CHEST TRAUMA WHAT IS IT?

? Chest trauma is often sudden and dramatic Accounts for 25% of all trauma deaths 2/3 of deaths occur after reaching hospital WHY DO IT OCCUR? Blunt Trauma- Blunt force to chest. E.g. automobile crashes and falls. Penetrating TraumaProjectile that enters chest causing small or large hole. E.g. gun shot and stabbing. Compression InjuryChest is caught between two objects and chest is compressed. WHAT DOES IT DO? Rib fractures Flail chest Pulmonary contusion Pneumothorax Haemothorax Rib Fracture A rib fracture is a break in a rib bone. Cause is blunt chest trauma (fall, blow to the chest, etc). Symptoms

Shallow respiration atelectasis & pneumonia Pain when coughing Swelling and bruising in the fracture area Internal bleeding Pneumothorax or heamothorax HOW TO DIAGNOSE?

Tachycardia Hypotension

Complication: Hypoventilation Atelectasis Mediastinal flutter (mediastinal structures tend to swing back n forth)

Diagnosis: Palpation : crepitus and tenderness near fractured ribs. chest x-ray ABGs PULMONARY CONTUSION It is damage to the lung tissues resulting in hemorrhage and localized edema. Ecchymosis at the site of the damage Crackels Cough may be present with bloodtinged sputum. Pulmonary contusions tend to worsen over a 24 to 48hour period and then slowly resolve unless complications occur (infection, ARDS). Patients with severe contusions may require endotracheal intubation and mechanical ventilation NURSING IMPLICATION

CHEST XRAY MANAGEMENT Most rib fracture heals in 3 6 weeks. Generally treated conservatively with rest, local heat and analgesics. Monitor for the sign of associated injuries. Rest and do not do physical activity. Adequate pain relief FLAIL CHEST

The flail segment has no bony or cartilaginous connection Moves independently of the chest wall Paradoxical chest movement PARADOXICAL MOVEMENT S/S OF FLAIL CHEST Shortness of Breath Paradoxical Movement Bruising/Swelling Crepitus (Grinding of bone ends on palpation)

Localized pain Tenderness over the fractured area on inspiration and palpation

NURSING DIAGNOSIS

Ineffective Airway Clearance Ineffective Breathing Pattern Impaired Gas Exchange Pain Risk for Infection Activity Intolerance Anxiety Decreased Cardiac output Impaired tissue perfusion Ineffective individual coping Altered health maintenance NURSING IMPLICATION

1. Intercostal Nerve Blocks 2. Epidural Anesthesia. 3. Wearing a chest binder Maintain IV flow rates Monitor S/S of adequate tissue perfusion Anxiety reducing techniques Coping mechanism Heath education/teaching

Closed Laceration in the visceral pleura that allows air from the lung to enter the pleural space; occurs as a result of blunt chest trauma Open Pneumothorax Open Pneumothorax Open Pneumothorax Open Pneumothorax Open Pneumothorax Open Pneumothoarx Open Pnuemothorax Pathophysiology

COMPLICATIONS Pneumonia ARDS Lung abscess Emphysema Pulmonary embolism.

Air enters the pleural space, the affected lung becomes compressed. As the lung collapses, the alveoli become underventilated, Causing V/Q mismatching and intrapulmonary shunting. If the pneumothorax is large, hypoxemia ensues and acute respiratory failure quickly develops. In addition, increased pressure within the chest can lead to shifting of the mediastinum, compression of the great vessels, and decreased cardiac output Tension Pneumothorax

INTERVENTION: Frequent and prompt Respiratory assessment Adequate oxygenation Analgesia to improve ventilation. Clearing secretion Stabilize the thoracic cage Deep breathing exercises Intubation and mechanical ventilation may be required to prevent further hypoxia NURSING IMPLICATION Pain Control Alternative to relieve pain:

PNEUMOTHORAX Pneumothorax is a pocket of air between the two layers of pleura (parietal or visceral), resulting in collapse of the lung. TYPES : Open Pneumothorax Tension Pneumothorax Types Open Laceration in the parietal pleura that allows atmospheric air to enter the pleural space; occurs as a result of penetrating chest trauma

Occurs when air is allowed to enter the pleural space but not exit it; as pressure increases inside the pleural space, the lung collapses and the mediastinum shifts to the unaffected side; may be a result of a spontaneous or traumatic pneumothorax. Tension Pneumothorax Tension Pneumothorax

Tension Pneumothorax S/S OF TENSION PNEUMOTHORAX Anxiety/Restlessness Severe Dyspnea Absent Breath sounds on affected side Tachypnea Tachycardia Poor Color Accessory Muscle Use Hypotension Tracheal Deviation

MEDICAL MANAGEMENT Depending on the severity of the specific disorder. At times requires only supplemental oxygen administration, unless complications occur or underlying lung disease or injury is present. At times urgently require intervention to evacuate the air from the pleural space and facilitate re expansion of the collapsed lung. Treatment Administering supplemental oxygen Inserting a large-bore needle or catheter into the second intercostal space at the midclavicular line of the affected side. This action relieves the pressure within the chest. The needle should remain in place until the patient is stabilized and a chest tube is inserted Chest tube insertion Needle Decompression Locate 2-3 Intercostal space midclavicular line Cleanse area using aseptic technique Insert catheter ( 14g or larger) at least 3 in length over the top of the 3rd rib( nerve, artery, vein lie along bottom of rib) Remove Stylette and listen for rush of air

Place Flutter valve over catheter Reassess for Improvement Needle Decompression Nursing Diagnosis Impaired Gas Exchange related to ventilation/ perfusion mismatching or intrapulmonary shunting

Ineffective Breathing Pattern related to decreased lung expansion Acute Pain related to transmission and perception of cutaneous, visceral, muscular, or ischemic impulses Anxiety related to threat to biologic, psychologic, and/or social integrity Disturbed Body Image related to actual change in body structures, function, or appearance

(late if seen at all) Hyperresonance to percussion Assessment and Diagnosis

Depend on the degree of lung collapse. When a pneumothorax is large, decreased respiratory excursion on the affected side may be noticed, along with bulging intercostal muscles. The trachea may deviate away from the affected side. Percussion reveals hyperresonance with decreased or absent breath sounds over the affected area.

Compromised Family Coping related to critically ill family member NURSING INTERVENTIONS

Continuous and vigilant respiratory assessment Optimizing oxygenation and ventilation, Maintaining the chest tube system Providing comfort and emotional support

ABGs will demonstrate hypoxemia and hypercapnia. A chest x-ray film will confirm the pneumothorax with increased translucency evident on the affected side

Maintaining surveillance for complications. Hemothorax Occurs when pleural space fills with blood Usually occurs due to lacerated blood vessel in thorax As blood increases, it puts pressure on heart and other vessels in chest cavity Each Lung can hold 1.5 liters of blood Hemothorax S/S of Hemothorax Anxiety/Restlessness Tachypnea Signs of Shock Frothy, Bloody Sputum Diminished Breath Sounds on Affected Side Tachycardia Flat Neck Veins Treatment for Hemothorax ABCs Secure Airway assist ventilation if necessary General Shock Care due to Blood loss RAPID TRANSPORT to hospital. Summary

patient survival. Airway management is very important and aggressive management is sometimes needed for proper management of most chest injuries. SICKLE CELL DISEASE What is Sickle Cell Disease? A group of disorders characterized by the production of abnormal hemoglobin S (Hb S) within the erythrocytes. How SCD works: Patho to de-oxygenation and dehydration by solidifying and stretching the erythrocyte into an elongated sickle shape, producing hemolytic anemia.Huether and McCane

Hemoglobin S reacts

Entangled and
enmeshed rigid sickleshaped cells intermittently block microcirculation, causing vascular occlusion.Lippincott Who gets SDC? African Americans Central and South Americans Mediterranean Greeks Italians

Researchers believe the defective hemoglobin gene that causes sickle cell anemia evolved many years ago, among people living in parts of Africa, the Mediterranean, the Middle East and India. At that time, malaria epidemics killed many people in those regions. But some people in those regions had a genetic mutation that caused some of their red blood cells to change shape a condition now known as sickle cell trait. The sickle cells actually interfered with the growth of the parasite that causes malaria. So people with sickle cell trait often survived malaria outbreaks. Over time, these survivors migrated and continued on with their lives. In some cases, two people with the sickle cell trait had children. And some of their children inherited two copies of the mutated gene, which results in sickle cell anemia. Today, millions of people all over the world have sickle cell anemia. How do you know if you have it? than 40 states, including Washington, now perform a simple, inexpensive blood test for sickle cell disease on all newborn infants. This test is performed at the same time and from the same blood samples as other routine newbornscreening tests. Hemoglobin

Blood test More

Caribbean Arabians East Indians Why does race matter?

Chest Injuries are common and often life threatening in trauma patients. So, Rapid identification and treatment of these patients is paramount to

electrophoresis is the most widely used diagnostic test. If the test shows the presence of sickle hemoglobin, a second blood test is performed to confirm the diagnosis. These tests also tell whether or not the child carries the sickle cell trait. Signs and Symptoms Anemia Episodes of Pain Jaundice Frequent infections Priapism Fatigue Paleness Shortness of breath Vision problems Gall Stones Complications Stroke-blood can become congested and form clots Acute chest syndrome Similar to pneumonia, this life-threatening complication is caused by infection or trapped sickled cells in the lung. It is characterized by chest pain, fever, and an abnormal chest X ray.

Infections-r/t damage to spleen Blindness-the microvasculature that supply the eyes with blood can become clogged with sickled red blood cells and this can lead to damage of the retina Gallstones-The breakdown of red blood cells produces a substance called bilirubin. Bilirubin is responsible for yellowing of the skin and eyes (jaundice) in people with sickle cell anemia. A high level of bilirubin in your body can also lead to gallstones. http://www.mayoclinic. com/print/sickle-cellanemia/DS00324/DSEC TION=all&METHOD=pri nt Stunted growth-a shortage of healthy RBCs can lead to slowing of growth and delay in puberty Hand-foot syndrome-r/t to swelling in the hands and feet due to sickled cells blocking blood flow This is often one of the first signs of SCD in babies

counseling to determine if SCD is a possibility (along with many other genetic diseases) A form of possible prevention: There is an in vitro fertilization procedure that improves the chances for parents who both carry the sickle cell gene to have a child with normal hemoglobin. This procedure is known as pre-implantation genetic diagnosis. First, eggs are taken from the mother. Then, sperm is taken from the father. In a laboratory, the eggs are fertilized with the sperm. The fertilized eggs are then tested for the presence of the sickle cell gene. Fertilized eggs free of the sickle cell gene can be implanted into the mother for normal development. However, this procedure is expensive and not always successful. http://www.mayoclinic. com/print/sickle-cellanemia/DS00324/DSEC TION=all&METHOD=pri nt Treatment Transfusions correct anemia by increasing the number of normal red blood cells in circulation. They can also be used to treat spleen enlargement in children before the condition becomes lifethreatening. Regular transfusion therapy can help prevent recurring

Other complications can occur most often r/t vaso-occlusion and the damage it causes Prevention The only way to definitely prevent SCD is to know your risk and act accordingly You and your partner can receive genetic

Blood Transfusions -

Organ damage-caused by vaso-occlusion

strokes in children at high risk.

Oral Antibiotics -

Giving oral penicillin twice a day beginning at 2 months and continuing until the child is at least 5 years old can prevent pneumococcal infection and early death. Recently, however, several new penicillinresistant strains of pneumonia bacteria have been reported. Since vaccines for these bacteria are ineffective in young children, studies are being planned to test new vaccines. first effective drug treatment for adults with severe sickle cell anemia was reported in early 1995, when a study conducted by the National Heart, Lung, and Blood Institute showed that daily doses of the anticancer drug hydroxyurea reduced the frequency of painful crises and acute chest syndrome. Patients taking the drug needed fewer blood transfusions.

Before the transplant can take place the patients current bone marrow needs to be destroyed using chemotherapy or radiation Potential complications: death, graft rejection, graft versus host disease, reoccurrence of SCD, long term immunosuppression, Why dont more patients have transplants? High rate of morbidity and mortality Only 38% of children with SCD meet the criteria of the National Collaborative Study for Transplantation IT HURTS!!!!!

drug seeking, their pain is what they say it is Treating Their Pain Ask what works for themmost of the time they know what eases their pain They need: rest, rehydration, analgesics

NSAIDsOpioids PCA Hydroxyureahas been used to treat acute chest syndrome and pain episodes Increases fetal hemoglo bin

Hydroxyurea - The

Dont be alarmed by dosesbecause of the severity of sickle cell pain doses of narcotics are often much higher

Pain occurs due to vaso-occlusion, sickled cells stick together and block blood flow through capillaries Vaso-occlusion leads to local tissue hypoxia, which in turn leads to tissue infarction and necrosis Recurrent sickle cell crises lead to damage of the bones, joints and visceral organs which leads to chronic pain Locations most often effected by pain: back, knees, arms, legs, chest & abdomen The reported incident of opioid addiction is no more than 3%--Do not make the mistake of assuming patients are

Cure Bone marrow or stem cell transplants are currently the only cure for sickle cell Indications for transplant: hx of stroke, recurrent episodes of acute chest syndrome, recurrent episodes of vasoocclusion without evidence of end organ damage

Ex: recommended dose range of morphine for someone with SCD is 2x the normally recommended range Doses are often higher than what would normally be used for pain management in other conditions

Teach about nonpharmacological methods of pain relief Ex: Heat application, massage, acupuncture, TENS

Nursing Diagnoses 1.) Activity intolerance r/t fatigue, effects of chronic anemia. 2.) Acute Pain r/t viscous blood, tissue hypoxia 3.) Deficient Fluid volume r/t decreased intake, increased fluid requirements during sickle cell crisis, decreased ability of kidneys to concentrate urine. 4.) Impaired physical Mobility r/t pain, fatigue. 5.) Risk for ineffective tissue perfusion: renal, cerebral, cardiac, gastrointestinal, peripheral r/t effects of red cell sickling; infarction of tissues Nursing Interventions

*Instruct in availability to assistive devices, if appropriate 5.) *Evaluate peripheral pulses *Inspect skin for arterial ulcers and tissue breakdown Outcomes

4.) *Client will increase physical mobility. *Client will meet mutually defined goals of increased mobility. *Client will verbalize feeling of increased strength and ability to move. *Client will demonstrate use of adaptive equipment to increase mobility. 5.) *Client will demonstrate adequate tissue perfusion as evidenced by palpable peripheral pulses, warm and dry skin, adequate urinary output, and absence of respiratory distress. *Client will verbalize knowledge of treatment regimen, including appropriate exercise and medications and their actions and possible side effects. *Client will identify changes in lifestyle that are needed to increase tissue perfusion. How can we help them? Patient teaching!

1.) *Client will maintain normal skin color and skin is warm and dry with activity. *Client will verbalize an understanding of the need to gradually increase activity based testing, tolerance, and symptoms. *Client will express an understanding of the need to balance rest and activity. *Client will demonstrate increased activity intolerance. 2.) *Client will use pain rating scale to identify current pain intensity and determine comfort/function goal. *Client will describe how unrelieved pain will be managed. *Client will report that pain management regimen relieves pain to satisfactory level with acceptable and manageable side effects. *Client will perform activities of recovery with reported acceptable level of pain. 3.) *Client will maintain urine output more than 1300ml/day. *Client will maintain normal blood pressure, pulse, and body temperature. *Client will maintain elastic skin turgor; moist tongue and mucous membranes; and orientation to person, place, and time.

1.) *Monitor cardio-respiratory response to activity *Monitor location and nature of discomfort or pain during movement/activity 2.) *Ensure that client receives attentive analgesic care *Perform a comprehensive assessment of pain, including location, characteristics, onset/duration, frequency, quality, intensity or severity and precipitating factors 3.) *Monitor hydration status (moist mucus membranes, adequacy of pulses, and orthostatic blood pressure) as appropriate 4.) *Assist the client to use footwear that facilities walking and prevents injury

1. Proper nutrition- foods high in folic acid 2. Good hygiene-provides some protection against infection and ulcers 3. Protection against infections 4. Avoidance of other stresses 5. Drink plenty of water 6. Exercise regularly, but dont over do it 7. Avoid high-altitude areas 8. Fly on commercial airplanes with

pressurized passenger cabins HIGH RISK PREGNANCY Is one in which concurrent disorder, pregnancy-related complication, or external factor jeopardizes the health of the mother, the fetus, or both

Marital status and children

Assessment of Fetal Health Nurses responsibility Preparing patient properly for test Explaining reason for test Clarifying and interpreting results in collaboration with other HCPs Providing support to patient ULTRASOUND IMAGES

Objective Assessment client, evaluate: Height Weight BMI

When observing the

HIGH RISK PREGNANCY CARE . . . refers to the identification and management of a highrisk pregnancy to promote HEALTHY OUTCOMES for the mother and the baby. NURSING ASSESSMENT Subjective Assessment female comes to you, you should ask: Name Age Medical history Genetic history Previous surgeries Current/past medications If they have ever or are using street drugs or smoking Alcohol/caffein e use Occupation and current working status

Blood Pressure General alignment Range painful movement

OTHER ASSESSMENT PARAMETERS Vital signs taking especially BP include weight for baseline 1st tri - 1.5-3lbs

4D US Images Kick Count Assessment Tool Doppler Ultrasound Blood Flow Assessment AFP Amniocentesis Amniocentesis Amniocentesis

When pregnant

2nd and 3rd tri 10-11 lbs with total allowable wt gain of 20-25lbs (10-12 kg) for the entire period

Pelvic exam empty

the bladder first

Internal exam and

pap smear position and drape the client, do not leave the client during the entire procedure especially with a male doctor. maneuver to determine presentation, position and attitude, estimated fetal weight through fundic height (FH13x.32), locate fetal parts and FHT FUNDIC HEIGHT MEASURING FUNDIC HEIGHT

determine the health of an unborn baby. Amniotic fluid contains cells that are normally shed from the fetus. Samples of these cells are obtained by withdrawing some amniotic fluid. The chromosome analysis of these cells can be performed to determine abnormalities. In addition, the cells may be cultured and analyzed for enzymes, or for other materials that may indicate genetically transmitted diseases. Other studies can be

Do the leopolds

done directly on the amniotic fluid including measurement of alpha-fetoprotein. NST Percutaneous Blood Sampling Percutaneous Blood Sampling Percutaneous Umbilical Blood Sampling is a diagnostic test that examines blood from the fetus to detect fetal abnormalities. PREGNANCY: Vaginal bleeding Persistent vomiting Chills & fever Sudden gush of fluid Abdominal or chest pain Increase/decre ase in fetal movements PIH

MATERNAL LIFESTYLE AND HABITS FAMILY CULTURE AND ETHNICITY FAMILY HISTORY Conditions During Pregnancy Constipation Affects half of pregnant women Causes: increase in progest erone the colon absorbi ng more water worse in first 1314 weeks

fatigue in the 1st trimester. Causes: Body is working harder More levels of progeste rone,

Treatment: Take naps Drink plenty of fluids, but avoid fluids 23hr before bed. Exercise Gentle stretches before bedtime can help prevent nighttim e cramping Eat foods rich in protein

DANGER SIGNS OF

Treatment: Drink plenty of fluids Eat high fiber foods Take fiber supple ments EXERCIS E!

FACTORS THAT PLACE THE WOMAN AT RISK AGE PARITY PRESENCE OF CHRONIC OR ACUTE MEDICAL CONDITION MATERNAL OBSTETRIC AND GYNECOLOGIC HISTORY MATERNAL MEDICAL HISTORY

Conditions During Pregnancy Back Ache Many women experience back aches during 2nd and 3rd trimesters Causes: Poor posture Extra weight

Conditions During Pregnancy Fatigue Almost all women report increased

Change in centre of gravity Hormon es

BLOOD LOSS intravascular volume venous return cardiac output blood pressure compensatory mechanism: heart rate respiratory rate vasoconstriction of peripheral blood vessels Feeling of apprehension Body changes

FIRST-TRIMESTER BLEEDING ABORTION defined as any interruption of a pregnancy before the fetus is viable. This is medically or surgically interrupted. 1. SPONTANEOUS MISCARRIAGE interruption occurs spontaneously without medical intervention. 2. ECTOPIC PREGNANCY refers to implantation of the ovum outside the uterine cavity FACTORS ASSOCIATED WITH SPONTANEOUS MISCARRIAGE FETAL FACTORS Defective embryonic development Faulty implantation of the fertilized ovum Failure of the endometrium to accept the fertilized ovum.

Treatment: Pay attentio n to posture Exercise S w i m m in g

Pillow support in bed Ask for assistan ce when lifting heavy objects Heat/col d Massag e Support belt Wear supporti ve low heel shoes

Cold, clammy skin uterine perfusion Persistent pressure in blood

renal, uterine, and brain perfusion Lethargy, coma, and decreased renal output Renal failure maternal and fetal death SIGNS AND SYMPTOMS OF HYPOVOLEMIC SHOCK 7 WEEKS 8 WEEKS 9 WEEKS 10 WEEKS 11 WEEKS 22 WEEKS Conditions associated with

PLACENTAL FACTORS Premature separation of the normally implanted placenta Abnormal placenta

BLEEDING DURING PREGNANCY

VAGINAL BLEEDING is a deviation from normal that may occur at any time during pregnancy. PATHOPHYSIOLOGY:

FACTORS ASSOCIATED WITH SPONTANEOUS MISCARRIAGE

MATERNAL FACTORS Maternal infection Severe malnutrition Abnormalities of the reproductive tract eg, incompetent cervix

TYPES OF SPONTANEOUS MISCARRIAGE miscarriage part of the conceptus (usually the fetus) is expelled, but the membranes or placenta is retained in the uterus.

DIAGNOSTICS Presence of hCG in the blood or urine confirms pregnancy Decreas ed hCG levels suggest spontan eous abortion

Incomplete

Missed miscarriage
early pregnancy failure, the fetus dies in utero but is not expelled.

OTHERS Drug ingestion Trauma, including surgical manipulation Blood group incompatibilit y and Rh isoimmunizati on

Recurrent pregnancy
loss description used for women who had three spontaneous miscarriages A miscarriage pattern.

Pelvic exam reveals size of the uterus, which is inconsistent with the length of pregnancy Tissue cytology indicates products of conception Lab test reflect decreased hgb levels and hct from blood loss Ultrasonograp hy positive for presence or absence of fetal heartbeats or an empty amniotic sac.

TYPES OF SPONTANEOUS MISCARRIAGE miscarriage manifested by vaginal bleeding initially in the beginning as scant bleeding, and usually bright red.

COMPLICATIONS OF MISCARRIAGE Hemorrhage Infection Septic abortion Isoimmunization Powerlessness ASSESSMENT SIGNS AND SYMPTOMS Spontaneous vaginal bleeding Passage of clots or tissue through the vagina Low uterine cramping or contractions Hemorrhage and shock

Threatened

Imminent

(inevitable) miscarriage uterine contraction and cervical dilatation occur. With cervical dilation, products of conception cannot be halted. miscarriage entire products of conception (fetus, membranes, and placenta) are expelled spontaneously w/o any assistance.

MANAGEMENT OF SPONTANEOUS MISCARRIAGE NURSING DIAGNOSES Acute or chronic pain Risk for infection Sexual dysfunction Anxiety

Complete

Situational low selfesteem Ineffective coping Deficient knowledge Risk for fluid volume deficit NURSING MANAGEMENT Do not allow bathroom privileges because the patient may expel uterine contents w/o knowing it. After bedpan use, inspect contents carefully for intrauterine material Note the amount, color, and odor of vaginal bleeding. Save all pads the patient uses for evaluation. Administer an analgesic and oxytocin as ordered. Assess vital signs q 4hrs for 24hrs or more frequently, depending on the extent of bleeding. Monitor urine output closely. NURSING MANAGEMENT Provide good perineal hygiene Check the patients blood type and administer RhoGam as ordered. Provide emotional support and counseling during the grieving process.

Encourage the patient and her partner to express their feeling Some couples may want to talk to a member of the clergy Others, depending on their religion, may wish to have the fetus baptized.

than mild abdominal pain ( the latter especially likely in abdominal pregnancy) Amenorrhea or abnormal menses (after fallopian tube implantation) Abnormally low hCG titers

Help the patient and her partner to develop effective coping strategies. Explain all procedures and treatments to the patient and provide teaching about aftercare and followup. ECTOPIC PREGNANCY Refers to the implantation of the fertilized ovum outside the uterine cavity. ECTOPIC PREGNANCY Most common location: fallopian tube

Rupture of the tube produces sudden, severe abdominal pain often radiating to the shoulder as the abdomen fills with blood. Pain is commonly precipitated by activities that increase abdominal pressure, such as bowel movement

Ruptured tube. . . Extreme pain with the movement of the cervix and palpation during pelvic exam Uterus boggy and tender Rectal pressure if blood collects in Douglas cul-de-sac Syncope Nausea and vomiting Shock with profuse hemorrhage

Second most common cause of vaginal bleeding during pregnancy Results from any condition that prevents or retards the passage of a fertilized ovum through the fallopian tube. ASSESSMENT Symptoms of normal pregnancy or no symptoms other

DIAGNOSTIC FINDINGS

Serum pegnancy test (hCG) tets result shows an abnormally low level of hCG Real-time ultrasonography determination of intrauterine pregnancy or ovarian cyst (performed if serum pregnancy test results are positive) Culdocentesis (aspiration of fluid from the vaginal culde-sac) detects free blood in the peritoneum (performed if ultrasuond detects absence of a gestational sac in the uterus. Laparoscopy may reveal pregnancy outside the uterus (performed if culdocentesis is positive) MANAGEMENT RUPTURE OF ECTOPIC PREGNANCY

Methotrexate administered to stop division of embryo. Careful follow-up of the hCG levels until not detectable. MANAGEMENT Supportive treatment: transfusion with whole blood or packed RBCs to replace excessive blood loss Administration of a broad spectrum IV antibiotic for sepsis Administration of supplemental iron (given orally or IM) Institution of a high protein diet.

NURSING MANAGEMENT Ask the patient the date of her last menses and obtain serum hCG levels as ordered. Assess vital signs and monitor vaginal bleeding for extent of fluid loss. Check the amount, color, and odor of vaginal bleeding; monitor pad count. Withhold oral food or fluid (maintain nothing by mouth status) in anticipation of possible surgery; prepare the patient for surgery, as indicated. NURSING MANAGEMENT Assess the patient for signs of hypovolemic shock secondary to blood loss from tubal rupture, and monitor urine output closely for a decrease suggesting fluid volume deficit. Administer blood transfusions (for replacement) as ordered and provide emotional support. Record the location and character of the pain, and administer an analgesic as ordered. Determine if the patient is Rhnegative; if she is, administer Rh0D immune globulin (RhoGAM) as ordered after

is an emergency situation and the womans condition must be evaluated quickly! MANAGEMENT Some ectopic pregnancies resolve spontaneously, requiring no treatment. Laparoscopic removal of the ruptured tube (salpingectomy); if ovarian pregnancy, oophorectomy. Incision on the tube to remove the pregnancy (salpingostomy).

Emotional support for parents grieving over the loss of the pregnancy. NURSING DIAGNOSES

Risk for deficient fluid volume related to bleeding or hemorrhage with ectopic rupture Parental role conflict related to fetal loss

Powerlessness related to early loss of pregnancy secondary to ectopic pregnancy

treatment or surgery. NURSING MANAGEMENT Provide a quiet, relaxing environment, and offer the patient emotional support To prevent recurrent ectopic pregnancy, urge the patient to have pelvic infections treated promptly to prevent diseases of the fallopian tube. Inform patients who have undergone surgery involving the fallopian tubes or those with confirmed pelvic inflammatory disease that theyre at increased risk for another ectopic pregnancy.