case presentation about ectopic pregnancy

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University of San Jose –Recoletos COLLEGE OF NURSING Cebu City, Philippines

A Study on the Case of Obstetric Client F.B.M., Female, 25 Years Old, Diagnosed with Ruptured Ectopic Pregnancy, Right Uterine Tube, undergone Exploratory Laparotomy, Right Salpingo-oophorectomy Removal of the fallopian tube/ removal of the ovary

In Partial Fulfillment of the Requirements in NCM 102 –RLE

Perpetual Succour Hospital Station 3B, Sto. Niño & St. Elizabeth Wards Third Rotation (Feb 15-19, March 1-5, 2010)

Presented to the Faculty of the University of San Jose –Recoletos College of Nursing

Submitted to Gonzalve, Ronnie, Jr, BSN, RN

5 March 2010

A Study on the Case of Obstetric Client F.B.M., Female, 25 Years Old, Diagnosed with Ruptured Ectopic Pregnancy, Right Uterine Tube, undergone Exploratory Laparotomy, Right Salpingo-oophorectomy

conducted by BSN II Block II Group I

TABLE OF CONTENTS Contents

i

Introduction

1

Objectives

3

Nursing Assessment Client’s Profile

4

Physical Assessment

5

Gordon’s Functional Health Patterns

6

Laboratory Findings

8

Anatomy and Physiology of the Female Reproductive System

10

Pathogenesis of Ectopic Pregnancy

12

Nursing Care Plans

13

Discharge Plan

16

Drug Study

17

Bibliography

21

Appendix

22

I. INTRODUCTION literature)

(lacking

of

statistical

data/

epidemiology

–Philippines-/

An ectopic pregnancy is one in which implantation occurs outside the uterine cavity. The implantation may occur on the surface of the ovary or in the cervix. The most common site (in approximately 95% of such pregnancies) is in the uterine tube. Of these uterine tube sites, approximately 80% occur in the ampullar portion, 12% occur in the isthmus, and 8% are interstitial or fimbrial. With ectopic pregnancy, fertilization occurs as usual in the distal third of the uterine tube. Immediately after the union of the ovum and the spermatozoon, the zygote begins to divide and grow normally. Unfortunately, because an obstruction is present, such as adhesion of the uterine tube from a previous infection (chronic salpingitis or pelvic inflammatory disease), congenital malformations, scars from tubal surgery, or a uterine tumor pressing the proximal end of the tube, the zygote cannot travel the length of the tube. It lodges at the strictured site along the uterine tube and implants there instead of in the uterus. Approximately 2% of pregnancies are ectopic; ectopic pregnancy is the second most frequent cause of bleeding in early pregnancy. The incidence is increasing because of the increasing rate of pelvic inflammatory disease, which leads to tubal scarring. Ectopic pregnancy occurs more frequently in women who smoke compared to those who do not. There is some evidence that intrauterine devices (IUDs) used for contraception may slow the transport of the zygote and lead to an increased of tubal or ovarian implantation. The incidence also increases following an in vitro fertilization. Women who have one ectopic pregnancy have a 10% to 20% chance that a subsequent pregnancy will also be ectopic. This is because salpingitis that leaves scarring is usually bilateral. Congenital anomalies such as webbing (fibrous bands) may also be bilateral. Surprisingly, oral contraceptives may reduce the possibility of ectopic pregnancy. (3 classification of ectopic pregnancy – pain, bleeding and abd tenderness) Assessment With ectopic pregnancy, there are no unusual symptoms at the time of implantation. The corpus luteum of the ovary continues to function as if the implantation were in the uterus. No menstrual flow occurs. A woman may experience the nausea and vomiting of early pregnancy, and pregnancy test for human chorionic gonadotrophin (hCG) will be positive. At weeks 6 to 12 of pregnancy (2 to 8 weeks after a missed menstrual period), the zygote grows large enough to rupture the slender uterine tube or the trophoblast cells break through the narrow base. Tearing and destruction of the blood vessels in the tube result. The extent of the bleeding that occurs depends on the number and size of the ruptured vessels. If implantation is in the interstitial portion of the tube (where the tube joins the uterus), the rupture can cause severe intraperitoneal bleeding. Fortunately, the incidence of tubal pregnancies is highest in the ampullar area (the distal third), where the blood vessels are smaller and profuse hemorrhage is less likely. However, continued bleeding from this area may in time result in a large amount of blood loss. Therefore, a ruptured ectopic pregnancy is serious regardless of the site of implantation. A woman usually expediencies a sharp, stabbing pain in one of her lower abdominal quadrants at the time of the rupture, followed by scan vaginal spotting. With placental dislodgement, progesterone secretion stops and the uterine decidua begins to slough, causing additional bleeding. The amount of bleeding evident with a ruptured ectopic pregnancy often does not reveal the actual amount present, however, because the products o conception from the ruptured tube and the accompanying blood may be expelled into the pelvic cavity rather than into the uterus. Therefore, this blood does not reach the vagina to become evident. If internal bleeding progresses to acute hemorrhage, a woman may experience lightheadedness and rapid pulse, signs of shock. When helping determine the possibility of an ectopic pregnancy, ask a woman whether she has pain or vaginal bleeding. Any woman with sharp abdominal pain and vaginal

spotting needs to be evaluated by her health care provider to rule out the possibility of ectopic pregnancy. Occasionally, a woman will move suddenly and move and pull one of her round ligaments, the anterior uterine supports. This can cause a sharp, but momentarily and innocent, lower quadrant pain. However, it would be rare for this phenomenon to be reported in connection with vaginal spotting. By the time a woman with a ruptured ectopic pregnancy arrives at the hospital of physician’s office, she may already be in severe shock, as evidenced by rapid, thready pulse, rapid respirations, and falling blood pressure. Leukocytosis may be present, not from infection but from trauma. Temperature is usually normal. A transvaginal sonogram will demonstrate the ruptured tube and blood collecting in the peritoneum. Either a falling hCG or serum progesterone suggests that pregnancy has ended. If the diagnosis of ectopic pregnancy is in doubt, a physician may insert a needle through the postvaginal fornix into the cul-de-sac under sterile conditions to see whether blood can be aspirated. A laparoscopy or culdoscopy can be used to visualize the uterine tube if the symptoms alone do not reveal a clear picture of what has happened. However, sonography alone usually reveals a clear-cut diagnostic picture. If a woman waits before seeking help, gradually her abdomen becomes rigid from peritoneal irritation. Her umbilicus may develop a bluish tinge (Cullen’s Sign). A woman may have continuing extensive or dull vaginal and abdominal pain; movement on the cervix on pelvic examination my cause excruciating pain. There may be pain in her shoulders from blood in the peritoneal cavity causing irritation to the phrenic nerve. A tender mass is usually palpable in Douglas’ cul-de-sac on vaginal examination. Therapeutic Management Although some ectopic pregnancies spontaneously end and then reabsorbed, requiring no treatment, it is difficult to predict when this will happen, so when an ectopic pregnancy is revealed by an early sonogram, some action is taken. If an ectopic pregnancy can be diagnosed before the tube has ruptured, it can be treated medically by oral administration of methotrexate and leucovorin. Methotrexate, a folic acid antagonist chemotherapeutic agent that attacks and destroys fast-growing cells. Because trophoblast and zygote growth is rapid, the drug is drawn to the site of ectopic pregnancy. Women are treated until a negative hCG titer is achieved. A hestrosalpingogram or sonogram is usually performed after the chemotherapy to assess whether the tube is fully patent. Mifepristone, an abortifacient, is also effective at causing sloughing of the tubal implantation site. The advantage of these therapies is that the tube is left intact, with no surgical scarring that could cause second ectopic implantation. If an ectopic pregnancy ruptures, it is an emergency situation. Keep in mind that the amount of blood evident is a poor estimate of the actual blood loss. A blood sample needs to be drawn immediately for hemoglobin level, tying, and cross-matching, and possibly hCG level for immediate pregnancy testing, if pregnancy has not yet been confirmed. Intravenous fluid using a large-gauge catheter to restore intravascular volume is begun. Blood then can be administered through this same line when matched. The therapy for ruptured ectopic pregnancy is laparoscopy to ligate the bleeding vessels and to remove or repair the damaged uterine tube. A rough suture line on the uterine tube may lead to another tubal pregnancy, so either the tube will be removed or suturing on the tube is done with microsurgical technique. If a tube is removed, a woman is theoretically only 50% fertile, because every other month, when she ovulates next to the removed tube, sperm cannot reach the ovum on that side. However, this is not reliable contraceptive measure. Research in rabbits has shown that translocation of ova can occur –that is, an ovum released from the right ovary can pass through the pelvic cavity to the opposite (left) uterine tube and become fertilized and vice versa.(salphigictomy-removal of the fallopian tube.)

As with miscarriage, women with Rh-negative blood should receive Rh (D) immune globulin (RhIG) after an ectopic pregnancy fro isoimmunization protection in future childbearing. (See Appendix for illustrations)

II. OBJECTIVES Generally, later than three weeks of orientation and exposure at the Perpetual Succour Hospital –Station 3B, the proponents should contribute to the practice of managing ectopic pregnancy cases in any clinical setting by utilizing the acceptable notions, skills, and outlooks that they will be achieving from this study. Specifically, later than three weeks, the proponents should: 1) devise a complete output on the specified client and condition through obtaining apt orientation and clear instructions from the clinical instructor on how to devise the study. 2) pool all data for printing and binding and finish the study before March 5, 2010, Friday, the scheduled date of presentation. 3) submit the final hard and soft copies of the output to the clinical instructor. 4) gather as a group for brainstorming of ideas making use of individual researches about the disease condition. 5) present the case study on the scheduled date. 6) defend the case study in front the panelists by answering the relevant questions thrown by them. 7) identify and describe the signs and symptoms of ectopic pregnancy. 8) map out and explain the disease process of ectopic pregnancy. 9) identify and describe the various management –for ectopic pregnancy.

managements

–especially

nursing

10)gather again as a group for pointers and reactions from each member and from the clinical instructor after the case presentation.

III. NURSING ASSESSMENT Client in Context Client F.B.M., 25 years old, female, 5 weeks age of gestation; admitted to Perpetual Succour Hospital for the first time on March 02, 2010 at 8:58 A.M., accompanied by her husband; in for complaints of right, lower abdominal pain; pre-operative diagnosis – ectopic pregnancy; operative diagnosis –ruptured ectopic pregnancy, right uterine tube; undergone major operation on March 02, 2010 at 10:00 A.M. –exploratory laparostomy, right salpingo-oophorectomy; under the services of Dr. Lyn Alana Busa of the Department of Obstetrics; with hospital number 219923.

Biographical Data Name of Client: F.B.M.

Sex: Female

Age:

25

years old Civil Status: Married Religion: Kristohanon Address: Holy Name, Mabolo, Cebu City Birthdate: October 6, 1984

Nationality: Filipino

Education: College Graduate

Occupation: Stocks In-charge, Ever Care

Contact No: 0926… Birthplace: Ipil, Zamboanga Sibugay

Health Insurance: PhilHealth Date and Time of Admission: March 02, 2010 at 8:58 A.M. Informant / Relation to Client: U.R.M. / Husband Reliability: Reliable

Chief Complaints and History of Present Illness Client not aware of pregnancy, LMP on January 22, 2010; experienced vaginal spotting with minimal bleeding on February 24, 2010, regarded as usual menstruation, drank beer; experienced abdominal pain on afternoon of February 27, 2010, 3 days PTA, started at RLQ, squeezing in quality, tolerable, radiated downwards to right thigh, no other associated symptoms such as fever, nausea and vomiting; no medications taken, no consultation; pain persisted and increased in quality on March 02, 2010, thus prompted admission; ER blotter: T 36.4°C, HR 92 bpm, RR 24 cpm, BP 90/60 mmHg.

Past Health History Childhood Illness: Fever, Cough, Cold Surgeries: None Serious Injuries: None Immunizations: Can’t recall Allergies: No known food, drug, dust allergies Blood Transfusions: None Hospitalizations:

CONDITION

INSTITUTION

DATE

None Medications before Admission Medication Name

Dose/Frequency

Time of Last Dose

Medication Name

Dose/Frequency

Time of Last Dose

None

PHYSICAL ASSESSMENT General appearance Client F.M, 25 years old married and resident of holyname mabolo cebu city. She was seen grimacing once in awhile. She can now move minimally with assistant and was able to turn sides occasionally. She was still pale and weak. Vital signs Temperature: 36.8°C Pulse: 79 bpm Respiration: 20 cpm Blood Pressure: 90/60 mmHg Height: 5 feet Weight: 47kg Integumentary Skin is fair colored, warm, soft, and smooth, with moles at the right lower face, left upper face behind the left nares and freckles around the left upper forehead; trauma in the right dorsal part of the hand; hairs is thick, long, wavy, without parasites nor flakes on the scalp; no clubbing present, negative capillary test (3 sec) HEENT Head/face normocephalic; no tenderness or masses; facial features symmetrical. Vision was not assessed, extraocular muscles intact, visual fields normal by confrontation, cornea and iris are intact, sclera is white, conjunctivae clear and pale pink, PERRLA, positive constriction and convergence. External ear canals clear without redness, swelling, lesions, and tympanic membrane intact, gray. Nares patent, no sinus tenderness present; nasal mucosa pink, cilia noted; septum intact, no deviation. Lips dry; oral mucosa and gingivae pink and moist without lesions; 32 ivory colored teeth, dental cary noted at the upper left canine; tonsils are not assessed; tongue is smooth pink, symmetrical, no lesions. Neck and Axillae Positive swallow reflex Thorax Breasts symmetrical; light brown areolas and nipples with no masses or discharges; normal spinal curvatures Abdomen Sutures seen in the abdomen, Wasn’t able to auscultate abdomen due to abdominal binder present and the client felt the pain when binder was loose Musculoskeletal System and Extremities Full ROM of lower extremities (patient was sitting with her legs dangling), upper extremities are not fully movable because of the IVF at the right arm and the left arm is still in trauma; skin is warm, hairs are visible in both legs; wasn’t able to assess gait, heelto-toe walk and the likes because client is still lethargic and still needs assistance in moving.

Neuro-sensory NO DATA Genitalia-Rectum Menarche at 13 years old, regular for 3 days, consumes 1 napkin in a day; positive dysmenorrheal; GORDON’S FUNCTIONAL HEALTH PATTERNS 

Health Perception –Health Management “Health is wealth. Importante ni aron mabuhi, so that we could do everything we want” as verbalized by the patient. She scaled her health as 7/10. Patient said that if ever she or a member of her family is sick, they usually buy OTC drugs. They don’t really go to health center because they are renting an apartment far from a health center. They sometimes use herbal medicine such as “kalabo” w/c can be used for treatment of cough.



Nutritional –Metabolic Patient eats 3 meals a day. For breakfast, she eats fish, rice and drinks milk. For lunch she eats 1cup of rice, fish and drinks orange juice and for dinner she usually eats vegetables, a cup of rice and milk. Patient eats snack between meals. When she was admitted she said that her eating pattern is not the same before, she can only eat 2-2 ½ cup of rice for the 3meals compared to 3-4 cups of rice for the 3 meals before she was admitted



Elimination Prior to admission and during admission, patient’s elimination pattern is still the same. She urinates 4-5x a day with approximately 240- 250 ml per void. She defecates 4-5x a week. She said that she is constipated. Patient said that she noticed if she eats apple in the morning she can defecate an hour or two after.



Activity –Exercise

She wakes up early every morning. Before going to work she strolls outside their apartment as her exercise. She spends 30mins- 1hr walking. At work, she usually rest during her break. She takes a nap every break time. Now that she is admitted her activity is limited because she needs rest due to her surgery. 

Sleep –Rest Patient usually wakes up at 6-7 in the morning and sleep at around 10:30 in the evening. She can only take a nap sometimes. So far she doesn’t talk while sleeping but ‘’hagok’’ if she’s very stress from work. She also mentioned that previously she treat her insomnia by means of taking ‘’4G’’ but as of now she takes ferrous sulfate to treat her insomnia. During her admission, patient sleeping pattern was different because patient doesn’t have enough sleep due to some noise in the ward.



Cognitive –Perceptual The client can understand well. She responds calmly to the interviewers. She has no difficulties in all her senses. When she was admitted, she said she was exhausted.



Role –Relationship Patient aware that her responsibilities in the family is to be a good, loving, caring, understanding wife to her husband and to their future children. As a wife, she said that she takes care of her husband’s needs like cooking him for breakfast, preparing his food for work. She is very close to her husband, she even ask advices from her husband. She is not very close to her siblings because it’s been long time since

they’ve seen each other. In work, she believes that she’s almost responsible to all. She defines roles and responsibilities in life as a law and is to be followed accordingly. The client felt sadness after knowing that her baby has already gone. Her husband is always at her side to comfort her . 

Value –Belief Patient doesn’t believe on horoscope as well as fortune/palm reading because she believes that we are the one making our future by means of self-decision making. She also believes that God has already planned our individual life. Patient is a protestant but considered herself as a catholic in general because she is one of the Christ believers but in terms of religious beliefs, she doesn’t worship saints and do the sign of the cross. During assessment, we observed that patient is religiously active.



Self-perception –Self-concept Patient describes herself as emotional, hard working and of course loving wife to her husband. She’s emotional, because according to her, she’s very sensitive (emotionally); hardworking, because she really focuses on her work; lastly, she’s loving wife, because she still have time for her husband although she’s workaholic.



Coping –Stress Patient stated that, ‘’A problem is part of our lives. It molds us to become stronger.’’ For her, problem is like a challenge that if without it; a person won’t fully enjoy and feel life’s accomplishments and satisfaction. She also mentioned during assessment that problems gives stress and makes a person very depress unless that certain person knows how to handle it. Her ways in coping up with problems/stressors are to always pray and ask God’s guidance; Work on it in order to solve it whether by herself or with the help of others.



Sexuality –Reproductive Patient stated that she had her first menstruation at the age of 13. Her menstruation is regular, usually lasts for 3 days, and she consumes at least 1 sanitary pad per day. She rated her sexual satisfaction as 9/10. .. … …. ….. …… ……

IV. LABORATORY FINDINGS Exam date: March 02, 2010 URINALYSIS MACROSCOPIC Color (Urine) Appearance Glucose Protein pH Specific gravity Bilirubin Urobilinogen Urine ketone Nitrite Leukocytes Blood

Umol/ L Mg/ dl

/hpf /hpf

MICROSCOPIC RBC/ hpf WBC/ hpf Epithelial cells Mucus threads Amorphous material Bacteria LEGEND NEG= Negative POS= Positive + = 30mg/dl TNTC= Too numerous to count ++ = 100mg/dl OCC= Occational +++ = 300mg/dl

BLOOD +

PROTEIN 0.03mg/dl

=

++

=

0.2mg/dl

+++

=

1.0mg/dl

++++

=

2000mg/dl BILIRUBIN + = 1mg/ dl ++ = 2mg/ dl +++ = 4mg/ dl

SCLOUD= Slightly Cloudy LTYLW= Lightly yellow DKYLW= Dark yellow

GLUCOSE UROBILINOGEN + + = 2mg/dl ++ = ++ = 4mg/dl +++ = +++ = 8mg/dl ++++ = ++++ = 12mg/dl KETONE LEUKOCYTES + = 25mg/dl + = 25wbcs/ ul ++ = ++ = 75 wbcs/ul

=50mg/dl 150mg/dl 500mg/dl 1000mg/dl

100mg/dl

LTORNG= Light orange

+++ = +++ = 500wbcs/ul

300mg/dl

Exam date: March 02, 2010 COMPLETE BLOOD COUNT RESULT

UNITS

REFERENCE RANGE

X10^9/L % % % % %

4.50- 13.0 25.0- 70.0 20.0- 65.0 0.00- 9.00 0.00- 8.00 0.00-3.00

g/ dL %

12.0- 16.0 36.0- 49.0

10^12/ L Fl Pg

78.0- 102.0 25.0- 35.0 31.0- 36.0

( % ) x 10^9/ L

140.0- 440.0

White Blood Cells Neutrophils Lymphocytes Monocytes Eosinophils Basophils Hemoglobin Hematocrit Mean Corpuscular vol. Mean Corpuscular Hgb Red Blood Cells Dist. Width Platelet Count

MANUAL PLATELET COUNT: 50,000/ cumm Exam date: March 02, 2010 HEMATOLOGY Test Name Clotting Time –LW Bleeding Time – IVY

Result 13’30’’

Units min sec

Reference Range 7.0-15

4’30’’

min sec

2.0-8.0

Exam date: March 02, 2010 CHEMISTRY Test Name

Results

Units

Referenc e Range

Results

Units

Referenc e Range

Creatinin e

0.86

mg/dL

0.60-1.50

76.02

mg/dL

53.4132.6

Sodium

134

mmol/L

133-146

134

mmol/L

133-146

Potassiu m

3.46

mmol/L

2.4-5.2

3.46

mmol/L

3.4-5.2

Exam date: March 02, 2010

PREGNANCY Result

POSITIVE

V. ANATOMY AND PHYSIOLOGY (Female Reproductive System) The system consists of external and internal genitalia, which develop and function according to hormonal influences that affect fertility and childbearing. It also consists of urinary structures. External genitilia include the mons pubis, clitoris, vestibule, labia majora, labia minora, vaginal introitus, hymen, Bartholin’s gland, Skene’s gland, and the urethral meatus. Internal genitalia include the vagina, cervix, uterus, adjacent structures (adnexa), ovaries, and uterine tubes. Internal urinary structures include the ureters, bladder, and urethra. The functions of the female reproductive system are:  Manufacturing and protective ova for fertilization  Transporting the fertilized ovum for implantation and embryonic/fetal development  Housing and nourishing the developing fetus.  Regulating hormonal production and secretion of several sex hormones.  Providing sexual stimulation and pleasure  Providing a drainage route for the excretion of urine (urinary structures)

Structures and Functions of the Female Reproductive System STRUCTURE 

Mons Pubis

DESCRIPTION/PRIMARY FUNCTION - Pad of subcutaneous fatty tissue lying over

anterior symphysis

pubis - Protects pelvic bones during coitus



Labia Majora

- Two longitudinal folds of adipose and connective

tissue

-

Extended

from

clitoris

gradually narrow to

anteriorly

merge

and

and form

posterior commissure of perineum - Outer surface of the labia majora becomes pigmented,

wrinkled and hairy at puberty - Inner surface is smoother, softer, and contains

subcutaneous

glands - Protects vulva components that it surrounds - Protects urethra and vagina from infections



Labia Minora form prepuce of skin forming

- Consists of two thin folds of skin that extend to of clitoris anteriorly and a transverse fold fourchette posteriorly - Contains sebaceous glands, erectile tissue, blood

vessels, and

involuntary muscle tissue - Secretions are bactericidal and aid in lubricating

vulval skin

and protecting it from urine - Protects urethra and vagina from infections



Clitoris

- Erectile body about 2.5 cm in length and 0.5 cm in

diameter - Contains erectile tissue and has significant supply of nerve

endings - Serves as primary organ for sexual stimulation



Vestibule

- Area between two folds of labia minora - Boat-shaped area containing the urethral meatus,

openings of

the Skene’s glands, hymen,

openings of the Batholin’s glands

and

vaginal introitus 

Skene’s Gland

- Surround urethral meatus - Provide lubrication to protect skin



Vaginal Introitus



Hymen

- Entrance to vagina; size and shape may vary - Avascular thin fold of connective tissue

surrounding vaginal

introitus in women who have not had

sexual experiences 

Bartholin’s Glands

-

Small,

pea-shaped

glands

deep

in

perineal

structures - Ducts are not visible - Secrete clear, viscid, odorless, alkaline mucus that improves

viability and motility of sperm along the

reproductive tract 

Perineum

- Space between fourchette and anus - Composed of muscle, elastic fibers, fascia, and

connective 

Vagina

tissue - Muscular tube from cervix to vulva - Located posteriorly to bladder and anteriorly to

rectum - serves a female organ of copulation, birth canal, and channel

through which menstrual flow exists



Cervix

- End of uterus that projects into vagina



Uterus

-

between bladder neck

Pear-shaped,

hollow,

muscular

organ

and rectal wall - Mucous membrane lining is the endometrium.

Muscular layer cervix, superior aspect

is the mesometrium. Inferior aspect is is fundus - Major functions include serving as implantation

site of developing embryo and 

Uterine Tubes

fertilized ovum as protective sac for fetus - Two 7-10cm long ducts on either side of fundus of

uterus - Extend from uterus almost to ovaries - Normally, fertilization takes place within the tubes

- Major functions include serving as fertilization site and

providing passage way for unfertilized ova

to travel to uterus 

Ovaries

- Almond-shaped glandular structures that

produce ova - Located laterally to uterine tubes -

Major

functions

fertilization by

include

producing

ova

for

sperm and producing estrogen and

progesterone (See Appendix for illustrations)

V. PATHOGENESIS Ectopic Pregnancy in the Uterine Tube HOST -Female, 25 y/o motor-unaware of pregnancy hus-

AGENT ENVIRONMENT Unknown

-rides on cycle with band

Fertilization Zygote travels along the uterine tube (UT) Possible Causes - adhesion of UT from previous infection (chronic salpingitis, PID) - congenital malformations pregnancy - scars from tubal surgery - uterine tumor - IUD

Reabsorbed If undiagnosed - no Tx - (-) pregnacy Conceptus grows

Zygote trapped on stinctured site Implantation on site - (+)

If diagnosed early - oral meds (methotrexate, leucovorin, Mifepristone)

Recovery ruptures

UT Destruction of conceptus - (-) pregnancy Recovery

Uterine deciduas sloughs off

scant vaginal spotting Bleeding

Pain (RLQ)

Additional bleeding Hemoperitoneum (1500 cc) - shoulder pain

Hypovolemia - tachycardia, thready pulse - tachypnea - hyptotension Total circulatory collapse Coma Death

NEED/NUR SING DIAGNOSI S/CUES

SCIEN TIFIC ANALY SIS

Acute pain related to post operative surgery as manifested by verbalized reports.

Unplea sant sensor y and emotio nal experie nce arising from actual or potenti al tissue damag e or describ ed in terms of such damag e

Subjective: Sakit jud kayo akong tinahi dong as verbalized by the patient. Objective: facial grimacing, difficulty in moving

OBJECTIV ES After 3 days of nursing interventio n the patient will be able to: -report pain -follow prescribed pharmacol ogical regimen verbalized methods that provide relief demonstra te use of relaxation skills

NURSING OBJECTIVES/ NURSING INTERVENTIO NS 1. Perform a comprehensiv e assessment of pain to include location, characteristics , onset/duration , frequency, quality, severity, and aggreviating factors. 2. Perform pain assessment each time pain occurs. 3. Monitor vital signs 4.Provide quiet environment 5. Encourage adequate rest periods

RATIONALE

-to assess etiology

-to rule out worsening of underlying condition/devel opment of complications. -to have baseline data of the client.

EVALUA TION

EVALUA TION

After 3 days of nursing interven tion/ teaching the goal will be met, actions perform ed and attain

-to be successful in alleviating pain

-to promote wellness and to prevent fatigue.

VI. NURSING CARE PLANS NAME OF CLIENT: F.B.M PHYSICIAN: Dr. Lyn Alana Busa AGE: 25 years old SEX: Female STATUS: Married RELIGION: Kristohanon COMPLAINT: RLQ abdominal pain ADDRESS: Holy Name, Mabolo, Cebu City DIAGNOSIS: Pregnancy, Right Uterine Tube DATE AND TIME OF ADMISSION: March 02, 2010 08:58 A.M PROFILE: Received client on bed, . with husband, afebrile, without IVF

ATTENDING

CHIEF Ruptured Ectopic CLIENT asleep,

NEED/ NURSING DIAGNOSI S/ CUES

SCIENTIFI C ANALYSIS

OBJECTIVES

Physiologi c needs:

Intact skin and mucous membran e are the body’s first line of defense against microorg anisms. Unless the skin and mucosa became crack and broken, they are an effective barrier against bacteria/ infectious agents.

After 8 hours of nursing interventions the patient will be able to:

Risk for infection related to tissue destructio n and increase in environme ntal exposure/ vertical incision O: Received pt. on bed with vertical incision at lower abdomen w/binder

Source: Fundame ntals of nursing 8th edition page 673

NEED/ NURSIN G DIAGNO SIS/ CUES

SCIENTIF IC ANALYSI S

NURSING RATIO OBJECTIVES NALE / NURSING INTERVENTI ONS

a) Verbaliz e understa nding of individu al causativ e risk factors. b) Identify interven tion to prevent/ reduce risk f infection . c) Demons trate techniqu e, lifetime changes to promote safe environ ment.

OBJECTIVES

1. Note risk factor s occur rence of infect ion. 2. Clean incisi on with betad ine or appro priate soluti on. 3. Chan ge dress ing as need ed or indic ated. 4. Provi de perin eal care. 5. Monit or for signs and symp toms of sepsi s.

NURSING OBJECTIVES/ NURSING INTERVENTI ONS

Proces s the causat ive factors of infecti on. To reduce spread of infecti on and to promo te optima l healin g. To mainta in skin integri ty at optima l level. To promo te wellne ss.

EVALUATION

VALUE INTEGR ATION

After 8 hours of nursing interventions the patient was able to:

I learned the value of service a) Verbaliz towards my e understa patient nding of on how individu to take care of al causativ them, the best e risk that I factors. can. b) Identify interven tions to prevent or reduce risk of infection . c) Demons trate techniqu e, lifetime changes to promote safe environ ment.

To assess patien t or in order to preven t further infecti ons.

RATIONA EVALUATION LE

VALUE INTEGRA TION

After 8 hours of nursing Powerle n is an interventions ssness the patient will related illness that be able to: to early causes a loss of a) Express pregnan person to feelings cy feel sad of seconda physical and ry to safety. ectopic hopeless b) Use pregnan much of effective cy. coping the time. It mechani is different sms to S: Client from reduce states depressi she normal on. feels c) Mobilize sad at feelings of support pregnan sadness, systems cy loss grief, or and but is low professio able to nal deal energy. resource with s as situatio Anyone necessar n; has can have y. returne d) Reestabli d to depression sh and work . It often maintain and has adaptive in forward- runs interpers thinking families. onal plans. But it can relations hips. also O: Receive happen to d pt. on someone bed with who grimace doesn't face, weak , have a conscio us and family has the history of followin depression g vital . You can signs: Depressio

have

T: P: R: BP:

depression one or

time many

times. If you think you

may

be depressed, tell

your

doctor. There are

1. Provid e the patien t with psych ologic al suppo rt. Visit freque ntly. 2. Be availa ble to listen. 3. Accept the patien t’s feeling s and behavi ors. 4. Instru ct the patien t in at least one fearreduci ng behavi or, such as seekin g suppo rt from others when frighte ned. 5. Help her under stand the phase s of crisis and the patien t’s reacti ons to the family memb ers.

To decreas e the patient’ s fear of being left alone and to encoura ge a trusting relation ship. To express empath y with the patient’ s feelings. To reassur e the patient that they’re appropri ate and valid. To help the patient gain a sense of mastery over the current situatio n.

These measur es help reduce anxiety.

After 8 hours of nursing interventions the patient was be able to: a) Express feelings of physical safety. b) Use effective coping mechani sm to reduce depressi on. c) Mobilize support systems and professio nal resource s as necessar y. d) Reestabli sh and maintain adaptive interpers onal relations hips.

I learned to have an understa nding and a caring heart to the patient, to be able to understa nd her feelings and to help her get through her problems .

good treatments that

can

help

you

enjoy

life

again. The sooner you get treatment, the sooner you

will

feel better.

VIII. DISCHARGE PLAN NAME OF CLIENT: WARD & BED NO: AGE: 25 years old

F.B.M. 3B-SE7 SEX: Female

STATUS:

COMPLAINT: RLQ abdominal pain ADDRESS: Holy Name, Mabolo, Cebu City Ever Care

Married

RELIGION:

OCCUPATION:

Kristohanon CHIEF

Stocks In-charge,

DIAGNOSIS: Ruptured Ectopic Pregnancy, Right Uterine Tube DATE AND TIME OF ADMISSION: March 02, 2010 08:58 A.M. TYPE DATE OF SURGERY: Exploratory Laparotomy, Right Spingo-oophoretomy 03/02/10 OBJECTIVES By the time the client will be discharged, she should: Medications - take his prescribed drugs unfailingly.

Environment - live in an environment conducive to faster recovery and health maintenance.

NURSING INTERVENTIONS

- explain why the drug is prescribed including side effects and immediate measure in case these occur (refer to drug study)

- explain the relation of a well environment to health

&

Treatment - recognize the necessity to comply with his treatment.

- site ways on how to provide a well environment

Health Teaching - learn about ectopic pregnancy

- advise to follow scheduled checkups (if there are any) - advise to give maintenance drugs such as vitamin supplements (if there are any)

Observable Signs & Symptoms - recognize the signs and symptoms of ectopic pregnancy

- health teaching session

Diet - identify due diet for faster

- advise for admission when these occur -encourage prenatal care

recovery Spirituality - improve spiritual wellness

- encourage to drink fluids as tolerated (water, fruit juices) - encourage to eat fruits and vegetables, and other nutrient-dense foods - allow to verbalize about personal matters about faith

IX. DRUG STUDY NAME OF CLIENT: F.B.M. CHIEF COMPLAINT: RLQ abdominal pain AGE: 25 years old SEX: Female STATUS:

Married

RELIGION:

DIAGNOSIS: Ruptured Ectopic Pregnancy, Right Uterine Tube ADDRESS: Nivel Hills, Brgy. Lahug, Cebu City OCCUPATION: Ever Care To lower down fever from 37.8°C to at least 37.5°C DATE AND TIME OF ADMISSION: March 2, 2010 08:58 A.M. PROFILE: client on bed, asleep, with husband, afebrile, without IVF

DRUG

CLASSIFIC ATION AND MECHANI SM OF ACTIONS

INDICATION S AND DOSAGE

CONTRAINDIC ATIONS

SIDE EFFECTS

Kristohanon

Stocks In-charge, GOAL: CLIENT Received

NURSING RESPONSIB ILITIES

mefenamic acid (Dolfenal)

Tramadol (TDL)

parecoxib (Dynastat)

cefazolin (Stancef)

ranitidine(E ntac)

Mefenamic acid is a nonsteroid al antiinflammato ry drug (NSAID) which is an anthranilic acid derivative. It exhibits antiinflammato ry, analgesic and antipyretic activity by inhibiting prostaglan din synthesis in body tissues. Unlike most other nonsteroid al antiinflammato ry drugs, mefenamic acid appears to compete with prostaglan dins for binding at the prostaglan din receptor site and thus, potentially affect prostaglan dins that have already been formed. Binds to mu-opoid receptors. Inhibits reuptake of serotonin and norepineph rine in the CNS. Therapeuti

GI ulceration of inflammation. Q6 RTC/ prn Kidney or liver for pain impairment. Relief of mild to moderately severe somatic and neuritic pain; headache, migraine,trau matic pain, post-partum Resp pain, postop depression, pain, dental especially in pain and in presence of pain and cyanosis and fever excessive following bronchial various inflammatory secretion, and after op on conditions; dysmenorrhe biliary tract. Acute al, menorrhagia alcoholism, accompanied head injuries, conditions in by spasm of which hypogastric intracranial pain pressure is raised. Attack of 50mg Q6 prn bronchospasm. Heart failure for secondary to painModerat chronic lung e to severe disease. acute and chronic pain, painful Hypersensitivit diagnostic y to parecoxib procedures or to any other and surgery ingredient of Dynastat. Patients who have demonstrated allergic-type reactions to Short term treatment of sulfonamides, acute pain & acetylsalicylic post-op pain. acid (aspirin) or May be used nonsteroidal antipre-op to inflammatory prevent or drugs (NSAIDS) reduce postincluding other op pain; can cyclooxygenas reduce e-2 (COX-2) opioid requirements specific inhibitors; when used concomitantl asthma and urticaria y. 500mg/tab

Gi disturbances and hemorrhage, blood dyscrasias. Drowsiness, dizziness, headache, visual disturbances. Skin reactions and nephropathy.

Nausea, vomiting, fatigue, headache, constipation, drowsiness, confusion, skin reactions, dry mouth, facial flushing, sweating, vertigo, bradychardia , palpitation, orthostatic hypotension, hypothermia, restleness, changes in modod, miosis. Rarely, muscle weakness,ap petite changes, difficulty in passing urine, biliary spasm. Body as a Whole: Back pain. Central and Peripheral Nervous System: Dizziness. GI System: Alveolar osteitis (dry

Instruct patient to avoid alcohol (includes wine, beer, and liquor) when taking this medicine since it can cause increases in stomach irritation. Avoid aspirin, aspirincontaining products, other pain medicines, other blood thinners (warfarin, ticlopidine, clopidogrel), garlic, ginseng, ginkgo, and vitamin E while taking. Talk with healthcare provider

®assess type, location and intensity of pain before 2-3 hr after administration. ®assess BP and RR. Respi depression has not occurred with recommended doses. ®advise patient to change position slowly

c effect: decreased pain

Parecoxib is a prodrug of valdecoxib. The mechanism of action of valdecoxib is by inhibition of cyclooxyge nase-2 (COX-2)mediated prostaglan din synthesis. Cyclooxyge nase is responsible for generation of prostaglan dins. Two isoforms, COX-1 and COX-2, have been identified. COX-2 is the isoform of the enzyme that has been shown to be induced by proinflammato ry stimuli and has been postulated to be primarily responsible for the synthesis of prostanoid mediators of pain, inflammati on and fever. At therapeutic doses,

History of shock by cefazolin.

500mg IVTT Q8H Infections of the resp, GIT & GUT, otic & bone; skin, soft tissue & post-op infections; bacteremia, septicemia, endocarditis & other infections due to susceptible organisms; surgical prophylaxis

Treatment of peptic ulcer disease, GERD, selected cases of persistent dyspepsia, pathological hypersecreto ry states eg ZollingerEllison syndrome, stress ulceration & in patient at risk of acid aspiration during general

Hypersensitivit y; some products that contain alcohol and should be avoided in patient with known intolerance; some products that contain aspartame and patient with phenylketonuri a.

socket), to minimize constipation orthostatic and hypotension. flatulence. ®do not Platelet, confuse Bleeding and tramadol from Clotting: toradol. Ecchymosis. Psychiatric: Agitation and insomnia. Skin and Appendages: Increased sweating and pruritus. Events Occurring ≥0.5% and
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