeling about pain. thereby reduces perception of
intensity of pain.

 Provide comfort measure


like backrubs, deep  It may enhance patient’s
breathing. Instruct in coping abilities by refocusing
visualization exercises. attention.

 Provide diversional
activities.  Aids in refocusing attention and
enhancing coping with
Dependent limitation.
 Administer medications as
indicated.  To maintain acceptable level of
pain.
Collaborative
 Laboratory as indicated.

 To determine blood loss


Intra-operatively

CUES NURSING GOAL and NURSING INTERVENTIONS RATIONALE EVALUATION


DIAGNOSIS OBJECTIVES

Goal: Independent: Does the


Risk for After using intervention,  Review history for preexisting  Risk of chorioamnionitis patient have
Infection related the patient will have no conditions/risk factors. Note time increases with the passage safe aseptic
to invasive signs of infection during of rupture of membranes. of time, placing mother and environment?
procedure, and after the procedure fetus at risk. Presence of √ yes?
break in the infectious process may _ no?
skin and Objective:  Assess for signs/symptoms of increase fetal risk of
exposure to After 1.5 hours of infection (e.g., elevated contamination
pathogens. invasive procedure the temperature, pulse, WBC;  Rupture of membranes
patient will have a safe abnormal odor/ color of vaginal occurring 24 hr prior to
> Impaired aseptic environment by discharge, or fetal tachycardia). surgery may result in
primary maintaining the sterility chorioamnionitis prior to
defenses and of the instruments and  Provide perineal care per surgical intervention and
inadequate the field. protocol, especially once may impair wound healing.
secondary membranes have ruptured.  Reduces risk of ascending
defense that infection.
resulted from  Carry out preoperative skin
the operation preparation; scrub according to
contributes to protocol.
the patient’s
 Reduces risk of skin
wound being contaminants entering the
invaded by  Verify sterility and integrity of all incision, reducing risk of
pathogenic items used in the procedure. postoperative infection.
micro organism.
(NANDA)
 Prepackaged items may
appear to be sterile;
 Verify that preoperative skin however each item must be
preparation was done scrutinized for sterile
aseptically. indicators and package
integrity.
 Examine skin for breaks or
irritation, signs of infection.  Cleansing reduces bacterial
count on the incision site.

 Identify breaks in aseptic  Disruptions of skin integrity


technique and resolve at or near the operative site
immediately on occurrence. are sources of contamination
to the incision.
Collaborative:
 Administer antibiotics, as  An unsterile item that
ordered. touches sterile items is
considered unsterile.

 May be given
prophylactically for
suspected infection or
contamination

Post-operatively
CUES NURSING OBJECTIVE and NURSING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSI GOAL
S
Subjective: Grieving, Goal: Independent
“Nawala ulit dysfunction After the end of  Identify(be aware of)  To assess contributing After 8 hours of
ang baby al related to nursing care the stage of grief being /causative factors that nursing
ko.” perceived patient will be able to expressed: Bargaining, precipitates/contributes grief intervention the
“Excited pa loss of a demonstrate progress Anger, Denial, and to indicate the appropriate patient is able to
naman ang child in dealing with stages Depression, Acceptance choice of therapeutic verbalizes a sense
anak ko na of grief at own pace. communication of progress toward
magkaroon Be aware of avoidance resolution of the
ng kapatid.” After 8 hours of behaviors (anger, grief and hope for
nursing intervention withdrawal) the future
Objective: the patient will be able
 Crying to verbalize a sense of  Identify factors and ways  To further assess the present
 Difficulty progress toward individual has dealt with situation
in resolution of the grief previous loss(es)
expressi and hope for the
ng loss future.  Encourage verbalization
 Labile without confrontation  Assist patient to deal
affect about realities appropriately with loss. Helpful
in beginning resolution and
Encourage patient to talk acceptance
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  To promote wellness
(teaching)
 Discuss health ways of
dealing with difficult
situation

Provide information about


normalcy of feelings/
actions in relation to
stages of grief
XI. DRUG ANALYSIS

Generic Dosage Action Indication Contraindicatio Adverse Effect Nursing Consideration


Name n
Paracetamol 600 mg IV Analgesic and Fever reduction. Paracetamol GI: hepatic 1. Do not use this
PRN Antipyretic Temporary relief should not be failure medication without medical
of mild to used in GU: renal failure direction for fever.
moderate pain hypersensitivity Skin: rash, 2. Do not self medicate
to the urticaria adults for pain more than 10
preparation and days without consulting a
in severe liver physician.
diseases. 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 Treat wide Contraindicated Diarrhea, 1. Inform the physician if you
cephalosporin variety of in patients nausea and have liver or kidney disease.
antibiotic similar infection hypersensitivity vomiting, 2. Instruct the patient to
to penicillin to drug or other abdominal pain. follow the prescribed
cephalosporin. Headache, rash, frequency of the drug even if
Use cautiously in vaginitis, and he feels better.
breastfeeding mouth ulcers. 3. Instruct the patient to
women and in take it with meals.
patients with 4. Instruct the patient to
history of colitis report any adverse reaction
or renal of the drug.
insufficiency.
Demerol 25 mg IV Analgesic, Medical: Hypersensitivity Cardiovascular: 1. If I.V. administration is
Narcotic Management of to meperidine or Hypotension required, inject very slowly
moderate to any component; Central nervous using a diluted solution;
severe pain; patients system: Fatigue, administer over at least 5
adjunct to receiving MAO drowsiness, minutes; intermittent
anesthesia and inhibitors dizziness infusion.
preoperative presently or in Gastrointestinal: 2. May cause hypotension,
sedation the past 14 days Nausea, dizziness, drowsiness,
vomiting, impaired coordination, or
constipation blurred vision; loss of
Neuromuscular appetite, nausea, or
& skeletal: vomiting; constipation.
Weakness 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
Diphenhydram 50 mg IV Antihistamine Can be used for Hypersensitivity Cardiovascular: 1. May experience
ine mild nighttime to Hypotension, drowsiness or dizziness; or
sedation; has Diphenhydramin palpitations, dry mouth, nausea, or
anesthetic e or any tachycardia vomiting. 2. Report
properties component; Central nervous persistent sedation,
should not be system: confusion, or agitation;
used in acute Sedation, changes in urinary pattern;
attacks of sleepiness, blurred vision; sore throat,
asthma; use in dizziness, difficulty breathing, or
neonates is disturbed expectorating (thick
contraindicated coordination, secretions)
headache, 3. Raise bed rails, institute
fatigue safety measures, assist with
Gastrointestinal: ambulation
Nausea,
vomiting,
diarrhea,
abdominal pain
Celebrex 200mg Non-steroidal Relief of signs Severe hepatic Back pain, 1. Periodically monitor Hct
anti- and symptoms of impairment; peripheral and Hgb, liver functions,
inflammatory osteoarthritis hypersensitivity edema, BUN and creatinine, and
and rheumatoid to celecoxib; abdominal pain, serum electrolytes.
arthritis. asthmatic diarrhea, 2. Monitor closely lithium
Treatment of patients with dyspepsia, levels when the two drugs
acute pain. aspirin triad; flatulence, are given concurrently.
advance renal nausea, 3. Monitor closely PT/INR
disease; dizziness, when used concurrently with
concurrent use of headache, warfarin.
diuretics and insomnia, 4. Monitor for fluid retention
ACE inhibitors. pharyngitis, and edema especially in
sinusitis, URI, those with a history of
and skin rash. hypertention or CHF.
Ketorolac 30mg IV NSAID, Exhibits Individuals with Drowsiness, 1. Correct hypovolemia prior
Antipyretic, analgesic, anti- complete or dizziness, to administration of
Analgesic, CNS inflammatory, partial syndrome headache, ketorolac.
agent and antipyretic of nasal polyps, nausea, 2. Periodic serum
activity angioedema and dyspepsia, GI electrolytes and liver
bronchospastic pain, functions
reaction to hemorrhage, 3. Monitor urine output in
aspirin, during edema older patients with the
labor and history of cardiac
delivery; patients decompensation, renal
with severe renal impairment, and heart
impairment or at failure.
risk for renal 3. Monitor for signs and
failure due to symptoms of GI distress or
volume bleeding
depletion, patien 4.Monitor for fluid retention
with risk for
bleeding.
Nalbuphine 5mg CNS agent, Analgesic action History of Hypotenton, 1. Assess respiratory rate
analgesic; that relieves emotional bradycardia, before drug administration.
narcotic agonis- moderate to instability or tachycardia, Withhold drug and notify
antagonist severe pain with drug abuse; head flushing; physician if respiratory rate
apparently low injury, increased Abdominal falls below 12.
potential for intracranial cramps, bitter 2. Watch for allergic
dependence pressure, taste, nausea response in person with
impaired and vomiting, sulfite sensitivity.
respirations, dry mouth; 3. Administer with caution to
impaired kidney sedation, patients hepatic or renal
or liver function; dizziness, impairment.
MI; biliary tract nervousness, 4. Monitor ambulatory
surgery. depression, patients, because it may
restlessness, produce drowsiness.
crying, Watch for respiratory
euphoria; depression in newborn if
Dyspnea, drug is used during labor
asthma, and delivery.
respiratory
depression;
pruritus,
burning
sensation

Infusion Classification Indication Contraindication Nursing Responsibility


D5NM 1L Hypertonic Maintenance of Hypersensitivity to any Check doctor’s order
solution fluid and of the components Observe 10 R’s when preparing and administering IVF.
electrolytes 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 patient
Monitor other electrolyte levels
Clean rubber port aseptically
Observe patient and report any untoward effect.
PNSS 1L Isotonic solution Fluid No known Check doctor’s order
replacement in contraindication Observe 10 R’s when preparing and administering IVF.
patient with dhn Check the sterility and integrity of the IV solution, IV set and
or fluid deficit. other devices.
Used solution in Place IV label on the IV bottle.
BT. 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 patient
Monitor other electrolyte levels
Clean rubber port aseptically
Observe patient and report any untoward effect.
D5LR Hypertonic Source of water, Contraindicated with Check doctor’s order
solution electrolytes and known allergy to corn Observe 10 R’s when preparing and administering IVF.
calorics as an and corn product. Check the sterility and integrity of the IV solution, IV set and
alkanizing agent 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 patient
Monitor other electrolyte levels
Clean rubber port aseptically
Observe patient and report any untoward effect.
D5NR Hypertonic Maintenance of Hypersensitivity to any Check doctor’s order
solution fluid and of the components Observe 10 R’s when preparing and administering IVF.
electrolytes 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 patient
Monitor other electrolyte levels
Clean rubber port aseptically
Observe patient and report any untoward effect.
PRBC Blood Used in patients Contraindicated to Check doctor’s order
Components with acute patient with severe Observe 10 R’s. Explain the procedure for giving blood
anemia whose congestive heart failure transfusion. Get the pt’s history regarding previous
symptoms were and to those unable to transfusion.
related to blood obtain appropriately Countercheck the compatible blood to be transfused against
loss and were matched blood X-matching sheet noting ABO grouping RH, serial no. of each
refractory to blood unit, and expiry date with the blood bag label and
crystalloid other lab blood exam done.
infusions, as well Get the baseline vital signs before transfusion.
as in patients Give pre-med 30 minutes before transfusion as prescribed.
with chronic Do hand hygiene before and after the procedure.
anemia in whom Observe patient for 10-15 minutes for any immediate
nontransfusion reaction.
therapies (eg, Observe patient on an on-going basis for any untoward s/sx
iron such as flushed skin, chills, elevated temp, itchiness,
replacement, urticaria, and dyspnea.
erythropoietin) Continue to observe and monitor patient post transfusion for
had not been delayed reaction.
effective. 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+ma
nagement+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 5th
edition. By Adele Pilliteri
• Foundation of Maternal- Newborn Nursing 4th edition. By Sharon Smith Murray, Emily Stone Mc
Kinney
• Maternal and Child Nursing Care 2nd 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