I.

INTRODUCTION
Ectopic Pregnancy is a complication of pregnancy in which the pregnancy implants
outside the uterine cavity. With rare exceptions, ectopic pregnancies are not viable.
Furthermore, they are dangerous for the mother, internal bleeding being a common
complication. Most ectopic pregnancies occur in the Fallopian tube , but
implantation can also occur in the cervix, ovaries, and abdomen. An ectopic
pregnancy is a potential medical emergency, and, if not treated properly, can lead
to death.

II. OBJECTIVES
General: To have a comprehensive study and knowledge about ectopic pregnancy.

Specific

1.) We will have better understanding of ectopic pregnancy by reading books, articles and journals
that are related with the disease;
2.) Understand clearly the pathophysiology of the disease, risk factors, manifestations and
treatment and modalities of the disease; and
3.) Equip ourselves with skills and health teachings that are appropriate for the care of patients with
ectopic pregnancy.

III. SOCIO-DEMOGRAPHIC PROFILE

a. Name of Patient: Mrs. A.
b. Age: 33 years old
c. Gender: Female
d. Religion: Roman Catholic
e. Civil Status: Married
f. Admitting Diagnosis: G3P1 (1011) Threatened Abortion 9 weeks
g. Final Diagnosis: G3P1 (1021) Ectopic, 9 Weeks Left Fallopian Tube, Ampullary
Ruptured, Endometriotic Cyst Left
h. Operation Performed: Exploratory Laparotomy + Salpingectomy + Left
Oophorocystectomy
i. Surgeon: Dr. B
j. Date of Operation: October 23, 2010/135501-2010
k. Type of Anesthesia: Spinal Anesthesia
l. Anesthesiologist: Dr. C.

IV. NURSING HISTORY

A. Past Health History

Mrs. A. has no previous medical problem and never hospitalized due to serious illness. Mrs. A. had
her first pregnancy last 2000 and delivered a live full term baby girl via normal spontaneous delivery.
On her second pregnancy last 2001, she had an incomplete abortion and undergo Dilation and
Curettage.

B. History of Present Illness

Mrs. A. is a G3P1 (1011) 9 3/7 weeks AOG with chief complaint of hypogastric pain and vaginal
bleeding.

On October 14, Mrs. A experienced vaginal spotting that lasted for 3 days so she decided to went to
her doctor for a consult and advised her to undergo trans-vaginal ultrasound. The UTZ revealed no
intrauterine, no extrauterine pregnancy with thin endometrium. She had her pregnancy test and
revealed positive with increase HCG level and advised her to take Duphaston three times a day.
 One day prior to hospitalization, the patient experienced hypogastric pain and cramping and non-
radiating with increase amount of vaginal bleeding that consumed 2 pads per day with minimal to
moderately soaked.

C. Family History

Mrs. A. had a familial history of hypertension on her father side. No known history of cancer,
asthma, diabetes mellitus and thyroid disease.

V. PHYSICAL ASSESSMENT
General Normal Standards Actual Findings Interpretation and
Appearance Analysis
1. Posture/Gait >Straight posture, have >Patient can lie on bed but >Limitations in usual role
balance gait unable to stand and sit on activities
her own. >The patient needs
guidance from the nurse
because of pain from
surgical site.
>Pain tolerance is the
maximum amount and
duration of pain that an
individual is willing to
endure. Some clients are
unable to tolerate even
the slightest pain.

(Kozier, B., Erb, G.,

Berman, A.J, & Snyder, S.
(2004). Fundamentals of
Nursing: Concepts,
Process and Practice. 7th
Edition. Page 1135.Upper
Saddle River, New Jersey:
Pearson Education Inc.)
2. Skin >Varies from light to >The patient’s skin is dry. >Normal
deep brown; from ruddy Skin color is brown which is
pink to light pink; uniform in all areas except
generally uniform for areas that are not usually
except in areas exposed to sun such as the
exposed to sun axillae, the legs and soles of
>Moisture in skin fold the feet.
3. Personal >Clean and neat, No >Clean and neat, No body >Normal
hygiene/ Grooming body and breath odor and breath odor
4. Nutritional >Eat three meals a day >DAT >Normal
Status and snacks that consist
of a balance diet (go, BMI: Height= 5’4" BMI Weight Status
grow, glow food). Weight= 49.5 kgs. Categories
Below 18.5= Underweight
Computation: 18.5 - 24.9 = Normal
BMI = Wt (kg)/Ht (m)2 25- 29.9= Overweight
= 49.5kg/(1.626 m)2 Above 30= Obese
= 49.5 kgs./2.644
= 18.72 BMI
= Normal
5. Verbal Behavior >Can communicate well >Can communicate well and >Normal
and express her express her feelings.
feelings.
6. Non-verbal >Actions coordinate >Seen to be always on deep >There are wider
Behavior with the mood of the thought; Flat affect; Biting of variations in non verbal
client. lower lips; Diaphoresis; response to pain. For
Sighing; Facial grimace many patients, nonverbal
 expressions may be the
only means of
communicating pain.
Facial expressions are
often the first indication of
pain.
7. Physiologic Cues T = 35.8°C - 37°C T: 36.8 ˚C >Physiologic responses
PR = 60 -100bpm P: 87 vary with the origin and
RR = 12 - 20bpm R: 19 duration of the pain. Early
BP = SP (100 – BP: 120 / 80 in the onset of acute pain,
140mmHg) the sympathetic nervous
DP (60 – 90mmHg) system is stimulated
resulting in increase BP,
PR, and RR.

Body Parts Normal Standards Actual Findings Interpretation and

(Technique Analysis
Used)
Head
 Skull >Rounded and >The patient’s skull is Normal
smooth skull contour proportional to the size of her
>Smooth, uniform body, round, with
consistency and prominences in the frontal
absence of nodules area anteriorly and the
occipital area posteriorly,
symmetrical in all planes,
gently curved.
 Scalp >White and uniform >The scalp is white, no lice, Normal
in color no nits and dandruff, no
>Absences of flakes lesions, no infection or
and lesion infestation. No areas of
tenderness.
 Hair >Evenly distributed; >Hair is black in color, evenly Normal
thick hair distributed and covers the
whole scalp, thin and free
from split ends.
 Face >Symmetrical facial >Oblong, symmetrical, facial Normal
features; expression is dependent on
symmetrical facial the mood and her true
movements feelings, smooth and free
>No erythema from wrinkles. There are no
involuntary muscle
movements.
Eyes
 Eyebrows >Hair evenly >Black, plucked eyebrows, >Plucking eyebrows
distributed and hairs are not evenly indicates that the patient is
symmetrical distributed, raise and lower conscious of her physical
symmetrically and inline, with appearance and body image.
equal movement >A person with a healthy
body image will normally
show concern for both health
and appearance.
(Kozier, B., Erb, G., Berman,
A.J, & Snyder, S. (2004).
Fundamentals of Nursing:
Concepts, Process and
Practice. 7th Edition. Page
960. Upper Saddle River,
New Jersey: Pearson
Education Inc.)
  Eyelashes >Hair equally >Eyelashes are black in color, Normal
distributed and evenly distributed and turned
curved slightly outward.
outward
 Eyelids >Skin intact; no >Upper lids cover a small Normal
discharged; no portion of the iris and the
discoloration cornea and the sclera when
the eyes are open. When the
eyes are closed, the lids meet
completely. Symmetrical. No
palpable mass.
 Conjunctiv >Shiny, smooth and >Shiny, smooth and pale Normal
a pink or red in color; conjunctiva; no presence of
no presence of lesions
lesions
 Sclera >White in color, clear >White in color, clear Normal
 Iris >Flat and round, >Iris is proportional to the Normal
black or brown in size of the eye, round, brown,
color and symmetrical.
 Pupils >Black in color, >Pupils are symmetrical, 3-5 Normal
equal in size; mm in diameter, equally
normally 3-7mm in reactive to light and
diameter; round accommodation
Pupil test >Illuminated pupil >Pupils equally round and Normal
constricts (direct react to light and
response), Non- accommodation
illuminated pupil
constricts
(consensual
response)
Extraocular >Both eyes >Both eyes coordinated, Normal
muscle coordinated, move in move in unison, with parallel
unison, with parallel alignment
alignment
 Lacrimal >No edema or >No edema or tearing over Normal
gland tearing the lacrimal gland
Ears
 Auricles >Color same as >Color same as facial skin, Normal
facial skin, symmetrical auricle aligned
symmetrical auricle with the outer canthus of eye,
aligned with the about 10° from vertical
outer canthus of eye, >Mobile, firm, and not tender,
about 10° from pinna recoils after it is folded
vertical
>Mobile, firm, and
not tender, pinna
recoils after it is
folded
 Hearing >Normal voice tones >Normal voice tones audible Normal
acuity test audible (Done by
standing 2 feet away
from the client and
ask her to repeat the
3 words what the
nurse will say).
Nose >Symmetrical in >Symmetrical in shape; no Normal
shape; no discharge discharge or flaring; uniform
or flaring; uniform in in color
color >Mucosa pink; no lesions
>Mucosa pink; no >Nasal septum intact and in
 lesions midline
>Nasal septum intact >No tenderness or lesion
and in midline >No rashes
>No tenderness or
lesion
>No rashes
Mouth
 Lips >Uniform pink/red >Uniform pinkish color; Normal
color; soft moist, symmetrical, lip margin well
smooth texture defined, smooth and moist
 Buccal >Uniform pink color; >Uniform pink color; moist, Normal
mucosa moist, smooth, smooth, glistening and elastic
glistening and elastic texture
texture
 Gums >Pink gums and >Pink gums, moist and firm Normal
moist, no bleeding texture. No bleeding.
 Tongue >Pink color, moist; >Pink color, moist; slightly Normal
slightly rough; thin rough; thin whitish coating;
whitish coating; smooth lateral margins; no
smooth lateral lesions raised papillae
margins; no lesions >Central position, moves
raised papillae freely, no tenderness smooth
>Central position, tongue base with prominent
moves freely, no veins
tenderness smooth
tongue base with
prominent veins
 Teeth >32 permanent >15 upper teeth, 14 lower >29 permanent teeth
teeth, well-aligned, teeth. present.
free from caries or >Free from caries. No >Some older adults may
filling, no halitosis halitosis. have few permanent teeth
left. Loss of teeth occurs
mainly because of
periodontal disease which
increases during pregnancy
because the rise in female
hormones affects gingival
tissue and increases its
reaction to bacterial plaque.

(Kozier, B., Erb, G., Berman,

A.J, & Snyder, S. (2004).
Fundamentals of Nursing:
Concepts, Process and
Practice. 7th Edition. Page
398. Upper Saddle River,
New Jersey: Pearson
Education Inc.)
Neck >Proportional to the >Proportional to the size of Normal
size of the body and the body and head,
head, symmetrical, symmetrical, and straight.
and straight. >No palpable masses.
>No palpable lumps, >Coordinated, smooth
masses, or areas of movements with no
tenderness. discomfort. Head flexes 45°,
>Coordinated, laterally flexes 40°, and
smooth movements laterally rotates 70°.
with no discomfort. >Neck muscles have equal
Head flexes 45°, strength and the same as the
laterally flexes 40°, shoulders.
and laterally rotates
 70°.
>Neck muscles have
equal strength and
the same as the
shoulders.
Thorax and
Lungs
Posterior >Anteroposterior to >Anteroposterior to Normal
Thorax transverse diameter transverse diameter ratio is
Shape and in a ratio of 1:2 1:2
Symmetry >Chest symmetric
>Chest is symmetric.
Spinal >Vertically aligned >Spine is vertically aligned Normal
Alignment when inspected and palpated.
Palpation >Skin intact, uniform >Skin is intact and of uniform Normal
temperature temperature
>Chest wall intact, >Chest wall intact, with no
no tenderness no tenderness no masses
masses
Respiratory >Full symmetric >Full symmetric chest Normal
/Thoracic chest expansion expansion
Excursion
Auscultation >Vesicular and >Vesicular and Normal
of thorax bronchovesicular bronchovesicular breath
breath sounds sounds
Heart Aortic valve – no Aortic valve – no pulsations Normal
pulsations
Pulmonic valve – no Pulmonic valve – no
pulsations pulsations
Tricuspid area – no Tricuspid area – no pulsations
pulsations
Apical area –
pulsations visible and Apical area – pulsations
palpable. visible and palpable.
Epigastric area –
abdominal aortic Epigastric area – no
pulsations visible and pulsations
palpable. The two heart sounds are
The two heart sounds audible in all areas but
are audible in all loudest at apical area, 4th
areas but loudest at ICS, LMCL
apical area. Cardiac rate has normal
Cardiac rate ranges ranges with a regular rhythm.
from 60-100
beats/minute.
Abdomen >Skin is >Skin is unblemished, no Normal
unblemished, no scars, color is uniform, flat,
scars, color is rounded (convex), or
uniform, flat, scaphoid (concave), slightly
rounded (convex), or protuberant for infants,
scaphoid (concave), symmetrical movements
slightly protuberant caused by respiration,
for infants, umbilicus is flat or concave,
symmetrical positions midway between
movements caused the xiphoid process and the
by respiration, symphysis pubis, color is the
umbilicus is flat or same as the surrounding skin.
concave, positions
midway between the
xiphoid process and
the symphysis pubis,
 color is the same as
the surrounding skin.
Arms >Skin color varies >Skin color is light brown, Normal
(pinkish, tan, dark symmetrical, absence of
brown), symmetrical, visible veins and scars.
fine hair evenly >Warm, dry and elastic; no
distributed, areas of tenderness.
presence/absence of
visible veins.
>Warm, dry and
elastic; no areas of
tenderness. Muscle
appears equal with
good muscle tone.
Palms and >Palms pinkish >Palms pinkish, warm and Normal
dorsal (dorsal surface), softer
surfaces warm
Nails >Nails are >Nails are short, transparent, Normal
transparent, smooth, smooth, and convex with pink
and convex with pink nail beds and white
nail beds and white translucent tips.
translucent tips. >Five fingers in each hand.
>Five fingers in each >As pressure was applied to
hand. the nail bed, it appears white
>As pressure is and pink color returns less
applied to the nail than 2 seconds.
bed, appears white
or blanched, and pink
color returns
immediately as
pressure is released.
Shoulders Raise both arms to >Able to raise both arms to Normal
vertical position – vertical position, and place
Performs with hands behind the small of the
relative ease back with relative ease.
Place head behind
the neck – Performs
with relative ease
Place hands behind
the small of the back
– Performs with
relative ease
Arms Abduct – Performs >The patient can perform Normal
with relative ease abduct, adduct and rotate
Adduct – Performs with relative ease.
with relative ease
Rotate – Performs
with relative ease
Elbows Bend and straighten >Able to bend and straighten Normal
elbow – Performs elbow with relative ease
with relative ease
Hands and Extend and spread >Can extend and spread the Normal
wrists the fingers – fingers and make a fist,
Performs with thumb across the knuckles
relative ease with relative ease.
Make a fist, thumb
across the knuckles –
Performs with
relative ease
Lower extremities
Legs >Skin color varies >Skin color was light brown; Normal
 (pinkish, tan, dark skin is smooth, absence of
brown), skin is varicose veins.
smooth, fine hair >Muscles appear equal,
evenly distributed, warm.
absence of varicose >With full range of motion,
veins. full and equal pulses.
>Muscles appear
equal, warm and with
good muscle tone.
>With full range of
motion, full and
equal pulses.
Toes >Five toes in each >Five toes in each foot; sole Normal
foot; sole and dorsal and dorsal surface is smooth;
surface is smooth; with pink nailbeds and white
with pink nailbeds translucent tips.
and white translucent
tips. >As pressure is applied, the
>As pressure is nailbed appears white; pink
applied, the nailbed color returns when pressure is
appears white or released.
blanched; pink color
returns when
pressure is released. >With full range of motion.
>With full range of
motion, full and
equal pulses.

VI. ANATOMY ANG PHYSIOLOGY

INTERNAL GENITALIA
a. Fallopian tube/Oviduct – 4 inches long from each side of the uterus (fundus). Ittransports the
mature ova form the ovaries to the uterus and provide a place for fertilization of the ova by the
sperm in its outer 3rd or outer half.
Parts:
 Interstitial – lies within the uterine wall
 Isthmus – portion that is cut or sealed in a tubal ligation.
 Ampulla – widest, longest portion that spreads into fingerlike projections/fimbriae and it is
where fertilization usually occurs.
  Infundibulum - rim of the funnel covered by fimbriated cells (hair covered fingerlike
projections) that help to guide the ova into the fallopian tube.
b. Ovaries – Oval, almond sized, dull white sex glands on either side of the uterus that measures 4 by
2 cm in diameter and 1.5 cm thick. It is responsible for the production, maturation and discharge of
ova and secretion of estrogen and progesterone.
c. Uterus – hollow, pear-shaped muscular organ, 3 inches long, 2 inches wide, weighing 50-60 grams
held in place by broad and round ligaments, and abundant blood supply from the uterine and
ovarian arteries. It is located in the lower pelvis, posterior to the bladder and anterior to the rectum.
Organ of menstruation, site of implantation and provide nourishment to the products of conception.
Layers:
1. Perimetrium – outermost layer of the uterus comprised of connective tissue, it offers added
strength and support to the structure.
2. Myometrium – middle layer, comprised of smooth muscles running in 3 directions; expels fetus
during birth process then contracts around blood vessels to prevent hemorrhage.
3. Endometrium – Inner layer which is visibly vascular and is shed during menstruation and
following delivery.
Divisions of the Uterus:
1. Fundus – upper rounded, dome-shaped portion that can be palpated to determine uterine growth
during pregnancy and the force of contractions and for the assessment that the uterus is returning to
its non-pregnant state following child birth.
2. Corpus – body of the uterus.
3. Isthmus – area between corpus and cervix which forms part of the lower uterine segment. It
enlarges greatly to aid in accommodating the fetus. The portion that is cut when a fetus is delivered
by a caesarian section.
4. Cervix – lower cylindrical portion that represents 1/3 of the total uterus. Half of it lies above the
vagina; half of it extends to the vagina. The cavity is termed the cervical canal. It has 2 openings/Os:
internal os that open to the uterine cavity and the external os that opens to the vagina.
5. Vagina – a 3-4 inch long dilatable canal located between the bladder and the rectum, it contains
rugnae which permit considerable stretching without tearing. It acts as an organ of
intercourse/copulation and passageway for menstrual discharges and fetus. Doderlein’s bacillus is the
normal flora of the vagina which makes the pH of vagina acidic, detrimental to the growth of
pathologic bacteria.

EXTERNAL GENITALIA

a. Mons Veneris/Pubis – Pad of fat which lies over the symphysis pubis where dark and curly hair
grows in triangular shape that begins 1-2 years before the onset of menstruation. It protects the
surrounding delicate tissues from trauma.
b. Labia Majora – Two (2) lengthwise fatty folds of skin extending from mons veneris to the perineum
that protects the labia minora, urinary meatus and vaginal orifice.
c. Labia Minora – 2 thinner, lengthwise folds of hairless skin extending from clitoris to fourchette.
  Glands in the labia minora lubricates the vulva
 Very sensitive because of rich nerve supply
 Space between the labia is called the Vestibule
d. Clitoris – small, erectile structure at the anterior junction of the labia minora that contains more
nerve endings. It is very sensitive to temperature and touch, and secretes a fatty substance called
Smegma. It is comparable to the penis in its being extremely sensitive.
e. Vestibule – the flattened smooth surface inside the labia. It encloses the openings of the urethra
and vagina.
f. Skene’s Glands/Paraurethral Glands – located just lateral to the urinary meatus on both sides.
Secretion helps lubricate the external genital during coitus.
g. Bartholin’s Gland/Vulvovaginal Glands – located lateral to the vaginal opening on both sides. It
lubricates the external vulva during coitus and the alkaline pH of their secretion helps to improve
sperm survival in the vagina.
h. Fourchette – thin fold of tissue formed by the merging of the labia majora and labia minora below
the vaginal orifice.
i. Perineum – muscular, skin-covered space between the vaginal opening and the anus. It is easily
stretched during childbirth to allow enlargement of vagina and passage of the fetal head. It
contains the muscles (pubococcygeal and levator ani) which support the pelvic organs, the arteries
that supply blood and the pudendal nerves which are important during delivery under anesthesia.
j. Urethral meatus – external opening of the urethra. It contains the openings of the Skene’s glands
which are often involved in the infections of the external genitalia.
k. Vaginal Orifice/Introitus – external opening of the vagina, covered by a thin membrane
called Hymen.

VII. PATHOPHYSIOLOGY

VIII. DIAGNOSTICS AND LABORATORIES

CBC
Test Oct. 23 Oct. 24 Reference Values
Hemoglobin 10.8 12.3 12:00 – 15.00 g/dL
Hematocrit 33.0 38 36.00 – 46.00 %
RBC Count 3.68 4.23 4.00 – 4.50 x 10^ 6/L
MCV 89.7 89 80.00 – 100.00 fl
MCH 29.3 29 27.00 – 31.00 pg
MCHC 32.7 33 32.00 – 36.00 %
Platelets 212 217 150.00 – 400.00 x 10^
3/L
WBC Count 6.63 9.7 4.50 – 11.00 x 10^ 3/L
Eosinophil 1 1 1.00 – 4.00 %
Neutrophil 60 66 36.00 – 66.00 %
Lymphocyte 32 23 22.00 – 40.00 %
Monocyte 8 10 4.00 – 8.00 %
RDW 12.7 12.8 8.50 – 15.00

ULTRASOUND (Oct. 23, 2010)

Trans-vaginal scan shows a normal sized cervix with intact endocervical lining. The uterus is normal
in size, retroverted woth no myometrial lesions. The endometrium is thickened at 1.2 cm with an
achogenic structure within measuring 1.9 x 1.7 x 0.5 cm suggestive of blood clot. The right ovary contains
a cystic cob web structure measuring 3.2 x 1.3 cm suggestive of corpus luteum. Inferior to the uterine
corpus and more on the left adnexa is a complex structure measuring 5.0 x 3.5 x 4.4 cm could be
extrauterine pregnancy surrounded by a hypoechoic structure total volume 25.3 ml could be
hemoperitoneum.
Findings:
NORMAL SIZED RETROVERTED UTERUS
THICKENED ENDOMETRIUM WITH BLOOD CLOTS
CORPUS LUTEUM, RIGHT OVARY
COMPLEX MASS, LEFT ADNEXA COULD BE EXTRAUTERINE
 GESTATION PROBABLY RUPTURED
HEMOPERITONEUM AS DESBRIBED

IX. MEDICAL-SURGICAL MANAGEMENT

Medical

Early treatment of an ectopic pregnancy with methotrexate is a viable alternative to surgical

treatment. If administered early in the pregnancy, methotrexate terminates the growth of the
developing embryo; this may cause an abortion, or the tissue may then be either resorbed by the
woman's body or pass with a menstrual period.

Surgical

If hemorrhage has already occurred, surgical intervention may be necessary. However, whether to
pursue surgical intervention is an often difficult decision in a stable patient with minimal evidence of
blood clot on ultrasound.

Surgeons use laparoscopy or laparotomy to gain access to the pelvis and can either incise the
affected Fallopian and remove only the pregnancy (salpingostomy) or remove the affected tube with
the pregnancy (salpingectomy).

X. NURSING CARE PLAN

Pre-operatively

Nursing Diagnosis Rank Justification

Acute pain related to rupture 1 An actual problem that needs intervention because it
fallopian tube can aggravate abdominal pressure

Risk for ineffective tissue 2 A potential problem that needs intervention to prevent
perfusion related to hemorrhage risk for hypovolemic shock and may lead to maternal
mortality

Intra-operatively

Nursing Diagnosis Rank Justification

Risk for infection r/t surgical
incision
Risk for falls r/t effects of
anesthesia
1 It is a potential problem that needs immediate
intervention because if it is not prevented, it can lead
to certain complications.
3 It is a potential problem that needs an immediate
intervention because it can cause physical harm.

Post-operatively
 Nursing Diagnosis Rank Justification
Grieving, dysfunctional related 1 An actual problem that needs attention because it
to perceived loss of a child may lead to psychological problem( major
depression, anxiety and suicide)

Risk for infection related to
surgical incision
Ineffective individual coping
related to personal vulnerability
2 It is a potential problem that should be given prompt
interventions so as not to worsen and aggravate the
patient’s condition.
It is also a sign that we need to monitor, and check if
the patient has the risk for infection
3 It is a possible problem that if not given proper
assessment and intervention may lead to serious
problem that may develop not just physically but also
emotionally.

Pre-operative

CUES NURSING GOAL and NURSING INTERVENTION RATIONAL EVALUATI

DIAGNOSIS OBJECTIVE E ON
Subjec Acute pain Goal Independent After 8
tive related to After 8 ● Perform assessment of pain to ●To hours of
“Masa rupture of hours of include location, assess nursing
kit ang fallopian tube nursing characterstics,onset,duration,fr factors interventio
tiyan interventio equency,quality and severity. that n,the
ko as n the precipitat patient
verbali patient will es and was able
zed by be able to contribute to report
the report pain sto the pain
patien relief/contr pain relief/contr
t” ol as sensation ol as
evidenced and to evidenced
by no indicate by no
guarding ●Monitor maternal vital signs. the guarding
behavior appropriat behavior
and e choice and
absence of of absence of
facial treatment facial
mask of . mask of
pain. ●To pain.
determine
presence
●Monitor for presence and of
amount of vaginal bleeding hypotensi
on and
tachycardi
a caused
by
rupture of
●Monitor for increase pain and hemorrha
abdominal distention and ge.
 rigidity ●To
further
assess
the
present
situation
indicating
hemorrha
ge
●Indicates
rupture
and
possible
intraabdo
minal
hemorrha
ge.

After 30
Objecti After 30 ●Monitor CBC ●To minutes of
ve minutes of determine nursing
Facial nursing the interventio
mask interventio ●Encourage verbalization of amount of n, the
of pain n,the feeling about pain. blood patient
Guardi patient will loss. was able
ng report ●It can to report
behavi reduction reduce reduction
or of pain anxiety of pain
Pain from 8 to 4 and fear from 8 to 4
scale of pain thereby of pain
of 8 (1 scale as ●Provide comfort measure like reduce scale as
as no evidenced backrubs ,deep breathing. perceptio evidenced
pain by less Instruct in visualization n of by less
10 as facial exercises. intensity facial
worst grimace. of pain. grimace.
pain) ●It may
enhance
patient’s
coping
● Provide diversional activities. abilities
by
refocusing
attention.

●Aids in
Dependent refocusing
●Administer medications as attention
indicated. and
enhancing
coping
with
Collaborative limitation.
●Laboratory as indicated.
●To
maintain
 acceptabl
e level of
pain.

●To
determine
blood loss

Independent:
Ectopic  Review history for preexisting
pregnancy is conditions/risk factors.
gestation
located outside
the uterine  Monitor vital signs.
cavity.
Predisposing  Provide perineal care per
protocol
factors:
Collaborative:
adhesion of the
 Carry out preoperative skin
tube preparation; scrub according to
,salphingitis,co protocol.
ngenital and
developmental
anomalies of  Verify sterility and integrity of
the fallopian all items used in the procedure.
tube,previous
ectopic
pregnancy,use  Verify that preoperative skin
d of IUD for preparation was done
more than 2 aseptically.
years and
 Examine skin for breaks or
multiple
irritation, signs of infection.
induced
abortions,
menstrual  Identify breaks in aseptic
reflux and technique and resolve
decreased immediately on occurrence.
tubal motility.
 Administer antibiotics, as
ordered.

Intra-operatively
CUES NURSING GOAL and NURSING INTERVENTIONS RATIONA EVALUATI
DIAGNOSIS OBJECTIVE LE ON
S

Goal: Independent: Does the

Risk for After using  Review history for preexisting Reduces patient
Infection related intervention, conditions/risk factors. Note risk of skin have safe
to invasive the patient time of rupture of membranes. contamina aseptic
procedure, will have no nts environmen
break in the signs of entering t?
skin and infection the √ yes?
exposure to during and incision, _ no?
pathogens. after the reducing
procedure  Assess for signs/symptoms of risk of
> Impaired infection (e.g., elevated postoperat
primary Objective: temperature, pulse, WBC; ive
defenses and After 1.5 abnormal odor/ color of vaginal infection.
inadequate hours of discharge, or fetal tachycardia).
secondary invasive
defense that procedure  Provide perineal care per
resulted from the patient protocol, especially once
the operation will have a membranes have ruptured.
contributes to safe aseptic
the patient’s environment Collaborative: Prepackag
wound being by  Carry out preoperative skin ed items
invaded by maintaining preparation; scrub according to may
pathogenic the sterility protocol. appear to
micro organism. of the be sterile;
(NANDA) instruments however
and the each item
 Verify sterility and integrity of
field. must be
all items used in the procedure.
scrutinized
for sterile
indicators
 Verify that preoperative skin
and
preparation was done
package
aseptically.
integrity.
 Examine skin for breaks or Cleansing
irritation, signs of infection. reduces
bacterial
count on
 Identify breaks in aseptic the
technique and resolve incision
immediately on occurrence. site.

 Administer antibiotics, as Disruption

ordered. s of skin
integrity at
or near the
operative
site are
sources of
contamina
tion to the
incision.

An
unsterile
item that
touches
sterile
items is
considered
unsterile.
May be
given
prophylacti
cally for
suspected
infection
or
contamina
tion
NURSING OBJECTIVE NURSING INTERVENTIONS RATIONALE EVALUATIO
DIAGNOSIS and GOAL N
Independent After 8
Grieving, Goal: Identify(be aware of) stage ●To assess hours of
dysfunctional After the of grief being expressed: contributing nursing XI. DRUG ANALYSIS
related to end of Bargaining, Anger, Denial, /causative interventio
Generic Name
perceived loss Dosage Depression,
nursing ActionAcceptanceIndication Contraindicati
n the Adverse Effect Nursing Consideration
factors that
on
of a child care the precipitates/ patient is
Paracetamol 600 mg IV
patient PRNBe aware
will Analgesic and Fever reduction.
of avoidance Paracetamol
contributes able to GI: hepatic 1. Do not use this
Antipyretic Temporary should not be failure medication without medical
be able to behaviors (anger, grief and to verbalizes
relief of mild to used in GU: renal failure direction for fever.
demonstrat withdrawal) the a sense of Skin: rash,
indicate hypersensitivity
moderate pain 2. Do not self medicate
e progress to the progress urticaria
appropriate adults for pain more than
in dealing Identify factors and ways toward
choice ofpreparation and 10 days without consulting
with stages individual has dealt with therapeutic resolution
in severe liver a physician.
of grief at previous loss(es) communicat of the grief
diseases. 3. Do not take other
own pace. ion and hope medications containing
for the acetaminophen without
After 8 To further future medical advice, overdosing
hours of assess the and chronic use can cause
liver damage and other
nursing present
toxic effects
interventio situation
Cefuroxime 750 mg IV q8 Semi- synthetic Treat wide Contraindicated Diarrhea, 1. Inform the physician if
n the cephalosporin variety of in patients nausea and you have liver or kidney
patient will antibiotic infection hypersensitivity vomiting, disease.
be able to similar to ●Assist to drug or other abdominal pain. 2. Instruct the patient to
verbalizes penicillin patient to
cephalosporin. Headache, rash, follow the prescribed
a sense of ●Encourage verbalization deal Use cautiously vaginitis, and frequency of the drug even
progress without confrontation in breastfeeding mouth ulcers.
appropriatel if he feels better.
toward about realities women and in
y with loss 3. Instruct the patient to
resolution patients with
-helpful in take it with meals.
of the grief beginninghistory of colitis 4. Instruct the patient to
or renal report any adverse reaction
and hope Encourage patient to talk resolution
insufficiency. of the drug.
for the about what the patient and
Demerol 25 mg IV Analgesic, Medical: Hypersensitivity Cardiovascular: 1. If I.V. administration is
future chooses and do not try
Narcotic to
Management acceptance
of to meperidine Hypotension required, inject very slowly
force the patient to face
moderate to or any Central nervous using a diluted solution;
as the fact severe pain; component; system: administer over at least 5
evidenced adjunct to patients Fatigue, minutes; intermittent
by no Active listen feelingsanesthesia
and and receiving MAO drowsiness, infusion.
guarding preoperative
be available for support/ inhibitors dizziness 2. May cause hypotension,
behavior sedation
assistance(speak in soft, presently or in Gastrointestinal: dizziness, drowsiness,
and caring voice) the past 14 Nausea, impaired coordination, or
absence of days vomiting, blurred vision; loss of
constipation appetite, nausea, or
facial mask Acknowledge reality of
Neuromuscular vomiting; constipation.
of pain. feelings of guilt and assist & skeletal: 3. Report chest pain, slow
patient to take steps Weakness or rapid heartbeat, acute
toward resolution

Respect the patient’s ●To

needs and wishes for quiet promote
 dizziness or persistent
headache; changes in
mental status; swelling of
extremities or unusual
weight gain; changes in
urinary elimination; acute
headache; back or flank
pain or muscle spasms;
blurred vision; skin rash; or
shortness of breath
Diphenhydrami 50 mg IV Antihistamine Can be used for Hypersensitivity Cardiovascular: 1. May experience
ne mild nighttime to Hypotension, drowsiness or dizziness; or
sedation; has Diphenhydrami palpitations, dry mouth, nausea, or
anesthetic ne or any tachycardia vomiting. 2. Report
properties component; Central nervous persistent sedation,
should not be system: confusion, or agitation;
used in acute Sedation, changes in urinary pattern;
attacks of sleepiness, blurred vision; sore throat,
asthma; use in dizziness, difficulty breathing, or
neonates is disturbed expectorating (thick
contraindicated coordination, secretions)
headache, 3. Raise bed rails, institute
fatigue safety measures, assist with
Gastrointestinal: ambulation
Nausea,
vomiting,
diarrhea,
abdominal pain

Infusion Classification Indication Contraindication Nursing Responsibility

D5NM 1L Hypertonic Maintenance of Hypersensitivity to any Check doctor’s order
solution fluid and of the components Observe 10 R’s when preparing and administering IVF.
electrolytes Check the sterility and integrity of the IV solution, IV set
and other devices.
Place IV label on the IV bottle.
Calibrate the IV bottle and regulate flow infusion
according to prescribed duration. Expel air bubbles if any.
Make sure IV line is patent and infusing well.
Assess patient’s fluid status. Monitor I/O of the patient
Monitor other electrolyte levels
Clean rubber port aseptically
Observe patient and report any untoward effect.
PNSS 1L Isotonic solution Fluid replacement No known Check doctor’s order
in patient with contraindication Observe 10 R’s when preparing and administering IVF.
 dhn or fluid Check the sterility and integrity of the IV solution, IV set
deficit. Used and other devices.
solution in BT. Place IV label on the IV bottle.
Calibrate the IV bottle and regulate flow infusion
according to prescribed duration. Expel air bubbles if any.
Make sure IV line is patent and infusing well.
Assess patient’s fluid status. Monitor I/O of the patient
Monitor other electrolyte levels
Clean rubber port aseptically
Observe patient and report any untoward effect.
D5LR Hypertonic Source of water, Contraindicated with Check doctor’s order
solution electrolytes and known allergy to corn Observe 10 R’s when preparing and administering IVF.
calorics as an and corn product. Check the sterility and integrity of the IV solution, IV set
alkanizing agent and other devices.
Place IV label on the IV bottle.
Calibrate the IV bottle and regulate flow infusion
according to prescribed duration. Expel air bubbles if any.
Make sure IV line is patent and infusing well.
Assess patient’s fluid status. Monitor I/O of the patient
Monitor other electrolyte levels
Clean rubber port aseptically
Observe patient and report any untoward effect.
D5NR Hypertonic Maintenance of Hypersensitivity to any Check doctor’s order
solution fluid and of the components Observe 10 R’s when preparing and administering IVF.
electrolytes Check the sterility and integrity of the IV solution, IV set
and other devices.
Place IV label on the IV bottle.
Calibrate the IV bottle and regulate flow infusion
according to prescribed duration. Expel air bubbles if any.
Make sure IV line is patent and infusing well.
Assess patient’s fluid status. Monitor I/O of the patient
Monitor other electrolyte levels
Clean rubber port aseptically
Observe patient and report any untoward effect.
PRBC Blood Used in patients Contraindicated to Check doctor’s order
Components with acute patient with severe Observe 10 R’s. Explain the procedure for giving blood
anemia whose congestive heart failure transfusion. Get pt’s history regarding previous
symptoms were and to those unable to transfusion.
related to blood obtain appropriately Countercheck the compatible blood to be transfused
loss and were matched blood against X-matching sheet noting ABO grouping RH, serial
refractory to no. of each blood unit, and expiry date with the blood bag
crystalloid label and other lab blood exam done.
infusions, as well Get the baseline vital signs before transfusion.
as in patients Give pre-med 30 minutes before transfusion as
with chronic prescribed.
anemia in whom Do hand hygiene before and after the procedure.
nontransfusion Observe patient for 10-15 minutes for any immediate
therapies (eg, reaction.
iron replacement, Observe patient on an on-going basis for any untoward
erythropoietin) s/sx such as flushed skin, chills, elevated temp, itchiness,
had not been urticaria, and dyspnea.
effective. Continue to observe and monitor patient post transfusion
for delayed reaction.
Recheck Hgb and Hct, bleeding time, serial platelet count
within specified hours.
Discard blood bag and BT set and sharps.
XII. HEALTH TEACHING

Diet and Bowel:

• Patients who have received spinal anesthesia may experience nausea and occasionally,
vomiting. It is therefore preferable to instruct the patient to eat a bland light meal or a
liquid diet once fully awake after surgery. Regular diet may be resumed the next day.
Also, pain medication may cause nausea if taken on an empty stomach. It would be better
to take that medication with a piece of toast or some food.

• To help to avoid constipation and promote healing eat fruits and vegetables and drink 6
to 8 glasses of water each day, stool softeners or mild laxative may be needed if no
positive bowel movement within 3 days after surgery as prescribed by the doctor.

• Patient should void spontaneously within 6 to 8 hours after catheter is removed. Normal
bowel function should return by third or fourth post op day.

Instruct the patient:

• Instructed the patient of no heavy lifting while in recovery from surgery, must not lift
weights over 15 pounds, heavy lifting puts too much strain on lower abdomen and
abdominal muscle may rupture, heavy lifting may pop the stitches in incision site.
• Walk or move legs as much as possible, to prevent blood clots and gradually resume
normal activity.
• Support abdomen when coughing, turning and deep breathing. Place a pillow over
abdomen and apply pressure on it to support and minimize pain.
• Medications compliance was instructed, teach patient and family to care for the wound
and perform dressing changes and irrigations as prescribed.
• Antibiotic is usually prescribed for seven to ten days following surgery. Instruct to take
them as ordered.
• Remind to keep the incision clean and dry during first week after surgery to prevent
infection.
• Instruct the patient that she may shower after removal of dressing; wash it with soap and
water then pat dry and instruct not to use oils and lotion over incision area.
• Instruct the patient to have slowly increase activities. Begin with light chores, short walks.
• Instruct the patient to avoid excessive stair climbing for two weeks after the surgery.
• Refer for home care nursing as indicated to assist with care and continued monitoring of
complications and wound healing.
• Reinforce need for follow-up appointment with the surgeon one week after the discharge
• Instruct the patient not to engage in strenuous exercise or resume sexual intercourse until
check up with the doctor.
XIII. BIBLIOGRAPHY