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INTRODUCTION
Ectopic Pregnancy is a complication of pregnancy in which the pregnancy implants outside the
uterine cavity. With rare exceptions, ectopic pregnancies are not viable. Furthermore, they are dangerous
for the mother, internal bleeding being a common complication. Most ectopic pregnancies occur in the
Fallopian tube , but implantation can also occur in the cervix, ovaries, and abdomen. An ectopic pregnancy
is a potential medical emergency, and, if not treated properly, can lead to death.
II. OBJECTIVES
Specific
1.) We will have better understanding of ectopic pregnancy by reading books, articles and journals
that are related with the disease;
2.) Understand clearly the pathophysiology of the disease, risk factors, manifestations and
treatment and modalities of the disease; and
3.) Equip ourselves with skills and health teachings that are appropriate for the care of patients
with ectopic pregnancy.
Mrs. A. has no previous medical problem and never hospitalized due to serious illness. Mrs. A. had her
first pregnancy last 2000 and delivered a live full term baby girl via normal spontaneous delivery. On her
second pregnancy last 2001, she had an incomplete abortion and undergo Dilation and Curettage.
Mrs. A. is a G3P1 (1011) 9 3/7 weeks AOG with chief complaint of hypogastric pain and vaginal
bleeding.
On October 14, Mrs. A experienced vaginal spotting that lasted for 3 days so she decided to went to
her doctor for a consult and advised her to undergo trans-vaginal ultrasound. The UTZ revealed no
intrauterine, no extrauterine pregnancy with thin endometrium. She had her pregnancy test and revealed
positive with increase HCG level and advised her to take Duphaston three times a day.
One day prior to hospitalization, the patient experienced hypogastric pain and cramping and non-
radiating with increase amount of vaginal bleeding that consumed 2 pads per day with minimal to
moderately soaked.
C. Family History
Mrs. A. had a familial history of hypertension on her father side. No known history of cancer, asthma,
diabetes mellitus and thyroid disease.
V. PHYSICAL ASSESSMENT
5. Verbal Behavior >Can communicate well >Can communicate well and >Normal
and express her express her feelings.
feelings.
6. Non-verbal >Actions coordinate >Seen to be always on deep >There are wider
Behavior with the mood of the thought; Flat affect; Biting of variations in non verbal
client. lower lips; Diaphoresis; response to pain. For
Sighing; Facial grimace many patients, nonverbal
expressions may be the
only means of
communicating pain.
Facial expressions are
often the first indication of
pain.
7. Physiologic Cues T = 35.8°C - 37°C T: 36.8 ˚C >Physiologic responses
PR = 60 -100bpm P: 87 vary with the origin and
RR = 12 - 20bpm R: 19 duration of the pain. Early
BP = SP (100 – BP: 120 / 80 in the onset of acute pain,
140mmHg) the sympathetic nervous
DP (60 – 90mmHg) system is stimulated
resulting in increase BP,
PR, and RR.
Pain Assessment
PQRST Mnemonic
P – Provocation and NT: “Ano’ng nagpapagaan P: “Pag humihinga ako Effective pain
Palliation at nagpapalala nito?” ng malalim medyo management requires
nawawala.” careful assessment and
P: “Lalong sumasakit regular review of pain.
kapag gumagalaw ako” Pain is a subjective
Q – Quality and NT: “Maaari nyo po bang P: “Una nagsimuLa ditto symptom. Pain
Quantity idescribe iyong pain na sa may bandang taas assessment tools are
nararamdaman ninyo?” tapos pababa sa may therefore based on the
tagiliran” patient’s own perception
NT: “San po masakit?” of their pain and its
R – Region and P: “Dito.” (Pointing at severity. Pain
Radiation NT: “Gaano po kasakit? left lower quadrant) assessment involves
from the rate po of 1-10, 1 P: “Mga 7”. initial, detailed
S – Severity and Scale po as no pain and 10 as the evaluation of each type
most painful.” of pain, and regular
reassessment of severity
NP:”Kelan po sya P: “Sumasakit kapag and response to
T – Timing and Type sumasakit?” gumagalaw ako.” treatment.
of Onset
Reference:
http://www.caresearch.c
om.au/caresearch/Clinica
lPractice/Physical/Pain/As
sessmentTools/tabid/748
/Default.aspx
INTERNAL GENITALIA
a. Fallopian tube/Oviduct – 4 inches long from each side of the uterus (fundus). Ittransports the
mature ova form the ovaries to the uterus and provide a place for fertilization of the ova by the
sperm in its outer 3rd or outer half.
Parts:
Interstitial – lies within the uterine wall
Isthmus – portion that is cut or sealed in a tubal ligation.
Ampulla – widest, longest portion that spreads into fingerlike projections/fimbriae and it is
where fertilization usually occurs.
Infundibulum - rim of the funnel covered by fimbriated cells (hair covered fingerlike
projections) that help to guide the ova into the fallopian tube.
b. Ovaries – Oval, almond sized, dull white sex glands on either side of the uterus that measures 4 by
2 cm in diameter and 1.5 cm thick. It is responsible for the production, maturation and discharge of
ova and secretion of estrogen and progesterone.
c. Uterus – hollow, pear-shaped muscular organ, 3 inches long, 2 inches wide, weighing 50-60 grams
held in place by broad and round ligaments, and abundant blood supply from the uterine and
ovarian arteries. It is located in the lower pelvis, posterior to the bladder and anterior to the rectum.
Organ of menstruation, site of implantation and provide nourishment to the products of conception.
Layers:
1. Perimetrium – outermost layer of the uterus comprised of connective tissue, it offers added
strength and support to the structure.
2. Myometrium – middle layer, comprised of smooth muscles running in 3 directions; expels fetus
during birth process then contracts around blood vessels to prevent hemorrhage.
3. Endometrium – Inner layer which is visibly vascular and is shed during menstruation and
following delivery.
Divisions of the Uterus:
1. Fundus – upper rounded, dome-shaped portion that can be palpated to determine uterine growth
during pregnancy and the force of contractions and for the assessment that the uterus is returning to
its non-pregnant state following child birth.
2. Corpus – body of the uterus.
3. Isthmus – area between corpus and cervix which forms part of the lower uterine segment. It
enlarges greatly to aid in accommodating the fetus. The portion that is cut when a fetus is delivered
by a caesarian section.
4. Cervix – lower cylindrical portion that represents 1/3 of the total uterus. Half of it lies above the
vagina; half of it extends to the vagina. The cavity is termed the cervical canal. It has 2 openings/Os:
internal os that open to the uterine cavity and the external os that opens to the vagina.
5. Vagina – a 3-4 inch long dilatable canal located between the bladder and the rectum, it contains
rugnae which permit considerable stretching without tearing. It acts as an organ of
intercourse/copulation and passageway for menstrual discharges and fetus. Doderlein’s bacillus is the
normal flora of the vagina which makes the pH of vagina acidic, detrimental to the growth of
pathologic bacteria.
EXTERNAL GENITALIA
a. Mons Veneris/Pubis – Pad of fat which lies over the symphysis pubis where dark and curly hair
grows in triangular shape that begins 1-2 years before the onset of menstruation. It protects the
surrounding delicate tissues from trauma.
b. Labia Majora – Two (2) lengthwise fatty folds of skin extending from mons veneris to the perineum
that protects the labia minora, urinary meatus and vaginal orifice.
c. Labia Minora – 2 thinner, lengthwise folds of hairless skin extending from clitoris to fourchette.
Glands in the labia minora lubricates the vulva
Very sensitive because of rich nerve supply
Space between the labia is called the Vestibule
d. Clitoris – small, erectile structure at the anterior junction of the labia minora that contains more
nerve endings. It is very sensitive to temperature and touch, and secretes a fatty substance called
Smegma. It is comparable to the penis in its being extremely sensitive.
e. Vestibule – the flattened smooth surface inside the labia. It encloses the openings of the urethra
and vagina.
f. Skene’s Glands/Paraurethral Glands – located just lateral to the urinary meatus on both sides.
Secretion helps lubricate the external genital during coitus.
g. Bartholin’s Gland/Vulvovaginal Glands – located lateral to the vaginal opening on both sides. It
lubricates the external vulva during coitus and the alkaline pH of their secretion helps to improve
sperm survival in the vagina.
h. Fourchette – thin fold of tissue formed by the merging of the labia majora and labia minora below
the vaginal orifice.
i. Perineum – muscular, skin-covered space between the vaginal opening and the anus. It is easily
stretched during childbirth to allow enlargement of vagina and passage of the fetal head. It
contains the muscles (pubococcygeal and levator ani) which support the pelvic organs, the arteries
that supply blood and the pudendal nerves which are important during delivery under anesthesia.
j. Urethral meatus – external opening of the urethra. It contains the openings of the Skene’s glands
which are often involved in the infections of the external genitalia.
k. Vaginal Orifice/Introitus – external opening of the vagina, covered by a thin membrane
called Hymen.
VII. PATHOPHYSIOLOGY
Fertilized Egg
Etiology
- Age
- Sex
Erosive action of villous trophoblast causes penetration of the tubal wall which may
extent to the peritoneal
Invasion of blood vessels causes bleeding into the lumen, tubal wall or
Uninterrupted invasion of
trophoblastic tissue or
tearing
of extremely stretched
Treatment/Management:
Rupture/Tubal
* Salphingectomy to remove
Rupture
affected
Vaginal tube and control bleeding
spotting * Salphingoophorectomy
(removal of
tube with adjacent ovary)
* Management of shock
Sharp abdominal * Methotrexate
pain. * Constant hCG monitoring
VIII. DIAGNOSTICS AND LABORATORIES
CBC
Test Oct. 23 Oct. 24 Reference Values
Hemoglobin 10.8 12.3 12:00 – 15.00 g/dL
Hematocrit 33.0 38 36.00 – 46.00 %
RBC Count 3.68 4.23 4.00 – 4.50 x 10^ 6/L
MCV 89.7 89 80.00 – 100.00 fl
MCH 29.3 29 27.00 – 31.00 pg
MCHC 32.7 33 32.00 – 36.00 %
Platelets 212 217 150.00 – 400.00 x 10^
3/L
WBC Count 6.63 9.7 4.50 – 11.00 x 10^ 3/L
Eosinophil 1 1 1.00 – 4.00 %
Neutrophil 60 66 36.00 – 66.00 %
Lymphocyte 32 23 22.00 – 40.00 %
Monocyte 8 10 4.00 – 8.00 %
RDW 12.7 12.8 8.50 – 15.00
Medical
Early treatment of an ectopic pregnancy with methotrexate is a viable alternative to surgical
treatment. If administered early in the pregnancy, methotrexate terminates the growth of the
developing embryo; this may cause an abortion, or the tissue may then be either resorbed by the
woman's body or pass with a menstrual period.
Surgical
Surgeons use laparoscopy or laparotomy to gain access to the pelvis and can either incise
the affected Fallopian and remove only the pregnancy (salpingostomy) or remove the affected tube
with the pregnancy (salpingectomy).
Pre-operatively
Intra-operatively
Post-operatively
Pain related to post-op surgery 3 A state in which an individual experiences and reports the presence of
severe discomfort or an uncomfortable sensation
Pre-operatively
CUES NURSING GOAL and NURSING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS OBJECTIVE
Subjective Acute pain Goal Independent
“Masakit ang related to After 8 hours of Perform assessment of pain To assess factors that After 8 hours of
tiyan ko as rupture of nursing to include location, precipitates and contributes to nursing intervention,
verbalized fallopian intervention the characteristics, onset, the pain sensation and to the patient was able
by the tube patient will be duration, frequency, quality indicate the appropriate choice to report pain
patient” able to report and severity. of treatment. relief/control as
pain relief/control evidenced by no
Objective as evidenced by Monitor maternal vital To determine presence of guarding behavior
• Facial no guarding signs. hypotension and tachycardia and absence of facial
mask of behavior and caused by rupture of mask of pain.
pain absence of facial hemorrhage.
• Guarding mask of pain. After 30 minutes of
behavior Monitor for presence and To further assess the present nursing intervention,
• Pain Objective amount of vaginal bleeding situation indicating the patient was able
scale of 7 After 30 minutes hemorrhage to report reduction of
(1 as no of nursing pain from 7 to 4 of
Monitor for increase pain
pain 10 intervention, the Indicates rupture and possible pain scale as
and abdominal distention
as worst patient will report intra-abdominal hemorrhage. evidenced by less
and rigidity
pain) reduction of pain facial grimace.
from 7 to 4 of
Monitor CBC To determine the amount of
pain scale. blood loss.
Provide diversional
activities. Aids in refocusing attention and
enhancing coping with
Dependent limitation.
Administer medications as
indicated. To maintain acceptable level of
pain.
Collaborative
Laboratory as indicated.
May be given
prophylactically for
suspected infection or
contamination
Post-operatively
CUES NURSING OBJECTIVE and NURSING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSI GOAL
S
Subjective: Grieving, Goal: Independent
“Nawala ulit dysfunction After the end of Identify(be aware of) To assess contributing After 8 hours of
ang baby al related to nursing care the stage of grief being /causative factors that nursing
ko.” perceived patient will be able to expressed: Bargaining, precipitates/contributes grief intervention the
“Excited pa loss of a demonstrate progress Anger, Denial, and to indicate the appropriate patient is able to
naman ang child in dealing with stages Depression, Acceptance choice of therapeutic verbalizes a sense
anak ko na of grief at own pace. communication of progress toward
magkaroon Be aware of avoidance resolution of the
ng kapatid.” After 8 hours of behaviors (anger, grief and hope for
nursing intervention withdrawal) the future
Objective: the patient will be able
Crying to verbalize a sense of Identify factors and ways To further assess the present
Difficulty progress toward individual has dealt with situation
in resolution of the grief previous loss(es)
expressi and hope for the
ng loss future. Encourage verbalization
Labile without confrontation Assist patient to deal
affect about realities appropriately with loss. Helpful
in beginning resolution and
Encourage patient to talk acceptance
about what the patient
chooses and do not try to
force the patient to face
the fact
Acknowledge reality of
feelings of guilt and
assist patient to take
steps toward resolution
Patients who have received spinal anesthesia may experience nausea and occasionally, vomiting. It is
therefore preferable to instruct the patient to eat a bland light meal or a liquid diet once fully awake
after surgery. Regular diet may be resumed the next day. Also, pain medication may cause nausea if
taken on an empty stomach. It would be better to take that medication with a piece of toast or some
food.
To help to avoid constipation and promote healing eat fruits and vegetables and drink 6 to 8 glasses of
water each day, stool softeners or mild laxative may be needed if no positive bowel movement within
3 days after surgery as prescribed by the doctor.
Patient should void spontaneously within 6 to 8 hours after catheter is removed. Normal bowel function
should return by third or fourth post op day.
Instructed the patient of no heavy lifting while in recovery from surgery, must not lift weights over 15
pounds, heavy lifting puts too much strain on lower abdomen and abdominal muscle may rupture,
heavy lifting may pop the stitches in incision site.
Walk or move legs as much as possible, to prevent blood clots and gradually resume normal activity.
Support abdomen when coughing, turning and deep breathing. Place a pillow over abdomen and apply
pressure on it to support and minimize pain.
Medications compliance was instructed, teach patient and family to care for the wound and perform
dressing changes and irrigations as prescribed.
Antibiotic is usually prescribed for seven to ten days following surgery. Instruct to take them as
ordered.
Remind to keep the incision clean and dry during first week after surgery to prevent infection.
Instruct the patient that she may shower after removal of dressing; wash it with soap and water then
pat dry and instruct not to use oils and lotion over incision area.
Instruct the patient to have slowly increase activities. Begin with light chores, short walks.
Instruct the patient to avoid excessive stair climbing for two weeks after the surgery.
Refer for home care nursing as indicated to assist with care and continued monitoring of complications
and wound healing.
Reinforce need for follow-up appointment with the surgeon one week after the discharge
Instruct the patient not to engage in strenuous exercise or resume sexual intercourse until check up
with the doctor.
XIII. BIBLIOGRAPHY
• http://en.wikipedia.org/wiki/Ectopic_pregnancy
• http://www.ispub.com/ostia/index.php?xmlFilePath=journals/ijgo/vol6n2/ectopic.xml
• http://www.google.com.ph/#hl=tl&source=hp&biw=1264&bih=541&q=medical+and+surgical+ma
nagement+on+patient+with
• Fundamentals of Nursing: Concepts, Process and Practice. 7th Edition.. Upper Saddle River, New
Jersey: Pearson Education Inc.)
• http://international.drugstore.com/default.asp
• Maternal and Child Health Nursing: Care of the Childbearing and Childrearing Family volume 1 5th
edition. By Adele Pilliteri
• Foundation of Maternal- Newborn Nursing 4th edition. By Sharon Smith Murray, Emily Stone Mc
Kinney
• Maternal and Child Nursing Care 2nd edition. By Marcia L London, Patricia W. Ladewig, Jane W.
Ball, Ruth Bindler.
• Progress in Obstetric and Gynecology. Edited by John Studd, Seang Lin Tan, Frank D. Chervenak
• Fundamentals of Nursing, Concepts, Process, and Practice updated 5 th edition By Barbara
Kozier, Glenora Erb, Kathleenn Blais, Judith M. Wilkinson