INTRODUCTION The group chose Ms.

Chuchu as their subject primarily because her case posed as a very intricate case requiring due understanding and knowledge. The group recognizes their partial knowledge about ectopic pregnancy and the surgical procedures involved in such condition, thus making this case a good avenue to broaden the proponents knowledge about the disease and the surgical procedures involved. An ectopic pregnancy is commonly referred to as a tubal pregnancy because 95% occur in a fallopian tube. An ectopic pregnancy needs to be treated immediately to avoid fallopian tube damage or life threatening blood loss. When identified early, ectopic pregnancies are treatable with medication that stops the pregnancy. If the pregnancy is further along, laparoscopy is usually performed to remove the ectopic tissue and repair the fallopian tube. Currently, laparotomy is the preferred technique when the patient is hemodynamically unstable, the surgeon has not been trained in laparoscopy, physical facilities and supplies to perform laparoscopic surgery are lacking or technical barriers to laparoscopy are present. If the ectopic pregnancy has ruptured or bleeding persists, salpingectomy is a very common option. This procedure involves excision of segment of the Fallopian tube involved in the ectopic pregnancy. The tubal segment to be removed is coagulated and cut off with bipolar forceps.

A.

Significance of the Study This case study was made possible so that every individual who reads and listens to this

presentation will gain knowledge about the disease, so that they can take action if they encountered such a case. This also serves as a tool to educate individuals about the possible complication of ectopic pregnancy which is necessary for them to understand the risks and be aware about the subject matter. Educating them to seek early and regular prenatal care is the best way to prevent complications that may lead to maternal various diseases. As member of the health care team, nurses have the responsibility in sustaining and maintaining the life and health of the patient who had this kind of complication. This condition needs a prompt care in monitoring the over-all condition of the patient, taking precautions and thorough understanding of the disease process so that any further deviations can be noted, evaluated, reported and intervened. B. General Objective: The main goal of the group is to be able to present the case study of our chosen client that would provide a comprehensive discussion of the pathological mechanism of the disease to yield significant information for the case study. Specific Objectives: In order to meet the general objective, the group aims to: y y y Establish rapport to the patient and the patients significant others, Interpret the pertinent data gathered from the patient and her significant others, State past and present health history of the patient

Evaluate the present developmental stage of the patient according to the theories of Erikson, Piaget, Kohlberg, and Havighurst,

y y y y y y y y y y

Define the complete diagnosis of the patient, Present the Gordons assessment obtained from the patient, Discuss the anatomy and physiology of the organ involved in the patients disease, Present the etiology and symptomatology of the patients disease, Trace the pathophysiology of the patients disease, Obtain and rationalize the doctors order, Interpret the laboratory test results of the patient, Discuss the nature of the drugs given to the patient, Discuss the surgical procedure performed to the patient Present a specific, measurable, attainable, realistic and time-bounded nursing care plans for the client,

y y y

Justify the clients prognosis according to the different criteria, Provide the patient and family with proper discharge planning (M.E.T.H.O.D), and Outline recommendations based on the case studys findings.

Chapter II PATIENT DATABASE A. Demographic Data This case study was conducted on patient Ms. Chuchu, a 22 years old female and single. She is undergraduate college student (HRM). She is working as a call center agent. She is a Roman Catholic. She was admitted last January 23, 2012 with the chief complaints of abdominal pain. She was diagnosed with Ectopic Pregnancy in the right ampullary site of the fallopian tube ruptured. B. Nursing History

1. Developmental Tasks a) Freuds Stages of Psychosexual Development (Genital) The final stage of psychosexual development begins at the start of puberty when sexual urges are once again awakened. The primary focus of pleasure is the genitals. The genital character is not fixed at an earlier stage. This is the person who has worked it all out. This person is psychologically well-adjusted and balanced. According to Freud to achieve this state you need to have a balance of both love and work. This stage is important in the development of social and communication skills and self-confidence. (Daniels, Grendell, & Wilkins, 2010) Because of the condition that our patient had experienced, losing her baby and not able to work because she was hospitalized makes her not achieve this stage that well.

b) Eriks stages of Psychosocial Development (Intimacy vs. Isolation) In this theory, the young adulthood has the developmental task of Intimacy versus Isolation. Intimacy is to be able to develop commitments to others or to have an intimate relationship with another person. This also means to able to have a career or life work. A negative resolution of isolation is characterized by impersonal relationships, avoidance of relationship, career, or lifetime commitments. (Kozier, Erb, Berman, & Snyder, 2004) The patient manifests a positive resolution of the tasks. She is committed to her work as a call center agent. She has also an intimate relationship with her boyfriend even though theyre not married and with her family as evidenced by supporting her in all her needs. c) Havighurts Developmental Stages In Middle Age stage patient is adjusting to his decreasing physical strength and altering on his health. In this time the patient is usually successfully on achieving of ones early task in life will leads to the happiness and to success with later tasks, and they also maintained their economic status. (Daniels, Grendell, & Wilkins, 2010) Our patient has been successful in this stage because she was able to support herself because she has a job. She was also able to support her family because she dont have her own family.

d) Kohlbergs (Universal Ethical Principle Orientation) Kolhbergs final level of moral reasoning is based upon universal ethical principles and abstract reasoning. At this stage, people follow these internalized principles of justice, even if they conflict with laws and rules. (Daniels, Grendell, & Wilkins, 2010) The patient is already in this stage because she is 22 in age. This is evidenced by accepting any treatment that is ordered by her physicians in treating her condition. 2. Health History a. History of Present Illness Patient was admitted in Manila Adventist Medical Center(MAMC) on January 23, 2011 with a chief complaint of 30 minutes prior to admission after consuming a meal experienced sudden abdominal pain, described as diffuse, severe persistent and aggravated by movement. She sought consult at MAMC ER, where she had episodes of vomiting and BP was noted to be 80/60 and tachycardia. A pregnancy test was done which yielded positive results and according the result of Ultrasound Dr. Soriano- Cocos, Percida, her attending physician, diagnosed her with ectopic pregnancy, R-ampullary of fallopian tube ruptured. She was then rushed to the O.R and exploratory pelvic laparotomy: Right salpingectomy was done. . Her last menstrual period was November 1, 2011. Admitted with a diagnosis of Gravida 1 Para 0 pregnancy; 12 weeks AOG; August 8, 2012 must be the EDC.

b.

Past Medical History Relating to her past medical history, she had no previous hospitalizations or previous

operations. She does not visit health care facilities. She was negative allergies to food and medication. She also had no history of previous abortion, miscarriage or other complications.
6

She had menarche at 13 years old but it is irregular. It is normally absence for one month and lasts five days consumes three pads a day. But sometimes it took three months for absence and lasted 7 days consumed three pads per day. She and her boyfriend did not use any birth control methods.

c.

Family Medical History The patient stated that Hypertension and Diabetes Mellitus is prominent in her fathers

side, while in her mothers side they are prominent in breast cancer. Aside from that, no other illnesses were known in their family.

3.

Medical Diagnosis and Chief Complaints The patient seeks for medical help with the chief complaint of Abdominal Pain. The

final diagnosis for the patient is Ectopic Pregnancy, right ampullary of fallopian tube ruptured.

CHAPTER III THE DISEASE ENTITY A. Normal Physiology Reproductive System

The vagina is a thin-walled tube 8 to 10 cm long. It lies between the bladder and rectum and extends from the cervix to the body exterior. Often called the birth canal, the vagina provides a passageway for the delivery of an infant and for the menstrual flow to leave the body. (Tate, 2009) The cervix (from Latin neck) is the lower, narrow portion of the uterus where it joins with the top end of the vagina. Where they join together forms an almost 90 degree curve. It is cylindrical or conical in shape and protrudes through the upper anterior vaginal wall. (Tate, 2009).

The passageway between the external os and the uterine cavity is referred to as the endocervical canal. It varies widely in length and width, along with cervix overall. Flattened anterior to posterior, the endocervical canal measures 7 to 8 mm at its widest in reproductiveaged women. The endocervical canal terminates at the internal os which is the opening of the cervix inside the uterine cavity. (Tortora, Gerard, & Derrickson, 2007) The uterus is shaped like an upside-down pear, with thick lining and muscular walls. Located near the floor of the pelvic cavity, it is hollow to allow a blastocyte, or fertilized egg, to implant and grow. It also allows for the inner lining of the uterus to build up until a fertized egg is implanted, or it is sloughed off during menses. (Tortora, Gerard, & Derrickson, 2007) The uterus contains some of the strongest muscles in the female body. These muscles are able to expand and contract to accommodate a growing fetus and then help push the baby out during labor. These muscles also contact rhythmically during an orgasm in a wave like action. It is thought that this is to help push or guide the sperm up the uterus to the fallopian tubes where fertilization may be possible. (Tortora, Gerard, & Derrickson, 2007) The uterus is only about three inches long and two inches wide, but during pregnancy it changes rapidly and dramatically. The top rim of the uterus is called fundus and is a landmark for many doctors to track the progress of a pregnancy. The uterine cavity refers to the fundus of the uterus. (Tortora, Gerard, & Derrickson, 2007) Helping support the uterus are ligaments that attach from the body of the uterus to the pelvic wall and abdominal wall. During pregnancy the ligaments prolapsed due to the growing uterus, but retract after childbirth. In some cases after menopause, they may lose elasticity and uterine prolapsed may occur. This can be fixed with surgery. (Tate, 2009)

The fallopian tubes are paired, tubular, seromuscular organs whose course runs medially from the cornua of the uterus toward the ovary laterally. The tubes are situated in the upper margins of the broad ligaments between the round and utero ovarian ligaments. Each tube is about 10 cm long with variations in length from 7 to 14 cm. (Tate, 2005) Peristaltic contraction of the smooth muscles fibers in the tubal wall allows the gametes (sperm and egg) to be brought together, thus allowing fertilization and subsequent transport of the fertilized ovum from normal site of the fertilization in the ampulla to normal site of implantation in the uterus. (Tortora, Gerard, & Derrickson, 2007) Ciliary activity is responsible for the pickup of ova by, the fimbrial ostium and movement through the ampulla, as well as the distribution of the tubal fluid which supports gamete maturation and fertilization and facilitates gamete and embryo transport. The close approximation between the ovary and fimbria is likely to be important for ovum pick up, although, transperitoneal migration has been reported. (Tortora, Gerard, & Derrickson, 2007) The paired ovaries are pretty much the size and shape of almonds. An internal view of an ovary reveals many tiny sacs like structures called ovarian follicles. The ovaries are for oogenesis- the production of eggs (female sex cells) and for hormone production (estrogen and progesterone. (Tortora, Gerard, & Derrickson, 2007) The process of ovulation is controlled by the hypothalamus of the brain and through the release of hormones secreted in the anterior lobe of the pituitary gland, (Luteinizing hormone (LH) and Follicle- stimulating hormone (FSH).. (Tortora, Gerard, & Derrickson, 2007) In humans, the few days near ovulation constitute the fertile phase. The average time of ovulation is the fourteenth day of an average length (twenty-eight day) menstrual cycle. It is 23

10

normal for the day of ovulation to vary from the average, with ovulation anywhere between the tenth and nineteenth day being common. (Tortora, Gerard, & Derrickson, 2007) Fertilization occurs when a single sperm cell has penetrated the oocyte. After spermentry, changes occur in the fertilized egg to prevent other sperm gaining entry. In fertilization, the genetic material of sperm combines with the ovum to form a zygote. After fertilization, the zygote travels to the uterus through peristalsis and cilia. The zygote generally gets implanted at the top of the uterus, beginning between 5 and 8 days after fertilization. This process is completed by 9 or 10 days. At this time, the outer layer of this cell mass or trophoblast attaches itself by secreting the required enzymes, which actually erode the uterine wall cells. (Tate, 2009) Ectopic pregnancy results from a delay in the passage of fertilized ovum through fallopian tube. This delay can result from anatomical abnormalities of the tubes, such as constriction and false passage formation or from tubal dysfunction as altered contractility or abnormal ciliary activity. (Murray & McKINNEY, 2010). B. Theoretical background- Definition An ectopic pregnancy is a condition in which a fertilized egg settles and grows in any location other than inner lining of the uterus. The most common site (in approximately 95% of such pregnancies) is in a fallopian tube. Of this fallopian tube sites, approximately 80% occur in the ampullary portion, 12% occur in the isthmus, and 8% are interstitial of fimbrial; however, they can occur in other locations, such as the ovary, cervix, and abdominal cavity. This abnormally implanted gestation grows and draws its blood supply from the site of abnormal implantation. As the gestation enlarges, it creates the potential for organ rupture because only the uterine cavity is designed to expand and accommodate fetal development. Ectopic pregnancy can lead to massive hemorrhage, infertility, or death. (Yates and Kings, 2007)
11

C.

Statistical Report Ectopic pregnancy presents a major health problem for women of childbearing age.

Approximately 2% of pregnancies are ectopic; it is the second most frequent cause of bleeding early in pregnancy. Ectopic pregnancy currently is the leading cause of pregnancy-related death during the first trimester in the United States, accounting for 9% of all pregnancy-related deaths. In addition to the immediate morbidity caused by ectopic pregnancy, the woman's future ability to reproduce may be adversely affected as well. (Burkman 2007)

D.

Risk/Aggrevating Factors With ectopic pregnancy, fertilization occurs as usual as in the distal third of the fallopian

tube. Immediately after the union of ovum and spermatozoon, the zygote begins to divide and grow. Unfortunately, because an obstruction is present, such as an adhesion of the fallopian tube from a previous infection (chronic salpingitis or pelvic inflammatory disease), congenital formations, scars from tubal surgery, or uterine tumor pressing on the proximal end of the tube, the zygote cannot travel the length of the tube. (Moos, 2007) Possible causes of ectopic pregnancy include salpingitis, peritubal adhesions (after pelvic infection, endometriosis, appendicitis), structural abnormalities of the fallopian tube (rare and usually related to DES exposure), previous ectopic pregnancy (after one ectopic pregnancy the risks of recurrence is 7% to 15 %; Lemus, 2006),previous tubal surgery, multiple previous induced abortions (particularly if followed by infection), tumors that distort the tube, and IUD and progestin-only contraceptives(slow the transport of zygote and lead to an increased incidence of tubal or ovarian implantation. (Burkman, 2007)

12

PID appears to be the major risk factor.The incidence is increasing because of increasing rate of pelvic inflammatory disease, which leads to tubal scarring. It occurs more frequently in women who smoke compared with those who not. Women who have one ectopic pregnancy have a 10% to 20% chance that a subsequent pregnancy will also be ectopic.(Teng, Kumar, & Ramli, 2007).

E.

Pathophysiology Narrative and Documentation Copulation happens then the union of sperm and egg cell takes place. The fertilized egg

develops normally arising to the fallopian tube, but there will be an unsmooth travel of the fertilized egg within the tube cause by certain etiological factors that affects the normal implantation such as history of Pelvic Inflammatory Disease, smoking or second hand smoker, age, using contraceptives (e.g. IUD), previous surgery at the pelvic region, and previous history of ectopic pregnancy, thus making it hard for the fertilized egg to anchor itself to the uterine cavity; it slows the movement of a fertilized egg through the fallopian tube to the uterus. Implantation on the tubal mucosa occurs.(Lozeau & Potter, 2005) At 6-8 weeks of pregnancy, the zygote grows large enough to the slender fallopian tube or the trophoblast cells and hCG level decreased. Because the fallopian tube is not ideal for the growth of the zygote, stretching of the tube happens. The continues growth of the zygote causes tubal rupture. Due to the environment of the fallopian tube, which is not ideal for the growth of an embryo, spontaneous regression usually occurs. Spontaneous regression is the death of the embryo early in gestation. There will be an excessive internal bleeding that will happen cause by the tubal rupture. If internal bleeding progresses to acute hemorrhage, a woman may experience hypovolemia
13

which is manifested by light headedness, rapid pulse, tachypnea, sunken eyes, pale skin, dry lips, low BP and usually normal temperature and it is a way to hypovolemic shock. (Burkman, 2007) In the other hand, when there is excessive internal bleeding there is also loss of blood products. And when that happens the hemoglobin & hematocrit is decreasing, resulting to body weakness, dizziness, etc. Because the body is not receiving sufficient oxygenated blood , it will lead to anemia. Leukocytosis may be present, not from infection but from the trauma. From this phenomenon, sudden abdominal pain is felt by the patient because of the electrical stimulation of the vomiting center receiving signals from the afferent, informing the brain that there was a mucosal irritation happens so this will induce vomiting.

14

Pathophysiology Diagram
Etiology: Unknown Non-modifiable: Modifiable: (Risk Factors) y y Historyofpelvic inflammatory disease Second hand smoker y y y y y Congenital malformations Use of contracentives(e.g IUD Previous history of ectopic pregnancy Previous surgery at the pelvic region Age (below 18 and above 35 years old)

Union of sperm and egg cell Pelvic Inflammatory Disease (January 23, 2012)

Unsmoothed travel of the fertilized egg within the fallopian tube

Fertilized ovum implants on the right fallopian tube Decreased hCG level Zygote grows inside the slender fallopian tube

Pain

Stretching of the tube Decreased WBC: H11.20 10q/l (normal:3.8-11)

Embryonic death

Tubal rupture

Tissue damage

Possible infection

Excessive internal bleeding -pale skin, sunken eyes, dry lips, tachypnea, HR: 112, BP: 80/60, Temp: 36 (January 23, 2012)

Scant vaginal bleeding

Pain at right lower quadrant (January 23, 2012) pain scale of 9/10 Electrical stimulation of the vomiting center Weakness, increase respiratory rate Vomiting episodes (January 23, 2012) 15

Hypovolemia Hypovolemic shock Maternal death

Loss of blood products Hgb: L 105 (normal:11-16g/dl) Hct: L 0.33 L/L(normal:34-47%) Anemia

F. Prognosis of Disease One-third of women who have had one ectopic pregnancy are later able to have a baby. A repeated ectopic pregnancy may occur in one-third of women. Some women do not become pregnant again. The likelihood of a successful pregnancy depends on the womans age; whether she has already had children; why the first ectopic pregnancy occurred. The rate of death to an ectopic pregnancy in the United States has dropped in the last 30 years to less than 0.1% because of the immediate recognition of the condition and treatment. The most common complication is rupture with internal bleeding that leads to shock. Death from rupture is rare. Ectopic pregnancy is fatal to the fetus, but if treatment occurs before rupture, maternal death is very rare. In the US, ectopic pregnancy probably accounts for 9% of pregnancy-related maternal deaths. The average rate of repeat ectopic pregnancies after one ectopic pregnancy is 12%. In women with indications of significant damage to a Fallopian tube, if surgery is to be performed, it might be preferred to remove that tube (salpingectomy) to decrease the risk of another ectopic pregnancy. If a woman has had two ectopic pregnancies, it might be better to perform in-vitro fertilization for conception to reduce the risk of having a third ectopic pregnancy.

16

CHAPTER IV ASSESSMENT A. I. Gordons or head to toe assessment Health Maintenance Perception Pattern Before admission in the hospital, the patient does not smoke but occasionally drinks 1-2 bottles of beer. She did not have regular exercises every day but she did 30- 45 minutes jogging on her day-off. No therapeutic drugs using because she has allergy with it, but no food and dyes allergies. During hospitalization, the patient does not smoke nor drink alcoholic beverages. She has no allergies to foods but certain drugs are causing allergy with her. She took cefuroxime, mefenamic acid, paracetamol, nordette, ketorolac, nalbuphine, ranitidine, tranexamic acid, kalium durule, and ferrius sulfate as ordered by the doctor. II. Nutritional Metabolic Pattern Before hospitalization, she did not have any special diet in her daily menu. She ate any kind of foods but more prefer vegetables than meat and she loves to eat fruits also. She did not have any special dietary supplements/ vitamins. She has healthy and good gums and teeth and hasnt experienced difficulty swallowing pattern but he appetite decrease when she was hospitalized. She consumed only half amount of the food what the hospital serves. So, she became weak and felt nausea.

17

III. Elimination Pattern Normally, the patient had bowel pattern of two times a day before the admission but she was now experiencing constipation since 23rd January 2012 that the day she was admitted to the hospital. She did not have catheterization during my care and has no bladder incontinency. She urinated at least 5 times (estimated amount 180 cc) with yellow urine during the shift. IV. Activity and Exercises The patient was very independent in her daily activities before but when she was admitted to the hospital she needed assistances from the others in all activities. During her hospitalization, she didnt ambulate. She just mostly lay in bed or sometimes semi fowlers position. V. Sleep/ Rest Pattern Being working as a call sender agent, her sleeping time is 12 am 7 am (total sleeping times is 7 hrs a day) and it is already familiar with her but sometimes she experiences insomnia. During hospitalization, she seldomly have straight hours of sleep because of her acute pain. VI. Cognitive Perceptual Pattern During first encounter with the patient, she is noted to be oriented, can speak well, her hearing and vision are also normal but her voice is a little bit weak. The level of anxiety is mild and she is experiencing acute pain (pain level 9/10).

18

VII. Role Relationship Pattern The patient is single and working as a call center agent. During her hospitalization, she was supported by her family members and her boyfriend who is also in the same career with her. She lives with her family and there is a good relationship between her boyfriend and family and her parents will also take care of her hospital bill. VIII. Sexuality Reproductive Pattern She has irregular menstruation cycle, normally every 2 months or sometimes it can be long last until 4 months but not beyond then. She had her last Menstrual Period on 1st November 2011. She had her last PAP Smear at 23rd January 2012 but no Self-Breast Examination and normal sexual concerns. She was pregnant almost 11 weeks and 6 days (LMP: November 1 2011) prior to admission (admission date to hospital: January 23 2012) but not aware of pregnancy. IX. Coping Stress Tolerance Her major concerning for present is to relieve her abdominal pain. She is very optimistic for her future outlook by grading 10 out 10. She did not have any major loss/ crisis/ change and no fear of violence at all in past year. X. Value belief Pattern Just like the rest of her family, the patient is a Roman Catholic. She always go to church with her family and boyfriend every Sunday before admission to hospital. There are no restrictions implemented in their religion regarding health pattern.

19

B. Book Picture vs. Patients Manifestations System Normal finding Standard book picture 1.Integumentary Warm and moist No discoloration Good capillary refill Clamminess Pale Poor capillary Patients manifestation Warm Pallor Poor capillary refill (took 3 secs)

No rashes, itching, refill bruises, lesions and swelling.

2. Eyes, Ears, Neck, Throat

Absence of headache, dizziness, head injury Clear vision,

(+)Pale palpebral conjunctiva

(+) Pale palpebral conjunctiva Sunken eyeballs Cracked and pale lips

no Sunken eyeballs

redness, Corneal light Lips pale and dry reflex shows equal

position of reflection Clear hearing, no

earaches, no infection and no discharges, no hearing aids No discharges,

absence of nosebleeds,
20

no sinus trouble Good condition of

teeth and gums, no bleeding, without use of dentures, mouth is moist, absence of sore tongue Absence of goiter,

pain, lumps, swollen glands and stiffness of the neck 3.Respiratory 16- 20 RR Tachypnea Clear and

Shortness of breath shallow breath Using of accessory muscles sounds No use of accessory muscles and quiet and effortless respiration 4.Cardiovascular HR 60-100 No visible apical impulse Tachycardia Low BP Nausea Weak but regular pulse BP 80/60

21

Normal capillary refill No cyanosis at extremities No dysrhythmia

dysrhythmia

HR 112, RR 24, T 36 C (Jan 23) Nausea Pallor at extremities (-) dysrhythmia

5.Gastrointestinal

Flat abdomen Normal bowel sounds (Presence of bowel

Vomiting Abdominal pain Anorexia

(+) Vomiting (+) Abdominal pain Hypoactive bowel sounds (2 times only in per min) Loss of appetite

sound in 4 quadrant515 per min) Absence of pain No palpable masses Good appetite

6.Genitourinary

No blood in urine

Hematuria Proteinuria

WBC 2-4 /HPF RBC 0-2 /HPF

7. Reproductive

No vaginal bleeding No abdominal or pelvic pain No palpable uterus and mass on either uterus or fallopian tube

Scant, dark brown vaginal bleeding Acute abdominal or pelvic pain

Moderate vaginal bleeding (+) Acute abdominal or pelvic pain

8.Musculoskeletal

No muscle atrophy

Weakness

Passive ROM

22

Full range of motion in activities

Fatigue Limited range of motion in activities

9.Neurologic

Conscious Alert and active (-) Lethargy

Unconscious Anxiety Vertigo (+)Lethargy

Conscious Coherent but weak voice Mild anxiety (+)Lethargy

10.Hematologic

Hemoglobin: 120-150 gm/L Hematocrit: 0.38-0.48 gm/L Erythrocyte: 4-6x10 12/L Leukocyte: 5-10x10 9/L Thrombocyte: 150350x10 9/L

Hypovolemic shock Low RBC, Hgb and hematocrit High WBC

Decrease RBC Result: L 3.74 10 12/l as of Jan-24-2012 (normal range: 4.00-6.00) Increase WBC Result: H 11.20 10 9/l (normal range: 5.0010.00) Low Hgb and hematocrit Result Hgb: L 105 g/l (normal

23

range 110-160) Hematocrit: L 0.33 L/l (normal range: 0.37-0.47) as of Jan-242012

References: Lippincott Manual of Nursing Practice (Ninth Edition) Brunner & Suddarths Handbook of Laboratory and Diagnostic Tests Maternal & Child Nursing Care (Third Edition) London, Ladewig, Ball, Bindler, Cowen

24

Chapter V The Management A. Diagnostic Test Result and Significance

Date A. Urinalysis January 23, 2012

Test Name

Result

Reference

Significance

Urine Pregnancy Positive Test

Positive (pregnant) Negative pregnancy)

12

weeks

of

pregnancy (LMP (no Nov. 1, 2011)

B.

Abdominal

ultrasound January 23, 2012 Ultrasound Confirming Pregnancy Test Right ampullary Normal Ectopic

of fallopian tube abdominal aorta, Pregnancy ruptured liver, gallbladder, bile pancreas, kidneys, ureters bladder uterus, and ducts,

25

C.Complete Blood Count January 23,2012 RBC Hematocrit Hemoglobin WBC Lymphocyte Monocyte Eosinophil Basophil MCV MCH MCHC Estimated Platelet January 24, 2012 Hemoglobin Hematocrit 105g/L 0.33 110-160 0.37-0.47 LOW LOW 3.74 10^12/L 0.24 L/L 82 g/L 11.20 10^g/L 0.37 0.03 0.03 0.00 87.7 28-1 pg 32-0 g/dl Normal NORMAL 4.00-6.00 0.37-0.47 110-160 5.00-10.00 0.25-0.35 0.03-0.07 0.01-0.03 0-0.-1 LOW LOW LOW HIGH

26

D. Blood Typing

January 23, 2012

Type of Blood

A (positive)

compatibility

Determine blood type

the of

expectant mothers and newborns in cases of blood

transfusion. E.Microbiology January 23, 2012 Epithelial cells: (10:03 PM) + Occasional The presence of

epithelial cells is epithelial cells is not remarkable not Large however, remarkable. numbers, are

abnormal and can conglomerate into tubular epithelial casts. These are most suggestive

of renal tubular disease toxicity. or

27

WBC

5-10/ LPF

When positive, it 0-4/ LPF (low indicates urinary power filed) tract infection

Gram bacilli

negative ++ With of Negative result, the doctor will be able to institute reasonable antiknowledge gram stain

biotic regimen. F.Parasitology Vaginal Mount January 23, 2012 WBC (09:18 PM) RBC Epithelial cells Bacteria Trichomonas 2-4/ HPF 0-2/ HPF ++ or clue ++ Non seen found slide. cells are vaginal on itching, No bacteria, trichomoniasis, yeast, A vaginal wet Wet

mount is done to find the cause of

the burning, rash, White odor, or discharge

28

Vaginalis Monilia

Non seen

blood cells are not very number. present low or in

G.Tissue Examination (Biopsy) January 24, 2012 Examine tissues Negative for disease Positive: tissue or the Normal cells Specimen: Right

have an unusual Fallopian Tube structure, shape, Gross: Specimen size,or condition. consists Negative: abnormality of an No enlarged fallopian tube measuring

6.0cm long and 2.3cm in greatest width. Section of the bulbous part shows blood clot. Micro: fallopian The tube

shows marked

29

dilatation. human immature chorionic villi.

The contains

Diagnosis: Tubal Pregnancy, Right

B. Therapeutic and Medical Interventions a. Surgeries/Treatment

Treatment 1.Intravenous Fluids Therapy

Procedure

Significance

Plain NSS, an isotonic solution, When fluid losses are severe or restores sodium chloride deficit the client cannot tolerate oral and extracellular fluid volume. Dextrose 5% in feeding, fluid volume is replaced

Lactated parenterally through intravenous

Ringer resembles the normal route. composition of blood serum plasma; K+ level below bodys daily requirement. This is a hypertonic solution. 2. Blood Transfusion: Packed RBC Before administering blood. To restore blood volume after severe hemorrhage and to restore

30

Verify that client has signed a

the capacity of blood to carry

blood administration consent oxygen and to increase the form Establish baseline data for vital signs, especially temperature, and assess skin for eruption or rashes. Check clients blood type clotting factors.

against the label on the whole blood or blood component prior to administration to ensure compatibility. i. Verify and record the blood product and identify the client with another nurse. ii. Identify clients name, blood group and RH type ii. Cross-match compatibility Cross matching serves as the final check for compatibility between a donors and a

recipients blood. Absence of agglutination indicates

31

compatibility

between

the

donors and the recipients blood Donor blood group and Rh Type Unit and hospital number Expiration date and time on blood bag Type of blood with product physicians

compared order

3.Salpingectomy (Right)

A surgical procedure where one To save the mother life and stop or both fallopian tubes are removed, leaving the ovary in place if not damaged. This operation is indicated for ruptured tube. Preoperative teaching. Keep the patients NPO after midnight on the day of the rest. Instruct the patient to void the haemorrhage.

32

before going to the operation because a distended bladder can be easily vital penetrated. signs and

Monitor

immediately report signs of developing shock 4.Foley Catheter Insertion To relieve discomfort due to To monitor an accurate bladder distention or to provide measurement of the patients

(Took out it on Jan 23- gradual decompression of a output Jan 25 at 6:30 AM) distended bladder. It is also used to empty the bladder completely prior to surgery. After surgery, it facilitates an accurate measurement of the patients output. This measure is also used as to manage well as

incontinence

continuous bladder irrigation

Aware for infection. Encourage the patient to drink large amount of fluids when not

33

contraindicated

to

facilitate

flushing of bladder. 5. Analgesics therapy Paracetamol (Biogesic) Ketorolac (Remopain) IV (Nonsteroidal anti-inflamm atory drugs (NSAIDs) Mefenamic Acid (Revalan) 6. Antibiotic therapy 7.Hormonal therapy Cefuroxime (Zegen) IV Nordette To control the infection Use as a immediate contraceptive medicine. 8. CNS depressant Nalbuphine To alter the CNS function so the patient can endure the pain To control the pain

b. Drugs i. y y y y Cefuroxime (Zegen) IV Order: Cefuroxime (Zegen) Action: Inhibits cell-wall synthesis, promoting osmotic instability; usually bactericidal Adverse Reaction: Diarrhea, nausea, vomiting, erythematous rashes, anaphylaxis, thrombocytopenia Nursing Responsibility
34

Determine patients allergy to penicillin or cephalosporins Obtain specimen for culture and sensitivity tests before giving first dose Reconstitute each 750-mg vial with 8ml and each 1.5-g vial with 16ml of sterile water for injection

Withdraw entire contents of vial for a dose For direct injections, inject over 3 to 5 minutes into a large vein or into tubing of a freeflowing IV solution

y -

Patient Teaching Tell patient to take medication exactly as prescribed, even after he feels better Instruct patient to take drugs with meal or milk to lessen GI comfort Tell patient to notify patient if rash occurs

ii. y y -

Mefenamic Acid (Revalan) Order: Mefenamic Acid (Revalan) Action: Relief of headache, migraine, traumatic, postpartum, post-op & dental pain. Pain & fever following various inflammatory conditions. Dysmenorrhea & menorrhagia accompanied by spasm or hypogastric pain.

y -

Adverse Reaction: GI effects; skin rashes, urticaria; headache, dizziness, depression; transient leukopenia, blurred vision, prolonged bleeding time.

y -

Nursing Responsibility Acute peptic ulcer;

35

y -

Asthma; epilepsy. Patient Teaching Should be taken with food (Take immediately after meals.).

iii. y y -

Paracetamol Order: Paracetamol (Biogesic) Action: Thought to produce analgesia by inhibiting prostaglandin and other substances that sensitize pain receptors. Drug may relieve fever through central action in the hypothalamic heat regulation center.

y y -

Adverse Reaction: Hematologic: hemolytic anemia, leukopenia, neutropenia, pancytopenia. Hepatic: jaundice Metabolic: hypoglycemia. Skin: rash, urticaria Nursing Responsibility Use cautiously in patients with any type of liver disease and for those who with long-term alcohol use because therapeutic doses cause hepatotoxicity in them.

Aware patients hypersensitive to drug.

36

Patient Teaching Tell patient that drug is only for short-term use and not to use for marked fever [temperature higher than 103.1 F (39.5 C)], fever persisting longer than 3 days or recurrent fever unless directed by prescriber. Warn patient that high doses or unsupervised long-term use can cause liver damage. Excessive alcoholuse may increase the risk of liver damage. Caution long-term alcoholics to limit drug to 2 g/day or less.

iv. y y -

Nordette Order: Nordette (Ethinyl estradiol and levonorgestrel) Action: Inhibit ovulation and may prevent transport of the ovum (if ovulation should occur) through the fallopian tubes.

Estrogen suppresses follicle-stimulating hormone, blocking follicular development and ovulation.

Progestin suppresses luteinizing hormone so that ovulation cant occur even if the follicle develops; it also thickens cervical mucus, interfering with sperm migration, and prevents implantation of the fertilized ovum.

y -

Adverse Reaction: CNS: headache, dizziness, depression, lethargy, migraine, stroke, cerebral hemorrhage. CV: thromboembolism, hypertension, edema, pulmonary embolism. EENT: worsening myopia or astigmatism, intolerance of contact lenses, exophthalmos, diplopia.

37

GI: nausea, vomiting, abdominal cramps, bloating, anorexia, changes in appetite, gallbladder disease, pancreatitis

GU: breakthrough bleeding, spotting, granulomatous colitis, dysmenorrhea, amenorrhea, cervical erosion or abnormal secretions, enlargement of uterine fibromas, vaginal candidiasis.

Hepatic: cholestatic jaundice, liver tumors, gallbladder disease. Metabolic: weight change, additive insulin resistance in diabetics. Skin: rash, acne, erythema multiforme, melisma, hirsutism Other: breast tenderness, enlargement, or secretion, anaphylaxis, hemolytic uremic syndrome.

y -

Nursing Responsibility Use cautiously in patients with any type of liver disease and for those who with long-term alcohol use because therapeutic doses cause hepatotoxicity in them.

y -

Aware patients hypersensitive to drug. Patient Teaching Tell patient that drug is only for short-term use and not to use for marked fever [temperature higher than 103.1 F (39.5 C)], fever persisting longer than 3 days or recurrent fever unless directed by prescriber.

Warn patient that high doses or unsupervised long-term use can cause liver damage. Excessive alcoholuse may increase the risk of liver damage. Caution long-term alcoholics to limit drug to 2 g/day or less.

38

v. y -

Ketorolac (Remopain) IV Action May inhibit prostaglandin synthesis, to produce anti-inflammatory, analgesic, and antipyretic effects y y Adverse Reaction Headache, dizziness, drowsiness, arrhythmias, edema, dyspepsia, nausea, renal failure Nursing Responsibility Correct hypovolemia before giving Oral therapy is only indicated as a continuation of IV/IM therapy. The maximum combined duration of parenteral and oral therapy is 5 days. Dont give drug epidurally or intrathecally because of alcohol content. Carefully observe patients with coagulopathies and those taking anticoagulants. Drug inhibits platelet aggregation and can prolong bleeding time. y NSAIDs may increase the risk of serious thrombotic events, MI, or stroke. Patient Teaching Warn patient that pain might occur in injection site Tell patient not to take drug for more than 5 days Teach patient signs and symptoms of GI bleeding, including blood in vomit, urine, or stool. Tell him to notify physician immediately

39

vi. y pain. y -

Nalbuphine Action Binds with opioid receptors in the CNS, altering perception of and emotional response to

Adverse Reaction Dizziness, headache, sedation, confusion, crying, unusual dreams bradycardia, blurred vision, dry mouth, respiratory depression, asthma

y -

Nursing Responsibility Reassess patients level of pain at least 15 to 30 minutes after administration For full analgesic effect, give drug before patient has intense pain. Monitor circulatory and respiratory status. Drug is indicated only for post-operative use if patient was receiving it before surgery or if pain is expected to persist for an extended time

For patients who are taking more than 60mg daily, stop drug gradually to prevent withdrawal symptoms

y -

Patient Teaching Instruct patient to take drug before intense pain Tell patient to take drug with milk or after eating Tell patient to swallow extended-release tablets whole Tell patient not to stop drug abruptly Inform patient to be cautious about getting out of bed or walking. For outpatient patients, warn them to avoid driving and other hazardous activities that require mental alertness until CNS effects are known.

40

vii. y -

Ranitidine (Ildecep) Action Completely inhibits action of histamine on the H2 receptor sites of parietal cells, decreasing gastric acid secretion.

y -

Adverse Reaction Headache, malaise, vertigo, blurred vision, jaundice, anaphylaxis, burning at injection site

y -

Nursing Responsibility Assess patient for abdominal pain. Note presence of blood in emesis, stool or gastric aspirate

y -

Drug may be added to total parenteral nutrition solutions Patient Teaching Instruct patient on proper use of OTC preparation, as indicated Remind patient to take once-daily prescription drug at bedtime for best results Instruct patient to take without regard to meals because absorption isnt affected by food. Urge patient to avoid cigarette smoking because this may increase gastric acid secretion and worsen disease.

viii. y y

Tranexamic Acid (Hemostan) Action A competitive inhibitor of plasminogen, which results in a prolonged thrombin time. Adverse Reaction

41

y y -

Abdominal Pain, anemia, arthralgia, headache, migraine, nasal sinus problem, fatigue Nursing Responsibility Patient Teaching Advise patient not to drive or operate machinery after receiving this drug. Instruct patient to report any visual abnormalities or vision changes. Advise patient not to use hormonal contraceptives while taking oral form of this drug Instruct patient to take missed drug as soon as possible, and then take the next dose at least 6 hours later. Patient should not take more than 2 tablets at a time to make up for missed doses.

ix. y y y y -

Kalium Durule Action Replaces potassium and maintains potassium serum level Adverse Reaction Nausea, vomiting, weakness, hyperkalemia, abdominal pain Nursing Responsibility Monitor ECG and electrolyte levels Monitor for renal function After surgery, dont give drug until urine flow is established Patient Teaching Teach patient signs and symptoms of hyperkalemia, and tell patient to notify physician immediately Tell patient to report discomfort at IV site

42

x. y y y y -

Ferrous Sulfate (Iburet) Action Provides elemental iron, an essential component in the formation of hemoglobin. Adverse Reaction Nausea, constipation, black stool, temporary stained teeth from liquid form Nursing Responsibility Monitor hemoglobin level and hematocrit during therapy GI upset may occur due to related dose Oral iron may turn stool black. This may mask melena. Patient Teaching Tell patient to take tablets with juice (preferably orange) but not milk or antacids. Instruct patient not to crush or chew extended-release form. Advise patient to report constipation and change in stool color or consistency

http://www.mims.com/Philippines/drug/info/Revalan/Revalan%20tab C. 1. Nurse Initiated Intertervention Nursing Care Plan

Problem #1: Post-operative Pain Subjective: Masakit ang hiwa ko lalo na pag gumagalaw at umiihi ako as verbalized by patient and the scale is 6/10 as reported by patient.

43

Objectives: Grimace when moving Guarding of the incision site Nursing diagnosis: Acute pain related to tissue damage 2 to surgical incision at right lower part of abdomen Rationale: Damage in tissue due to the surgical incision contributes to the release of prostaglandins thus making thus the patient experience pain. This pain is experienced by the patient in a duration of less than 6 months since the damage tissues will be repaired by the body followed by nutritional and pharmacological management. (Maternal & Child Health Nursing Care 6th Edition, Pillitteri) Expected outcomes NOC: Pain Control Short term: After 4 hours of nursing intervention the patient will be able to report decrease in pain scale from 6/10 to 1/10.

44

Long term: After 2 days of nursing intervention the patient will only have minimal pain scale of 1/10 as evidenced by patients performance of personal Activities of daily living with minimal assistance. Nursing interventions: NIC: Pain Management Independent: 1. Monitored vital signs and assessed the pain skill characteristics such as quality, severity,

location, onset, duration and relief factors. *it will help to evaluate the pain and they are the most first step in planning pain management. (Nursing Diagnosis Handbook 7th Edition)

2.

Made patient environment as comfortable as possible by giving assistance to the patient

to comfortable position (A semi-fowlers position is usually most comfortable, because the stress on the suture line is relieved). *will help the patient to alleviate the anxiety and pain. (Bruner and Suddharts Textbook of Medical and Surgical Nursing, 2009) 3. Offered and taught non-pharmacological pain interventions if desired (e.g back rub, music, splinting incision with pillow, rolling to side before rising from bed, etc). * will distract the pain perception and splinting and rolling will prevent traction on the incision site. (Rick Daniels, Fundamentals of Nursing)
45

4. Taught deep breathing exercise, one of the alternative coping mechanisms. *will help to alter the stress and anxiety which is caused by acute pain. (Rick Daniels, Fundamentals of Nursing) 5. Instructed the patient to report pain. *will give the relief measures may be instituted. (Nursing Diagnosis Handbook 7th Edition) 6. Guided imagery is a relaxation technique that relieves stress and creates a sense of peace and tranquility such as back rubbing, listening to music, reading some magazines & news papers, etc. *it helps you quiet your mind to allow you to relax so that your body may heal and be able to better cope with stressful situations, like surgery. It can also help you deal with pain, anger, depression (Nursing Diagnosis Handbook 7th Edition) 7. Encouraged the patient to do the Activities of daily living with minimal assistance (e.g eating food, changing clothes, going to the toilet, etc.). * will help the patient for building self-confidence. (Sharon L. Lewis, Medical and Surgical Nursing 6th Edition) Dependent: 1. Administered Mefenamic Acid (Revalan) 500 mg 1 tab every 6 hrs as ordered by the physician. (January 24, 2012) * to relieve the pain (Nursing 2012 Drug Handbook, 2012)

46

2. Administered Paracetamol (Biogesic) 500 mg 1 tab every 4 hrs as ordered by the physician. (January 26, 2012) * To relieve the pain (Nursing Diagnosis Handbook 7th Edition) Evaluation Short term Goal met: After 1 hrs of nursing interventions, the patient was able to report the pain skill went down from 6/10 to 1/10. Long term Goal met: After 2 days of nursing intervention the patient will only have minimal pain scale of 1/10 as evidenced by patients performance of personal Activities of daily living with minimal assistance. Problem #2: Presence of Operative Incision Subjective kumikirot yung tiyan ko, as verbalized by the patient. Objectives Presence of incision on right lower abdominal quadrant Nursing diagnosis: Impaired skin integrity r/t tissue damage secondary to surgical incision.

47

Rationale: Due to surgical procedure done that needs a surgical incision there will be presence of trauma in the area that signals an actual tissue damage and inflammation, this damage will cause inflammation of the nerves when the nerves are affected. (Medical-Surgical Nursing) Expected Outcomes NOC: Wound Healing Short term: After 30 minutes of nursing intervention the patient will be able to verbalize understanding of the importance of wound care and demonstrate behaviors/techniques to promote healing and prevent complications. Long term: Within 8 hours of nursing intervention the patients wound will be intact and free from purulent discharged. Nursing interventions: NIC: Incision Site Care Independent: 1. Assessed patient condition and monitor vital sign specially the temperature. * indicate to know the base line information, early recognition of developing infection enables rapid institution of treatment. (Ackley & Ladwig, 2007) 2. Assessed incision site for color, blister formaton; note drainage from donor site.

48

*color will be affected by availability of circulatory supply. Blister formation provides a site for bacterial growth/infection. (Ackley & Ladwig, 2007) 3. Provided patient health teaching about the important of wound care. *for effective wound healing. (Ackley & Ladwig, 2007) 4. Assisted in performing wound care. *to gain confidence and have therapeutic care (Luxner, 2005) 5. Encouraged her to eat a balanced diet rich in protein, Vit. C, and carbohydrate. * to promote easy healing of the wound.(Luxner, 2005) Dependent: 1. Administered Cefuroxime (Zegen) 500 mg 1 tab BID for 7 days as ordered by the physician.(January26, 2012) * Inhibits cell-wall synthesis, promoting osmotic instability; usually bactericidal. (Nursing 2012 Drug Handbook, 2012) Evaluation: Short term: Goal met! After 30 minutes of nursing intervention the patient will be able to verbalize understanding of the importance of wound care and demonstrate behaviors/techniques to promote healing and prevent complications such as cooperating in cleaning the wound.

49

Long term: Goal met. Within 8 hours of nursing intervention the patients wound was intact and free from purulent discharged as evidenced by absence of blisters, redness around the incision and absence of pus.

Problem #3: (-) BM for 3 days Subjective: 3 araw na akong hindi dumudumi as verbalized by patient. Objective: Hypoactive bowel sounds (2 times per minute: normal 5-15 per minute) (-)BM for 3 days Nursing diagnosis: Constipation r/t decreased motility of gastrointestinal tract secondary to insufficient physical activity. Rationale: After surgery, patients will have difficulty moving around. A movement is required for the wastes to pass through the system. Spending most of the time in bed reduces the bowel movements leading to constipation. (Lozeau & Potter, 2005).

50

Expected Outcomes: NOC: Bowel Elimination Short term: After 2 hours of nursing intervention the patient will be able to display active bowel sounds/ peristaltic activity. Long term: After 8 hours of nursing intervention the patient will be able defecate. Nursing interventions: NIC: Bowel Management Independent: 1. Assessed patient condition and monitor vital sign. *To indicate to know the base line information (Luxner, 2005) 2. Recorded frequency,characteristics, and amount of stool. *To helps identifying the degree of impairment or dysfunction and required level of assistance. (Ackley & Ladwig, 2006) 3. Assessed patients bowel sounds, noting location and characteristics. Note abdominal distention, presence of nausea/ vomiting. *indicators of presence/resolution of ileus, affecting choice of interventions. (Ackley & Ladwig, 2006) 4. Assisted client with sitting on edge of bed and walking.

51

*early ambulation helps intestinal function and return of peristalsis. (Ackley & Ladwig, 2006) 5. Encouraged adequate fluid intake, including fruit juices, when oral intake is resumed. * to promote softer stool; may aid in stimulating peristalsis. (Ackley & Ladwig, 2006) 6. Provided health teaching about foods that are rich in fibres such as papaya, beans, nuts, oats *for effective bowel management and easy defecation. (Ackley & Ladwig, 2006) 7. Provided for meticulous skin care *loss of sphincter control and innervaton in the area potential risk of skin irritation and breakdown. (Luxner, 2005) Dependent: 1. Administer Colace (generic name: docusate sodium) capsule 50-250 mg (2 times a day onset 1-3 days) as order by the doctor. 2. Administer Surfak (generic name: docusate calcium) capsule 240 mg (2 times a day onset 1-3 days) as order by the doctor. * both of them will help to encourage for bowel movement (Nurses Drug Guide, 2004) Evaluation: Short term: Goal met: After 4 hrs of nursing interventions, the patient was able to display active bowel sounds/ peristaltic activity. Long term: Goal not met: After 8 hrs of nursing intervention, the patient was not able to defecate.

52

Problem #4: Weakness Subjective: Nang Hihina talaga ako, parang lantang lanta ang katawan ko as verbalized by patient. Objectives: Hgb L 105 g/l (110-160) as of Jan -24-2012 (Hgb L 82 g/l (110-160) as of Jan-23-2012) Potassium L 3.5 mmol/L (3.6 5.0) as of Jan-24-2012 Drowsy, Dry and pale lips Need nurse/family assistance when she change clothes or move Inability to restore energy even after sleep Consumed of served food Nursing diagnosis: Activity Intolerance related to imbalance oxygen supply and demand secondary to low amount of hemoglobin Rationale: Due to blood loss, hemoglobin level goes down and also the amount of oxygen in the blood is decreased. So, it will give the result of decreasing energy and fatigue (Kozier,2008: 1262, Kozier,2001:1029)

53

Expected outcomes: NOC: Endurance Short term: After 20 minutes of health teaching the patient will be able to verbalize two effective ways to conserve energy Long term: After 2 days of nursing intervention the patient will be able to improve the energy level as evidenced by tolerance of activities of daily living, with minimal assistance. Nursing interventions: NIC: Energy Management Independent: 1. Assessed patient condition and monitor vital sign. * will indicate to know the base line information. (Nursing Diagnosis Handbook 7th Edition) 2. Provided quiet and safe environment. * will help the patient to maintain the energy restored sleeping pattern. (Delmars MaternityInfant Nursing Care: Second Edition) 3. Encouraged the patient to perform daily livings activities without assistance.

54

* will help the patient to bring back the self- confidence on her. (Delmars Maternity-Infant Nursing Care: Second Edition) 4. Provided health teaching regarding the importance of protein and iron intake. * will help the patient to enhance her hemoglobin level and Immune System. ( Lowdermilk & Perry: Sixth Edition of Maternity Nursing) 5. Encouraged to eat energy-giving foods * will help the patient to get the nourishment that the body required. ( Lowdermilk & Perry: Sixth Edition of Maternity Nursing) Dependent: 1. Administered FeSO4 (Iberet) 1 tab TID x 2 weeks (started at Jan 24 2012)as ordered by the doctor. * Because it is also an essential component in the formation of hemoglobin (Sharon L. Lewis Medical and Surgical Nursing : Sixth Edition) 2. Administered 2 'u' PRBC (started at 10:15pm on Jan 23 2012 ) as ordered by the doctor. * To maintain the level of red blood cells in the body. (Sharon L. Lewis Medical and Surgical Nursing : Sixth Edition) 3. Administered Kalium Durule 1 tab TID x 4 days (started at Jan 24 2012) as ordered by the doctor.

55

* to maintain potassium serum level in the blood for preventing the muscles cramping. (Sharon L. Lewis Medical and Surgical Nursing : Sixth Edition) Evaluation: Short term: Goal met: After 20 minutes of health teaching the patient was able to verbalize two effective ways to conserve energy by increasing intake of food rich in protein and by maintaining the regular sleeping pattern. Long term: Goal met: After 2 days of nursing intervention the patient was able to improve the energy level as evidenced by tolerance of activities of daily living, with minimal assistance. Problem #5: Grieving Subjective: I hope that I will have more baby in the future as verbalized by patient. Objectives: Mild anxiety She was irritable while she was asked about the history of her pregnancy Facial flushing when she saw the other infants Nursing diagnosis: Anticipatory grieving related to loss of pregnancy and threat to fertility.

56

Rationale: As being loss of the current pregnancy, the patient will experience sad, grieve, agony, guilt, fear of unspecified consequences depression related to loss of her pregnancy. They are also faced with the possibility of future pregnancy losses or infertility because of the increased risk for recurrent ectopic pregnancy. ( Lowdermilk & Perry: Sixth Edition of Maternity Nursing) Expected outcomes: NOC: Coping Short term: After 20 minutes of health teaching the patient will be able to identify at least two complications in ectopic pregnancy (e.g. bleeding, pain and infertility, etc.) Long term: After 8 hours of nursing intervention the patient will be able to verbalize feelings about her present condition Nursing interventions: NIC: Grief work facilitation Independent: 1. Taught the patient how to minimize the risk of ectopic pregnancy such as seeking prompt

treatment for genital infections and PID. ( Diagnosis on Jan-23-2012) * will help the patient to understand how to decrease the risk of a future ectopic pregnancy. ( Lowdermilk & Perry: Sixth Edition of Maternity Nursing)
57

2. Provided the information about the possibility of her future pregnancy with a clear forthright manner. *will give the knowledge about her present condition and can help the patient begin the grieving process. (Nursing Diagnosis Handbook 7th Edition) 3. Encouraged client for verbalization of feelings & concerns of her present situation. * will help to relieve and alleviate her grief. (Nursing Diagnosis Handbook 7th Edition) 4. Maintained a clam, supportive, confidence and nonjudgmental manner while interacting with the patient. * will help to facilitate the development of trust. (Delmars Maternal-Infant Nursing Care: Second Edition) 5. Accepted the patient's emotional response, and allowed her to cope in the manner she has established for herself. *Because ectopic pregnancy may result from an STD and resulting PID, the patient may perceive it as a punishment for dysfunctional relationships or sexual indiscretions. (Delmars Maternal-Infant Nursing Care: Second Edition) 6. Allowed the significant persons or family member to visit frequently. * will provide the patient to feel a sense of security and reduce her grief. (Delmars MaternalInfant Nursing Care: Second Edition) 7. Provided a quiet, safe and restful environment. * will give a sense of security and help to decrease a sense of irritability also (Nursing Diagnosis Handbook 7th Edition)

58

8. Encouraged the client to follow comforting grief rituals such as interacting with nature, prayer, or whatever ritual brings spiritual comfort in dealing with the loss. *will help the patient to relieve her grief. (Nursing Diagnosis Handbook 7th Edition) 9. Offered a Prayer. * it will help the patient to relieve her grief and strengthen her feelings. Collaborative: 1. Family supporting *will provide the patient to feel a sense of security and reduce her grief. (Delmars MaternalInfant Nursing Care: Second Edition) 2. Referred the patient for spiritual counseling if desired because the people who has stronger spiritual beliefs seemed. * to resolve their grief more rapidly than the ones with no spiritual beliefs (Delmars MaternalInfant Nursing Care: Second Edition) Evaluation: Short term: Goal met: After 20 minutes of health teaching the patient was able to identify at least two complications in ectopic pregnancy (e.g bleeding, pain and infertility, etc.)

59

Long term: Goal met: After 8 hours of nursing intervention the patient was able to verbalize feelings about her present condition. Problem #6: Dizziness upon moving Subjective : Nanghihina ako as verbalized by patient. Objectives: Hgb L105 g/l (110-160) as of Jan -24-2012 (Hgb L 82 g/l (110-160) as of Jan-23-2012) Pale palpebral conjunctiva Nursing diagnosis: Risk for injury r/t body weakness secondary to low hemoglobin count. Rationale: Because of the lack of oxygen going to the brain, people with low hemoglobin often complain of headaches. Dizziness may occur when rising from a chair quickly, move side to side and they may faint if standing for long periods. (National Heart Lung and Blood Institute) Expected outcomes: NOC: Safety Behavior Personal Short term: After 30 minutes of nursing intervention the patient will be able to verbalize at least 2 ways to prevent injury.
60

Long term: Within 8 hours of nursing intervention the patient will be free from injury Nursing interventions: NIC: Safety Surveillance Independent: 1. Assessed patient condition and monitor vital sign will indicate. * to know the base line information (Luxner, 2005) 2. Assisted patient in performing of activity of daily livings. *help to improve confidence (Luxner, 2005) 3. Provided health teaching such as using the call light to ask for assistance. *to prevent injury (Luxner, 2005) 4. When stands up do it slowly, sit first then dangle feel then stand. *to prevent orthostatis hypotension (Luxner, 2005) Dependent: 1. Administered FeSO4 (Iberet) 1 tab TID x 2 weeks (started at Jan 24 2012) as ordered by the doctor. *Provides elemental iron, an essential component in the formation of hemoglobin. (Nursing 2012 Drug Handbook, 2012) Evaluation: Short term:
61

Goal met: After 30 minutes of nursing interventions, the patient was able to verbalize at least 2 ways to prevent injury such as using call light and having assistance when going to the bathroom. Long term: Goal met: Within 8 hours of nursing intervention, the patient was able to free from injury. 2. DISCHARGE PLAN (M.E.T.H.O.D.)

Medication y Instruct client to continue take her prescribed medications such as: Medicine Name Cefuroxime (500) g Paracetamole (500)g FeSO4 Kalum Durule Nordette Dosage 1 cap 1 tab 1 tab 1 tab 1 tab Frequent 2 x a day every 4 hrs (for pain) 2 x a day 3 x a day Once a day Time 8 am-8pm (7 days)

For 1 month

Orient the client about the name of drugs, their actions, the exact dosage, the frequency and the route of administration.

y y y

Instruct client to follow the instruction when administering medication. Advice the significant others not to leave the client during medication Explain to the client the side effects and adverse effects of the drugs she takes by prescribing its manifestations.

Advice client not to stop intake of prescribed medications, unless approved by the physician.

62

Exercise y y y y Instruct client to balance activities with adequate rest periods. Educate client on proper body mechanics to prevent muscle strain and enable client to relax. Encourage client to ambulate and assume normal Encourage deep breathing exercise

Treatment y y Educate client the importance of drug compliance. Discuss to the client the complication of the condition because knowledge about the condition supports learning that will decrease deficit and anxiety. y To promote healing, eat a balanced diet rich in fresh fruits and vegetables.

Hygiene y y y Keep your incision sites clean and dry. Encourage client to do daily hygiene Encourage client to ask assistance if needed Outpatient orders Call the doctor if any of the following occurs: y y y y y Develop a fever. Become dizzy and faint. Experience nausea and vomiting. Become short of breath. Have heavy bleeding.
63

y y y

Have leakage from the incision or the incision opens up. Have pain when you urinate. Have questions about the procedure or its result. Diet

To promote healing, eat a balanced diet rich in fresh fruits and vegetables. Depending on how much blood loss occurred during surgery, you may require a daily iron supplement.

y y

Eat high-fiber foods, drink plenty of water, and if necessary, use stool softeners. Instruct client to eat foods that are high in protein and vitamins and minerals.

64

CHAPTER VI GENERAL EVALUATION OF THE STUDY a. Summary Ectopic pregnancy is the leading cause of pregnancy-related death during the first trimester. Ectopic pregnancy is an abnormal pregnancy that occurs outside the womb. It happens when the fertilized egg attaches itself in a place other than inside the uterus. It is often caused by a condition that blocks or slows the movement of a fertilized egg through the fallopian tube to the uterus. Most of the series of ectopic pregnancies have a reasonable proportion of patients who have used or are using an intrauterine device (IUD). Pelvic inflammatory disease (PID) is widely accepted source in the massive increase of occurrence of ectopic pregnancy. It is also universally accepted as the major causative factor for ectopic pregnancies. Ultrasound is the most comfortable diagnosis to identify the ectopic pregnancy with an accuracy of 79% - 94%. As the pregnancy grows, it can cause the tube to rupture, if this occurs, it can cause major internal bleeding. This can be life threatening and needs to be treated with surgery: salpingectomy and salpingotomy. More research is still need to determine the etiology of ectopic pregnancy as well as the ways to prevent and treat PID. All physicians must realize the seriousness of ectopic pregnancy and must offer the patient the means for prevention and the optimum therapy for preserving fertility.

65

b.

Recommendation

This case study has provided the proponents with important information about the patients disease. In order to ensure that optimal health is restored and maintained, the group would like to recommend the following. To the Patient whenever there is, the onset of a certain disease it implies one to contribute her cooperation and willingness to be responsible for her own health. The patient must be sensitive of her own needs and be able to expect liability for her actions. She is also encouraged to verbalize her own thoughts and feelings concerning how she perceives her condition affect her life and her expected duration of her recovery. She is advised to take part in complying with therapeutic regimen designed for her recovery. She should realize the importance of complying with her medication and the benefits this practice would bring to the improvement of her wellbeing. Moreover, she must not hesitate on seeking medical assistance whenever she feels signs and symptoms, which may be due to other health illness. To the patients family, the patients family plays an important role in the patients illness and recovery. The family should make they physically present so that the patient would somehow feel their support and concern. They are encouraged to be the patients source of strength and inspiration as she undergoes painful, traumatic and harrowing procedures. In addition, it is of prime importance that they are oriented and educated basic facts regarding the patients condition so that they will understand her even better and assist her in her daily activities. To the Clinical Instructors, we would like to encourage each one of you to continue improving the standards of the AUP Nursing Curriculum by providing quality education to students. Also they, themselves, must be well-trained to delegate learning to student nurses. It is

66

important that they continue to inspire generations of today to perceive nursing as a gift and act of charity rather than a mere means to success. To our fellow nursing students, this case study would help us better understand the patients condition. What is entrusted to student nurses is the life of their patient. Even with the clinical instructors presence, they can still make mistakes and errors, which can harm the patient. Hence, they are encouraged to equip themselves with necessary knowledge that will enable them to render quality and holistic nursing care and intervention to patients in need. It is known that nurses play a major role in helping the client and family implement healthy behaviours and help them monitor the clients health. Thus, anticipatory guidance and knowledge about health should be supplied to help clients attain, maintain, or regain an optimal level of health. Student nurses should prioritize interaction with family members and significant others to provide support, information, and comfort in addition to caring for the patient. Thus, they should prepare themselves with the reality that they are soon to become health professionals. Genuineness, empathy, and respect are key elements for the nurse to possess. Student Nurses must develop patience, love for our work, and empathy to our patients. They must assist in facilitating a remarkable experience as well as share our knowledge regarding the case. They must also continue to study different cases and be able to impart this to other student nurses, patients and their significant others.

67

CHAPTER VII BIBLIOGRAPHY Richard E. Jones and Kristin H. Lopez (2006) Human Reproductive Biology, Third Edition, Elsevier, Gerald J. Tortora & Bryan H. Derrickson. (2009) Principles of Anatomy and Physiology, 12th Edition Vol. 2 John Wiley & Sons, (Asia) Pte. Ltd Nursing 2012 Drug Handbook. (2012). Lippincott Williams & Wilkins. Pilliteri, A. (2010). Maternal & Child Health Nursing: Care of the Childbearing & Childrearing Family. Philadelphia: Lippincott Williams & Wilkins. Daniels, R., Grendell, R. N., & Wilkins, F. R. (2010). Fundamentals of Nursing: Nursing Foundations Vol. 1. Philippines: Cengage Learning. Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H. (2009). Brunner and Suddhart's Textbook of Medical-Surgical Nursing. Lippincott Williams & Wilkins. Ackley, B. J., & Ladwig, G. B. (2006). Nursing Diagnosis Handbook: a guide to planning care. Philippines: Mosby Elsevier. Arenson, J., & Drakee, P. (2007). Maternal and Newborn Health. Philippines: Jones and Barlett Publishers, Inc. Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2010). Nurse's Pocket Guide Diagnoses, Prioritized Interventions, and Rationales 12th edition. Philadelphia, Pennsylavnia: F. A. Davis Company..

68

Kozier, B., Erb, G., Berman, A., & Snyder, S. J. (2004). Fundamentals of Nursing 7th edition. Philippines: Pearson Education South Asia Pte Ltd. Luxner, K. L. (2005). Delmar's Maternal-Infant Nursing Care Plans. Thomas Learning. Murray, S. S., & McKINNEY, E. S. (2010). Foundations of Maternal-Newborn and Women's Health Nursing. Missouri: Saunders Elsevier. Nursing 2012 Drug Handbook. (2012). Lippincott Williams & Wilkins. Pilliteri, A. (2010). Maternal & Child Health Nursing: Care of the Childbearing & Childrearing Family. Philadelphia: Lippincott Williams & Wilkins. Tate, P. (2009). Seeley's Principles of Anatomy and Physiology. New York: McGraw-Hill Companies, Inc. Tortora, Gerard, J., & Derrickson, B. (2007). Anatomy and Physiology. Lippincott Manual of Nursing Practice (Ninth Edition) Brunner & Suddarths Handbook of Laboratory and Diagnostic Tests Ladewig, Ball, Bindler, Cowen Maternal & Child Nursing Care (Third Edition) London

69