By: Oronce, Aiza F.

Cruz, Kryzia Margaret Macaranas, Bien Balanon, Mark Paulo Chong, Mike Neilsen Edrada, Joneil Ngking, Amado II. BSN 3

An ectopic pregnancy, or eccyesis, 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 (so-called tubal pregnancies), 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. Ectopic pregnancy can be difficult to diagnose because symptoms often mirror those of a normal early pregnancy. These can include missed periods, breast tenderness, nausea, vomiting, or frequent urination. The first warning signs of an ectopic pregnancy are often pain or vaginal bleeding. You might feel pain in your pelvis, abdomen, or, in extreme cases, even your shoulder or neck (if blood from a ruptured ectopic pregnancy builds up and irritates certain nerves). Most women describe the pain as sharp and stabbing. It may concentrate on one side of the pelvis and come and go or vary in intensity.

An ectopic pregnancy results from a fertilized egg's inability to work its way quickly enough down the fallopian tube into the uterus. An infection or inflammation of the tube might have partially or entirely blocked it. Pelvic inflammatory disease (PID), which can be caused by gonorrhea or chlamydia, is a common cause of blockage of the fallopian tube. Endometriosis (when cells from the lining of the uterus implant and grow elsewhere in the body) or scar tissue from previous abdominal or fallopian surgeries can also cause blockages. More rarely, birth defects or abnormal growths can alter the shape of the tube and disrupt the egg's progress.

The significance of the study is for us third year students to apply the principles and concepts that we have learned in the NCM 101 (Maternal and Child Nursing) in our rotation at St. Mattheus Hospital, with the following specific learning objectives:

1. Cognitive To be able to review concepts and theories in maternal and child nursing. To be able to describe the development, pathophysiology, medical-surgical management, and nursing care of a client who had undergone an ectopic pregnancy. To be able to design a Nursing Care Plan for the patient. To be able to provide information and heath teachings to the patient in the postpartum period.

2. Psychomotor To be able carry-out hospital routines and the treatment prescribed to the patient. To be able to perform nursing procedures and nursing considerations for a client in the preoperative and postoperative stages To be able to implement the nursing care plan 3. Affective To be able to establish a good working relationship with the patient and hospital staff.

The "Core, Care, and Cure" theory was developed in the late 1960's. She postulated that individuals could be conceptualized in three separate domains: the body (care), the illness, (cure), and the person (core).

Nursing functions in all three of the circles (core, care, and cure) but shares them to different degrees with other disciplines. For example, the nurse's function in the cure circle is limited to helping patients/families deal with the measures instituted by the physician. She felt that the care circle was exclusive to nursing. The core circle was shared with social workers, psychologists, clergy, etc. For the care aspect which goal is to comfort the patient, we should complete such basic daily biological functions as eating, bathing, elimination, and dressing. By this we are providing opportunity for closeness, and as this develops, the patient can share and explore feelings with the nurse, which in this case the chance for having another baby. Our patient experience an ectopic pregnancy which deeply affects her reproductive system, so for the care or the body we as nurses function as a support for her, so we should explain deeply and carefully that there are still possible ways to have another baby and that she should also face the reality.

Patient once verbalized that she didnt know that she is pregnant until she experienced abdominal pain. The goal of the core or the person is to discuss with the patient her condition which may help her with the nurse find a way for a fast recovery, with the use of therapeutic communication we somehow develop an interpersonal relationship with the patient, by this we should help the patient verbally express feelings regarding the disease process and its effects, as well as discuss the patients role in recovery. Cure or the illness, we are the one who are giving the medications, monitor the patient, and the one which is in close contact with the patient, so any confusion with the prescription or orders of the doctors, we are the one that will act as their advocate, we are the one that will help the patient and family to understand it.

Patients Profile

Name: Address: Sex: Age: Date of Birth: Educational Attainment: Nationality: Religion: Civil Status: Date of admission: Time admitted: Chief Complaint:

MC San Mateo, Montalban Female 22 years old. September 03, 1988 High School Graduate Filipino Catholic Single September 19, 2010 5:40pm Abdominal Pain

History of Present illness: Patient MC noted vaginal spotting a day prior to admission. Few hours prior to admission, she felt abdominal pain at her left lower quadrant and scaled the pain 8/10. No medications were taken. Persistence of pain prompted her to seek consultation. She was brought by stretcher in St. Mattheus Hospital on September 19, 2010, 5:40 pm. Pregnancy test was done with positive result. She was there then diagnosed to consider Ectopic Pregnancy. Past Medical History According to patient MC, she was hospitalized upon birth at Philippine Heart Center for the diagnosis of a cardiac-related problem. Later in life, her menarche was during her age of 13. And her first coitarche was at age of 15. She confirms to have been never given any immunizations. She had never experience any childhood illnesses. Patient claims to have sought consultation as of the reason that she verbalized, nalipasan ako ng gutom. She claims to only have experiences cough and colds but denies any serious illnesses. She also claims to have not taken any vitamins or herbal supplements and denies any allergies.

Obstetrical History Patient MC has a Gravida 3, Parity 1, Term 1, Preterm 0, Abortion 2, Living 0. Her first pregnancy was at her age of 16 and gave birth at St. Mattheus Hospital on November 3, 2005. But after 11 months, her child died. She confessed to engage inabortion at 19 y/o . Her third pregnancy is at present which resulted to Ectopic Pregnancy at 11 weeks AOG. Both of her pregnancies were unexpected and unplanned. Her LMP was July 7, 2010.

E. Social History Patient MC is currently living with her step mother and live-in partners at Novaliches. She claims to have experienced engaging in smoking and alcohol at the age of 18 because of grieving from the loss of her first baby but claims to have ceased 6 months after death. She denies to have engaged in drugs. She loves to eat longganisa and other meat products but also includes vegetables on her daily food intake. She sometimes skips meals. F. Developmental Data According to Erik Eriksons Psychosocial Theory, the patient developmental task at her age (22) is Intimacy versus Isolation. At this stage it involves the affiliation or the ability to give and receive love, commitments and mutuality with others, collaboration in work and affiliations, sacrificing for others and responsible sexual behavior. Intimacy is achieved when an individual has developed the capacity for giving oneself to another and is learned when one has been the recipient of this type of giving within the family. In relation to the patient, the patient has been able to receive and learn love from her family members however, achieving intimacy might be at a struggle lately as she has no plan of marriage or commitment and her child from her live-in-partner resulted into a loss. In addition to that, she confirms that she does not enjoy sexual encounter with her live-in partner and her dad is currently at her province. On the other hand the patient has is with her step-mother and live-in-partner who gives emotional support and love at her stay at the hospital

FamilyGenogram

Family History According to the patient, her grandmother on her mothers side died with a disease related to a heart problem, Moreover her mother died also with a cardiac related problem upon giving birth to her. According to the patient, her first baby died on October 22, 2006, 11 months after birth because of inability to admit her baby at Philippine Heart Center as recommended by doctors because her first born had a uncorrected ventricular septal defect. Her Gravida 3 was unexpected and has resulted to an ectopic pregnancy. No other illness on the fathers side was traced by her. No other noted disease like Asthma, Diabetes, Tuberculosis, Cancer, or Liver diseases is in their family except for a cardiac related problem.

Anatomy of female reproductive system The female reproductive system is designed to carry out several functions. It produces the female egg cells necessary for reproduction, called the ova or oocytes. The system is designed to transport the ova to the site of fertilization. Conception, the fertilization of an egg by a sperm, normally occurs in the fallopian tubes. The next step for the fertilized egg is to implant into the walls of the uterus, beginning the initial stages of pregnancy. If fertilization and/or implantation do not take place, the system is designed to menstruate (the monthly shedding of the uterine lining). In addition, the female reproductive system produces female sex hormones that maintain the reproductive cycle. During menopause the female reproductive system gradually stops making the female hormones necessary for the reproductive cycle to work. When the body no longer produces these hormones a woman is considered to be menopausal.

Parts of the Female Reproductive Anatomy: The female reproductive anatomy includes parts inside and outside the body. The function of the external female reproductive structures (the genitals) is twofold: To enable sperm to enter the body and to protect the internal genital organs from infectious organisms. The main external structures of the female reproductive system include:

Labia majora: The labia majora enclose and protect the other external reproductive organs. Literally translated as "large lips," the labia majora are relatively large and fleshy, and are comparable to the scrotum in males. The labia majora contain sweat and oilsecreting glands. After puberty, the labia majora are covered with hair. Labia minora: Literally translated as "small lips," the labia minora can be very small or up to 2 inches wide. They lie just inside the labia majora, and surround the openings to the vagina (the canal that joins the lower part of the uterus to the outside of the body) and urethra (the tube that carries urine from the bladder to the outside of the body). Bartholin's glands: These glands are located besides the vaginal opening and produce a fluid (mucus) secretion. Clitoris: The two labia minora meet at the clitoris, a small, sensitive protrusion that is comparable to the penis in males. The clitoris is covered by a fold of skin, called the prepuce, which is similar to the foreskin at the end of the penis. Like the penis, the clitoris is very sensitive to stimulation and can become erect.

The internal reproductive organs in the female include: Vagina: The vagina is a canal that joins the cervix (the lower part of uterus) to the outside of the body. It also is known as the birth canal.

Cervix: The lower one-third of the uterus is the tubular "cervix," which extends downward into the upper portion of the vagina. The cervix surrounds the opening called the "cervical orifice," through which the uterus communicates with the vagina. Uterus (womb): The uterus is a hollow, pear-shaped organ that is the home to a developing fetus. The uterus is divided into two parts: the cervix, which is the lower part that opens into the vagina, and the main body of the uterus, called the corpus. The corpus can easily expand to hold a developing baby. A channel through the cervix allows sperm to enter and menstrual blood to exit. Ovaries: The ovaries are small, oval-shaped glands that are located on either side of the uterus. The ovaries produce eggs and hormones. Fallopian tubes: These are narrow tubes that are attached to the upper part of the uterus and serve as tunnels for the ova (egg cells) to travel from the ovaries to the uterus. Conception, the fertilization of an egg by a sperm, normally occurs in the fallopian tubes. The fertilized egg then moves to the uterus, where it implants into the lining of the uterine wall. The fallopian tubes stretch from the uterus to the ovaries and measure about 8 to 10 cm (4 to 6 inches) in length. The ends of the fallopian tubes lying next to the ovaries feather into ends called fimbria (Latin for "fringes" or "fingers"). Millions of tiny hair-like cilia line the fimbria and interior of the fallopian tubes. The cilia beat in waves hundreds of times a second catching the egg at ovulation and moving it through the tube to the uterine cavity. Other cells in the tube's inner lining or endothelium nourish the egg and lubricate it's path during its stay inside the fallopian tube. Once inside the fallopian tube, the egg and sperm meet and the egg is fertilized. If an egg doesn't become fertilized within 24 to 36 hours after ovulation, it will

Date/ Time September 19, 2010 5:40pm

Laboratory Results/ Medications Vital Signs URINALYSIS Color: yellow Transparency: Clear Reaction: 6.0 Specific Gravity: 1.020 RBC: 1-2 hpf Pus Cells: 2-3 hpf Albumin: Negative Amorphous Urates: ++ Epithelium Squamous Cells: ++ -Cefazolin 2 g IV as Loading Dose -Then shift to Cefazolin 500mg IV every 6 hours

Treatment -IVF Started D5LR 1L at 20gtts/min -Second line PNSS 1L at 20gtts/min

Nursing Intervention

September 19, 2010 8:00pm

Assess patient to know previous/ present status of the patient. Check the level of pain. Base on the pain scale. Check for -Tramadol 100mg -To PACU PQRST ( slow IV push every 8 -Monitor Vial Signs precipitating/predisp hours at 3 doses every 15 minutes and osing factor, quality, record radiation, severity, -Ketorolac 30 mg IV -Regulate present time ) push every 6 hours at IVF: Prepare the 4 doses 1. D5LR 1L at medications and 30gtts/min double check it. 2. PNSS at KVO Check for the rate expiration date. -Flat on bed for 6 Make sure to apply hours the 10Rights. -O2 at 5LPM via Check the O2 at Facemask 5lpm every q15 -Monitor Urine Regulate and check Output every hour the IVF fluid q15. and record Monitor V.S -Watch out for thoroughly every 15 hypotension and minutes and record. bleeding Monitor Urine Output every hour and record Watch out for hypotension and bleeding Reassess

Date/ Time
September 20, 2010 2:30 am 7:45am

Laboratory Results

Medications

Treatment

Nursing Intervention

-Cefalexin 500mg capsule every 6 hours for 7 days -Mefenamic Acid 500mg capsule every 6 hours for pain -multivitamins 1 cap once a dat -Ferrous Sulfate 1 cap once a day -Cefalexin 500mg capsule every 6 hours for 7 days -Mefenamic Acid 500mg capsule every 6 hours for pain -multivitamins 1 cap once a dat -Ferrous Sulfate 1 cap once a day

9:00am

-May transfer to ward Assess patient to know -Continue VS monitoring previous/ present status of every hour for 6 hours the patient. Patients Lab results, V.S, -Continue IVF to Chart. complete IV antibiotics Continue VS monitoring for 24 hours then shift to every hour for 6 hours Oral Check the level of pain. -May remove IFC at Base on the pain scale. 6pm Check for PQRST ( -Encourage early precipitating/predisposing ambulation factor, quality, radiation, -Continue VS monitoring severity, time ) Prepare the medications and double check it. Check for the expiration date. Make -Patient seen and sure to apply the 10Rights. examined Teach on how to prevent -Monitor Input and infection, proper hygiene, Output hourly and record and proper nutrition to -Continue present prevent infection and to medications boost immunity. Monitor Input and Output hourly and record Reassess patient

Date/ Time

Laboratory Results/Vital Signs

Medications

Treatment

Nursing Intervention

September 21, 2010 6am 5pm

-Cefalexin 500mg capsule every 6 hours for 7 days BP 110/70mmHg -Mefenamic Acid Temp: 38.50C 500mg capsule PR 70bpm every 6 hours for RR 25cpm pain Pain Scale: 8/10 -multivitamins 1 cap once a day -Ferrous Sulfate 1 cap once a day BP 110/70mmHg - Paracetamol Temp 37.30C 300mg/IV PR 68bpm RR 20cpm Pain Scale: 4/10

-Encourage full ambulation -Continue medications and VS monitoring

Assess patient to know previous/ present status of the patient. Continue Health Teachings esp. to encourage patient full ambulation Continue medications and VS monitoring, I and O. Monitoring and recording. Reassess patient.

9pm

-TSB done -Reassessed temperature after 30 minutes -Administered Paracetamol through IV

Date/ Time

Laboratory Results/Vital Signs

Medications

Treatment

Nursing Intervention Assess patient to know previous/ present status of the patient. Esp. Assess for bowel movement. (auscultation, ask for flatus) Continue Health Teachings esp. to encourage patient full ambulation Continue medications and VS monitoring, I and O. Monitoring and recording. Reassess patient.

September 22,2010 6am

5pm

BP 110/70mmHg Temp 36.70C PR 67bpm RR 18cpm Pain Scale: 3/10

-Cefalexin 500mg capsule every 6 hours for 7 days -Mefenamic Acid 500mg capsule every 6 hours for pain -multivitamins 1 cap once a day -Ferrous Sulfate 1 cap once a day

-may have DAT once with Bowel Movement -encourage early ambulation

9pm

BP 120/80mmHg Temp 37.00C PR 72bpm RR 18cpm Pain Scale: 3/10

Date/ Time

Laboratory Results/Vital Signs

Medications

Treatment

Nursing Intervention
Assess patient to know previous/ present status of the patient. Esp. to follow up Laboratory results. Continue Health Teachings esp. to encourage patient full ambulation Continue medications and VS monitoring, I and O. Monitoring and recording. Reassess patient.

September 23, 2010 6am

-Cefalexin 500mg capsule every 6 hours for 7 days -Mefenamic Acid 500mg capsule every 6 hours for pain -multivitamins 1 cap once a day -Ferrous Sulfate 1 cap once a day

-follow up Labs -continue medications and Vital Signs Monitoring

Date/ Time

Laboratory Results/Vital Signs

Medications

Treatment

Nursing Intervention Assess patient to know previous/ present status of the patient. Esp. to follow up Laboratory results. Follow up CBC, APC, BT, UA, Histopath. Continue Health Teachings esp. to encourage patient full ambulation Continue medications and VS monitoring, I and O. Monitoring and recording. Reassess.

September 24. 2010 6am

-Cefalexin 500mg capsule every 6 hours for 7 days -Mefenamic Acid 500mg capsule every 6 hours for pain -multivitamins 1 cap once a day -Ferrous Sulfate 1 cap once a day

-follow up CBC, APC, BT, UA,Histopath -Continue Medications and Vital signs Monitoring

Date/ Time

September 25,2010 6:33am

Laboratory Results/Vital Signs BP 110/70mmHg Temp 36.50C PR 73bpm RR 20cpm Pain Scale: 2/10

Medications

Treatment

Nursing Intervention Assess patient to know previous/ present status of the patient. Continue Health Teachings esp. to encourage patient full ambulation Continue medications and VS monitoring, I and O. Monitoring and recording. Reassess patient. MGH.

-Cefalexin 500mg capsule every 6 hours for 7 days -Mefenamic Acid 500mg capsule every 6 hours for pain -Multivitamins 1 cap once a day -Ferrous Sulfate 1 cap once a day

-follow up all lab results -continue ordered medications and Vital Signs Monitoring

BLOOD MORPHOLOGY

September 19, 2010

Exam Name Haemoglobin Hematocrit WBC Count

Result 112 0.35 14.6

Normal Findings 110-150 g/L 0.37-0.45 4.6 x 10^g/L Normal Decreased Increased

Analysis

Interpretation

Indicates anemia or massive blood loss. Associated with inflammatory process from trauma acquired from surgery.

RBC Count

3.75

4.0-5.5^3/L

Decreased

Indicate anemia, dilution due to fluid overload or hemorrhage lasting more than 24 hours.

Platelet Count Differential Count: Segmenters Lymphocytes Monocytes

360

150-400 x 10g/L

Normal

0.70 0.26 0.04 93.2 29.9 320

0.50-0.70 0.20-0.40 0-0.07 80.9-99.9 fL 27.0-31.0 pg 330-370 g/L

Normal Normal Normal Normal Normal Normal

MCV MCH MCHC

BLOOD TYPING Type: O Rh: + URINALYSIS Physical

September 19, 2010

September 20, 2010 Result Normal Findings Analysis Interpretation

Color Transparency pH

Yellow Clear 6.0

Amber-Yellow Clear-Hazy 4.5-7.8

Normal Normal Normal

Specific Gravity
Cells Red Blood Cells Pus Cells

1.020

1.001-1.035

Normal

1-2 hpf 2-3 hpf

0-5 hpf Negative

Normal Positive
Indicates the presence of infection

Chemical Albumin Sugar Epithelium Squamous Cells +2 0-4/hpf Normal Negative Negative Negative Negative Normal Normal

XII. MEDICAL AND SURGICAL MANAGEMENT The medical management for ectopic pregnancy includes the medications given by the doctor such as follows:
Ketorolac 30mg IV q6

-Toradol -Nonsteroidal anti-inflammatory agents, nonopioid analagesics Cefazolin 500mg IV q6 Oral -Anti-infectives Paracetamol 300mg IV stat medication Tramadol 100mg Iv q8 Ferrous Sulfate 1cap PO OD Multivitamins 1cap OD Cefalexin 500mg q6 oral Mefenamic acid 500 mg cap q6

SURGICAL MANAGEMENT The surgical management done is salpingectomy that involves the removal of the whole fallopian tube on the side where the ectopic occurred. It is done if conservative surgery is not possible, like when the tube is damaged or deformed. This procedure decreases fertility even more than salpingostomy; there is the chance of subsequent ectopic pregnancy, but not as much as with salpingostomy. It is important to understand that this surgery itself does not cause more ectopics. It is simply that women who had an ectopic because of one abnormal tube are more likely to have the same abnormality in the other tube, and thus more chance of an ectopic.

Medication Instruct the patient to take her medicines as prescribed by her physicians. Do not buy medicines or other food supplements without the doctors order. Do not quit taking medicines until the physician said so. Exercise Advise the patient to continue to do exercises such as Deep breathing and coughing exercises because these exercises can promote faster recovery. After several weeks the client should have a routine exercise like walking to remain physically fit. Exercise helps blood move through the body and may help prevent blood clots from forming. Treatment 1. Cefalexin 500mg capsule every 6 hours for 7 days 2. Mefenamic Acid 500mg capsule every 6 hours for pain 3. Multivitamins 1 cap once a day 4. Ferrous Sulfate 1 cap once a day

Health Teaching Instruct the patient to do proper wound care. Teach patient and also her relatives to do aseptic technique while doing wound care by washing his/her hands to minimize the spread of infection. Proper wound care can help prevent the spread of infectious microorganisms.
Out- patient follow up The patient must have a regular check-up with her physician routinely. Instruct the client to write down any questions he may encounter during the past days so that she can ask questions to her physicians if she has concerns for her conditions and how will she take care her health. Diet Encourage the patient to eat nutritious foods such as vegetables and fruits. Try to lessen foods that are too salty and fatty. Ask the physician about her diet such as how many servings of fat, carbohydrates, protein and sweets. In that way, she will know what dishes she will eat to promote good health. Spiritual Advise the patient to continue to have faith in God in spite of losing two of her babies. She must read the bible regularly to regain her trust to the Lord. Encourage the patient to have a one on one relationship with God so that she can have a peaceful mind and a positive outlook in life.