Ectopic Pregnancy

LIST OF IDENTIFIED PROBLEMS 1. Acute pain related to tissue trauma secondary to surgical procedure 2. Powerlessness related to early loss of pregnancy secondary to ectopic pregnancy. 3. Rick for infection related to related to breakdown of the body's first line of defense. 4. Impaired skin integrity related to tissue trauma secondary to surgical procedure 5. Activity intolerance related to body weakness. PRIORITIZATION OF PROBLEMS

Nursing Diagnosis

Rationale It is a high priority since my patient

Acute pain related to tissue trauma secondary verbalized a 7/10, 10 as most severe. Other to surgical procedure

problems below are underlying problems caused by pain. This is the second because following “ABC”

Impaired skin integrity related to tissue this falls down in Circulation. But although trauma secondary to surgical procedure

there may be an alteration in the patient’s circulation, it is not that much. This is the third since this falls in “Basic

Activity weakness.

intolerance

related

to

body

needs” of Maslow’s hierarchy of needs. It is because physical activity can be accomplished with intact and functioning neuromuscular and skeletal systems.

This is the fourth since this belongs to “Love Powerlessness related to early loss of and belongingness” of Maslow’s Hierarchy of pregnancy secondary to ectopic pregnancy.

needs. The mother lost a child to be cared and loved.

Rick for infection related to related to breakdown of the body's first line of defense.

This is the fifth since this is just a risk and we can do intervention to prevent this from happening.

NURSING CARE PLAN Assessment: Problem: Postoperative Pain Subjective Data:  “ Nu agpagpagna ak ket nasakit jay sugat ko pati metlang nu agtugtugaw ak”  Rated pain as 7/ 10, 10 being most severe, characterized as dull, localized over wound, intermittent and aggravated by movement. Obejective Data:  T: 37.1 C  BP: 100/ 60  PR: 113 bpm  RR: 28 bpm  With good skin turgor and 1-2 seconds capillary refill  With an abdominal binder in place  Guards abdominal area and grimaces noted.

Nursing Diagnosis: Acute pain related to tissue trauma secondary to post surgical procedure. Explanation of the Problem: Ectopic pregnancy is a possible cause of severe abdominal pain in the first trimester. This happens when the egg implants inside the fallopian tubes or elsewhere outside the uterus. The first sign a woman may notice is vaginal bleeding followed by lower abdominal pain that intensifies with time. Vomiting, dizziness, and shoulder pain could also occur. It is very important for a woman experiencing these symptoms to get medical attention as soon as possible wherein there will be a need for eplore laparotomy and salpingectomy. The abdominal pain associated post status salphingectomy may be described as cramping or severe continuous pain. Pain is a typical sensory experience that may be described at the unpleasant awareness of a noxious stimulus or bodily harm. Reference: Med-Surg by BRUNNER SUDDARTH pages 1404 Goals/ Objectives: Short Term Objective: After 8 hours of nursing intervention, the patient will be able to rate pain from 7/ 10 to 2/10, 10 being most severe. Long Term Objective: After 3 days of nursing intervention, the patient will be able to verbalize absence of pain. Goal: The patient will be free of pain on the surgical site.

Interventions

Rationale

Dx.  Assessed vital signs and dressings

 Increase

in

BP

and

CR

indicates patient is in pain. Moistened

dressings

are

favorable

site

for

microorganisms

to

culture

and

would

if

there

be

inflammation, it would cause pain at the incision site.  Assessed for pain using PQRST.

 Pain

is

a

experience;

subjective experience of

pain can be answered through Tx.

verbalization.

Independent:  Provided

additional

measures like back rub

comfort

 This can be explained by Gate Theory

wherein

the

transmission painful impulses to the level of consciousness are being inhibited by the closure of the gate blocking these sensations.  Communicate with patient

 Attention can be diverted, letting the focus on other

Dependent:

stimulus.

 Intake of pain relievers as per doctor’s order and advise

 NSAID

activity

includes

modulation of T-cell function, inhibition and inflammatory



Celecoxib(Celebrex) 200mg 1

cell

tab BID

release of superoxide, radicals

Classification: Analgesic

or increased scavenging of

MOA: inhibits cyclo-oxgenase

these

2 which is responsible for

inflammatory sites.

prostaglandin reduces

chemotaxis,

decreased

compounds

at

synthesis;

inflammation

and

relieves pain. Nursing Consideration: Take in preferably with food and full glass of water to prevent GI upset. Edx.  Encouraged technique

of

relaxation

 There would be a better

deep

breathing

perfusion / circulation of

use like

blood

exercises

providing

adequate

oxygen to the traumatized tissue

therefore

inhibiting

pain to occur.  Recommended progressive exercise

planned

or

 Prevents undue strain on operative

site.

Promotes

return of normal function and enhances feelings of general well being. It relieves pain by

diverting her attention not focusing on her postoperative pain.  Encouraged enough rest and sleep

 Pain can be prevented by reducing basal metabolic rate and

allowing

oxygen

and

nutrients to be utilized for tissue

growth

regeneration

to

and prevent

inflammation of the wound which causes pain.  Noted to avoid weight bearing until

 Avoid straining of the sutures

allowed

which

may

possibly cause pain, activities that may extend the cut must then be avoided.

References: Med-Surg by Brunner Suddarth pages 1404 – 1406 Maternal and Child Health Nursing by Pillitteri pages 559 - 560 Evaluation: Objective partially met as evidenced by the verbalization of patient rating pain as 3/ 10, 10 being most severe.