Ectopic Pregnancy Edited By Ainiesam27

ECTOPIC

GROUP B BLOCK AAA CASE PRESENTATION

PREGNANCY

PATIENT’S PROFILE

DEMOGRAPHIC DATA 

Pt. CL is a 28-year old woman, a housewife who is married and has 4 children. Stands 5’2 and weighs 52 kgs. She lives in Baraas, Iligan City and is a Roman Catholic. She was admitted because of her chief complaints of abdominal pain.

HEALTH HISTORY CHIEF COMPLAINT

Abdominal pain ADMITTING DIAGNOSIS

The impression/admitting diagnosis was t/c ectopic pregnancy.

HISTORY OF PRESENT ILLNESS 5 days prior to admission pt felt pain in the entire abdomen and also a stabbing knife-like pain in the supraclavicular area. Pt. took up pain medications but it did not take effect so it prompted admission.

HISTORY OF PAST ILLNESS This was the first time pt was admitted in the hospital. In the past she had no infectious disease acquired, has completed all her immunizations and prenatal for all her 4 children. Pt. CL is not a chain smoker, does not drink alcoholic beverages and has no medications taken regularly.

HEALTH HABIT/S FREQUENCY

AMOUNT

PERIOD

TOBACCO

NONE

NONE

NONE

ALCOHOL

NONE

NONE

NONE

OTC DRUGS; NONPRESCRIPTION DRUG SPECIFY

NONE

NONE

NONE

FAMILY HISTORY

HISTORY OF HERIDO-FAMILIAL DISEASES:

Cancer DM Asthma Hypertension Cardiac Disease Mental Disorder

_____ __X__ _____ _____ _____ _____

GENOGRAM Mother’s Side



Legend: Grandma

- Male;

Father’s Side

- Female;

- Patient;

-DM

REVIEW OF SYSTEMS

GENERAL 

Pt’s appearance is appropriate w/ age, oriented, awake, and coherent, normal and symmetrical facial features, brown skin color. She appears weak and has drooping eyelids.

HEENT Head: normocephalic w/ thick hair, long and coarse and evenly distributed  Eyes: her eyes are symmetrical, black in color, almond shape, PERRLA, size 3mm, EOMS intact, brows and lashes present, blinks involuntarily 

HEENT(cont…) Ears: skin intact, no discharges present, flicked fingers heard bilaterally, symmetrical in size and shape  Nose: symmetric, nares present, septum in midline, no swelling of mucous membrane and presence of nasal hairs were seen.  Throat: pink mucosa, soft 

INTEGUMENTARY Brown skin, dry and warm to touch, even pigmentation, good skin turgor, hair on skin evenly distributed, presence of clubbing in nails is noted, CRT is more than 4 seconds. Bipedal edema w/ 2+ is noted  Face is slightly edematous 

RESPIRATORY 

26 respirations per minute, dyspneic upon supine position, breaths w/ accessory muscles, no tenderness upon palpitations in the chest

CARDIOVASCULAR Pulse rate is 106 bpm, heart rate 100 bpm, CRT – more than 4 seconds, PMI @ 5th intercostal space left midclavicular line, s1 is louder @ base, S2 is heard best @ apex  Intact pulses @ different sites 

DIGESTIVE Decreased appetite  Tender, rounded abdomen, cold to touch  bowel sounds present  I and O  hypoactive 

EXCRETORY Urinates 3-4x/day, light yellow, clear about 100-200ml  Defecates 1-2x/day, brown, semiformed amount varies, bipedal enema of 2+ noted  States that she has no problem with urinating and defecating 

MUSCULOSKELETAL 2/5 muscle strength  since hospitalization pt reports of general weakness  ADLs are limited such as grooming one’s self, bathing, and dressing up  Passive ROM performed 

NERVOUS Oriented, coherent, slightly lethargic, speech appropriate, no memory problems, facial movements symmetric, intact sensation, hearing is equal bilaterally, able to swallow, w/ gag reflex, can shrug shoulders, can sense light touch  Referred pain is felt on shoulders (phrenic nerve) 

ENDOCRINE 

No history of diabetes, or thyroid diseases, decreased appetite, gets thirsty sometimes, has equal hair distribution, appropriate height and weight for age, face is not oily

GORDON’S FUNCTIONAL HEALTH PATTERNS

NURSING ASSESSMENTS II

Activities- Rest Pattern 

Pt. CL is a housewife and she does the typical house chores such as cooking and cleaning. Before hospitalization, she regularly sleeps for about 7 hours , takes a nap every afternoon for about 3o minutes to one hour.

Activities- Rest Pattern(cont…) 

During hospitalization, she appears weak and is confined to bed, she verbalizes she sleeps around 8pm and wakes up around 4am. “Sige raman ko ug katulog diri”, added by patient. Able to have enough rest most of the time. She can ambulate but

Nutritional-Metabolic Pattern 

Typical intake is rice for about 3 cups w/ favorite viand fish w/ 1-2 cups of vegetables seldom eats meat. Has a regular diet and has no restrictions. Drinks 3-4 glasses of water daily about 150 – 200ml. She verbalizes she does not know her weight but she feels that she

Nutritional-Metabolic Pattern(cont…) 

She has no medications or supplements taken regularly. During hospitalizations, pt was weighed she weighed 52 kgs pt was ordered NPO but post-op she was able to drink soups and sips of water. She was given Vit. K.

Elimination Pattern Pt before hospitalization urinates 45x/day about 50-100ml, light yellow, clear.  Defecates 1-2x/day w/ formed brown stools. 

Elimination Pattern(cont…) 

During hospitalization, pt CL states “panagsa raman ko maka-ihi ug makalibang diri sa ospital”. She urinates 2x/day for about 50ml. she added her urine is still the same like before. Light yellow, clear urine w/ no odious odor. August 28, 2009, she was able to defecate for only once. Stool was brown semi-formed.

Ego-Integrity Pattern Perception of self - “ulawon man ko nga pagkatawo” as verbalized by patient.  Coping mechanism – to relieve or let go of problems she discusses it w/ her husband or mother 

Ego-Integrity Pattern(cont…) Support Mechanism – her husband and her mother are the persons she would run to in times when she needs them most  Mood/affect – pt is not expressive in feelings but shows strong feelings when angry. Upon admission she was irritable. 

Neuro-Sensory Pattern 

Mental state – mentally balanced and is a coherent person. She is oriented to time, age, place, has good memory. During hospitalization, she was slightly lethargic but still able to interact

Neuro-Sensory Pattern(cont…) Condition of 5 senses  sight – able to see far and near problems without any strain felt  hearing – both ears can hear normally,  smell – can detect odors and has no problem with distinguishing them  taste – able to differentiate taste sensations  touch – she can feel light touch and has no problems feeling things around her 

Oxygenation & Vital Signs Before hospitalization pt doesn’t have the idea about her vital signs. Now her vital signs are RR – 26 rpm, Pulse rate – 106 bpm, BP – 100/50 mmHg  Pt’s lung sounds are fine crackles all over. She tells us she has no history of respiratory aside from having common flu and cough seldom 

Pain-Comfort 

  





Pt was admitted due to her abdominal pain P – sudden movement Q – throbbing R – it radiates in the entire abdomen, relieved by rubbing of hands in the abdomen S – pt verbalizes of a pain scale of 10 T – intermittent w/ an interval of 10

Hygiene 

Pt’s is not well groomed, noted w/ presence of body odor, unwashed hands and feet, uncombed hair and dirty fingernails and toenails.

Sexuality-Reproductive  Pt’s menarche happened when she was still 12 years old  she states she has no problem w/ her sexual life  her LMP was on July 2, 2009 but she had spotting on August 2, 2009  she already has 4 children  obstetric history: GTPALM -

SUMMARY OF

MEDICATIONS DRUG STUDY

SUMMARY OF MEDICATION Date

Medication

8 - - 09

Penicillin G 5, 000, 000 “u” IVTT q 6H ANST Chloramphenicol 1 g IVTT q 8H ANST Cefuroxime 750 mg IVTT q 8H Paracetamol 300 mg IVTT now then q 4H PRN Ranitidine 50 g IVTT q 8 H Metronidazole 1g supp per rectum q 12H Tranexamic Acid 500mg IVTT Bisacodyl 2 adult supp per rectum Ciprofloxacin 500mg tab BID Ferrous Sulfate 500mg tab BID Vitamin K amp (IM) q 12H Nalbuphine 5 mg IVTT q 4H x 6doses

8 - - 09 8 - - 09 8 - - 09 8 - - 09 8 - - 09 8 - - 09 8 - - 09 8 - - 09 8 - - 09 8 - - 09

Remarks

Given & Tolerated Given & Tolerated Given & Tolerated Given & Tolerated Given & Tolerated Given & Tolerated Given & Tolerated Given & Tolerated Given Given Given Given

& & & &

Tolerated Tolerated Tolerated Tolerated

GENERIC NAME BRAND NAME CLASSIFICATION S

PRESCRIBED AND RECOMMENDED DOSAGE, FREQUENCY, AND ROUTE OF ADMINISTRATION

MECHANISM OF ACTION

INDICATION

CONTRAINDICATIO N

ADVERSE REACTION

NURSING RESPONSIBILITIE S

Ranitidine (Histamine-2 antagonist)

33 doses

H2 antagonist selectively blocked Histamine-2 receptor sites. This blocking leads to a reduction in gastric acid secretion and reduction in overall pepsin production.

Duodenal and gastric ulcer (short term treatment; hypersecretor y conditions such as ZollingerEllison syndrome.

Should not be used with known allergy to any drugs of this class. Caution should be used during pregnancy per lactation or renal dysfunction that would interfere with drug metabolism and excretion.

GI: diarrhea or constipation CNS: dizziness, headache, hypotension EENT: blurred vision Hepatic: jaundice Other: burning and itching at infection site

>Use cautiously in pts. with hepatic dysfunction. Adjust dosage in pt. with impaire renal function >Assess pt. for abdominal pain. Note presence of blood in emesis, stool, or gastric aspirate >Ranitidine may be added to total parenteral nutrition solutions.

GENERIC NAME BRAND NAME CLASSIFICATIONS

Bisacodyl Dulcolax Laxatives

PRESCRIBED AND RECOMMENDED DOSAGE, FREQUENCY, AND ROUTE OF ADMINISTRATIO N

10-15mg

MECHANISM OF ACTION

INDICATION

CONTRAINDICATI ON

Stimulates peristalsis by directly irritating the smooth muscle of the intestine, possibly the colonic intramural plexus; alters water and electrolyte secretion producing net intestinal fluid accumulation and laxation

Relieve constipation and prepare the bowel for diagnostic or surgical procedures requiring the bowel to be empty.

Hypersensiti vity to bisacodyl or any component of the formulation; abdominal pain, obstruction, nausea or vomiting

ADVERSE REACTION

Central nervous system: Vertigo

NURSING RESPONSIBILITIE S

>Use as a temporary measure.

>Have the tablet be swallowed whole. >Do not drink drug within one hour of drinking other drugs. >Report Gastrointesti sweating, flushing, nal: Mild muscle abdominal cramps, and cramps, excessive nausea, thirst. vomiting, rectal burning Endocrine & metabolic: Electrolyte and fluid imbalance (metabolic acidosis or alkalosis, hypocalcemi a)

GENERIC NAME BRAND NAME CLASSIFICATIONS

PRESCRIBE D AND RECOMMEN DED DOSAGE, FREQUENCY , AND ROUTE OF ADMINISTR 300 mg ATION

Paracetamol Brand Name: tab BID Biogesic Classifications : Non-opioid analgesic

MECHANISM OF ACTION

INDICATION

CONTRAINDIC ATION

ADVERSE REACTION

NURSING RESPONSIBILITIES

Paracetamol is usually classified along with nonsteroidal antiinflammat ory drugs (NSAID), but is not considered one.

To relieve mild to moderate pain due to things such as headache, muscle and joint pain, backache and period pains. It is also used to bring down a high temperature.

Hypersensi tivity to acetaminop hen or phenacetin; use with alcohol.

Side effects are rare with paracetamol when it is taken at the recommended doses. Skin rashes, blood disorders and acute inflammation of the pancreas have occasionally occurred in people taking the drug on a regular basis for a long time.

~ Monitor for S&S of: hepatotoxicity, even with moderate acetaminophen doses, especially in individuals with poor nutrition. ~ Do not take other medications (e.g., cold preparations) containing acetaminophen without medical advice; overdosing and chronic use can cause liver damage and other toxic effects.

GENERIC NAME BRAND NAME CLASSIFICATIONS

Paracetamol Brand Name: Biogesic Classifications : Non-opioid analgesic (CONTIBUATI ON)

PRESCRIBE D AND RECOMMEN DED DOSAGE, FREQUENCY , AND ROUTE OF ADMINISTR ATION

MECHANISM OF ACTION

Its main mechanism of action is the inhibition of cyclooxygena se (COX), an enzyme responsible for the production of prostaglandin s, which are important mediators of inflammation, pain and fever.

INDICATION

For this reason, paracetamol can be given to children after vaccinations to prevent postimmunisation pyrexia (high temperature). Paracetamol is often included in cough, cold and flu remedies.

CONTRAINDIC ATION

ADVERSE REACTION

NURSING RESPONSIBILITIES

One advantage of paracetamol over aspirin and NSAIDs is that it doesn't irritate the stomach or causing it to bleed, potential Side effects of aspirin and NSAIDs.

~ Do not use for fever persisting longer than 3 d, fever over 39.5° C (103° F), or recurrent fever. ~ Do not give children more than 5 doses in 24 h unless prescribed by physician.

GENERIC NAME BRAND NAME CLASSIFICATIONS

Tranexamic acid brand name: Hemostan classification: antihemorrhagic

PRESCRIBED AND RECOMMENDE D DOSAGE, FREQUENCY, AND ROUTE OF ADMINISTRATI 500 mg ON

IVTT

MECHANISM OF ACTION

INDICATION

CONTRAINDICAT ION

ADVERSE REACTION

NURSING RESPONSIBILITIES

inhibits breakdown of fibrin clots; inhibits activation of plasminoge n, thereby preventing the conversion of plasminoge n to plasmin

antihemorrhagi c and antifibrinoly tic for effective hemostasis in various surgical clinical cases, traumatic injuries, hematuria; prevent excessive bleeding

hypersensitivi ty, pt's exposed with prolonged thrombosis, active intravascular clotting

dizziness, headache, nausea, vomiting, anorexia, diarrhea, hypotension, thromboembol ism, thrombosis

check for doctor's order, should not be given if positive skin test, advise pt to report any discomfort on the IV insertion site, monitor v/s, administer via slow injection, monitor clotting time, caution pts to avoid products containing aspirin or NSAIDS w/o consulting health care professionals, should not be used in pts with active intravascular clotting.

GENERIC NAME BRAND NAME CLASSIFICATIONS

Cefuroxime Sodium Cefuroxime Axetil

PRESCRIBED AND RECOMMENDED DOSAGE, FREQUENCY, AND ROUTE OF ADMINISTRATION

MECHANISM OF ACTION

750 mg IVTT q 8H

Semisynthetic secondgeneration cephalosporin antibiotic with structure similar to that of he penicillins. Resistance against betalactamaseproducing strains exceeds that of firstgeneration cephalosporin s.

INDICATION

CONTRAINDICATI ON

ADVERSE REACTION

NURSING RESPONSIBILITIE S

Moderate to severe infections

Hypersensitivit y to cephalosporin s and related antibiotics; pregnancy (category b), lactation.

BODY AS A WHOLE: thrombophlebi tis; pain, burning, cellulites; superinfection s, positive Coomb’s test. GI: diarrhea, nausea, antibioticassociated colitis. SKIN: rash pruritus, urticaria UROGENITAL : increased serum creatinine and BUN, decreased creatinine clearance.

>inspect IM and IV injection sites frequently for signs of phlebitis. >report onset of loose stools or diarrhea. >monitor for manifestations of hypersentivity. Discontinue drug and report their appearance promptly.

GENERIC NAME BRAND NAME CLASSIFICATIONS

Cefuroxime Sodium Cefuroxime Axetil (CONTINUATION )

PRESCRIBED AND RECOMMENDE D DOSAGE, FREQUENCY, AND ROUTE OF ADMINISTRATI ON

MECHANISM OF ACTION

Antimicrobial spectrum of activity resembles that of the penicillinbinding proteins located on cell walls of susceptible organisms. This inhibits third and final stage of bacterial cell wall synthesis, thus killing thus bacterium.

INDICATION

CONTRAINDICATI ON

ADVERSE REACTION

NURSING RESPONSIBILITIE S

>monitor I&O rates and pattern: especially important in severely ill patients receiving high doses. Report any significant changes. >report loose stools or diarrhea promptly.

GENERIC NAME BRAND NAME CLASSIFICATIONS

Ciprofloxacin Hydrochloride

PRESCRIBED AND RECOMMENDED DOSAGE, FREQUENCY, AND ROUTE OF ADMINISTRATION

500 mg tab bid

MECHANISM OF ACTION

INDICATION

Synthetic >UTI quinolone that is a broad spectrum bactericidal agent. Inhibits DNA-gyrase, an enzyme necessary for bacterial DNA replication and some aspects of transcription, repair, recombination , and transposition.

CONTRAINDICATI ON

ADVERSE REACTION

NURSING RESPONSIBILITIE S

Known hypersensitivit y to ciprofloxacin or quinolones, pregnant women (category c), lactation, and children.

GI: nausea, vomiting, diarrhea, cramps, gas METABOLIC: transient increases in liver transaminases , alkaline phosphatases, lactic dehydrogenas e, and eosinophilia count. MUSCULOSK ELETAL: tendon rupture

>monitor urine pH; it should be less than 6.8, especially in the older adult and patients receiving high doses of ciprofloxacin, to reduce the risk of crystalluria. >monitor I&O ratio and patterns: patient should be well hydrated; assess for S&S of crystalluria

GENERIC NAME BRAND NAME CLASSIFICATIONS

Ciprofloxacin Hydrochloride (CONTINUATION )

PRESCRIBED AND RECOMMENDED DOSAGE, FREQUENCY, AND ROUTE OF ADMINISTRATION

MECHANISM OF ACTION

INDICATION

CONTRAINDI CATION

ADVERSE REACTION

CNS: headache, vertigo, malaise, seizures (especially with rapid IV infusion) SKIN: rash, phlebitis, pain, burning, pruritis, and erythema at infusion site. SPECIAL SENSES: local burning and discomfort, crystalline precipitate on superficial portion of cornea, lid margin crusting, scales, foreign body sensation, itching, and conjunctival hypereremia.

NURSING RESPONSIBILITIE S

>do not give an antacid within 4h of the oral ciprofloxacin dose. >discontinue other IV infusion while infusing ciprofloxacin or infuse through another site. >for patients wit renal impairment, oral and IV doses are lowered according to creatinine clearance.

GENERIC NAME BRAND NAME CLASSIFICATIONS

Metronidazole

PRESCRIBED AND RECOMMENDED DOSAGE, FREQUENCY, AND ROUTE OF ADMINISTRATION

1g supp/rectum Q 12H

MECHANISM OF ACTION

INDICATION

Synthetic Anaerobic compound infections with direct trichomonacid al and amebicidal activity as well as antibacterial activity against anaerobic bacteria and some gramnegative bacteria.

CONTRAINDICATI ON

ADVERSE REACTION

NURSING RESPONSIBILITIE S

Control of essential hypertension. Safety during pregnancy (category c), lactation, or in children <12y is not established.

BODY AS A WHOLE: hypersensivity (rash, urticaria, pruritus, flushing), fever, fleeting joint pains, overgrowth of Candida CNS: vertigo, headache, ataxia, confusion, irritability, depression, restlessness, weakness, fatigue, drowsiness, insomnia, paresthesia, sensory constipation

>discontinue therapy immediately if symptoms of CNS toxicity develop. >report appearance of candidiasis or its becoming more prominent with therapy to physician promptly. >adhere closely to the established regimen without schedule interruption or changing the dose.

GENERIC NAME BRAND NAME CLASSIFICATIONS

Metronidazole (CONTINUATION )

PRESCRIBED AND RECOMMEND ED DOSAGE, FREQUENCY, AND ROUTE OF ADMINISTRA TION

MECHANISM OF ACTION

INDICATION

CONTRAIN DICATION

ADVERSE REACTION

NURSING RESPONSIBILITIES

GI: nausea, vomiting, anorexia, epigastric distress, abdominal cramps, diarrhea, constipation, dry mouth, metallic or bitter taste, proctitis. UROGENITAL: polyuria, dysuria, pyuria, incontinence, cystitis, decreased libido, dyspareunia, dryness of vagina and vulva, sense of pelvic pressure. SPECIAL SENSES: nasal congestion CV: ECG changes (flattening of T wave)

>instruct patient to refrain from intercourse during therapy for trichomoniasis unless male partner wears a condom to prevent reinfection. >instruct patient not to drink alcohol during therapy; may induce a disulfiram-type reaction. Avoid alcohol or alcohol-containing medication for at least 48h after treatment is completed. >report symptoms of candidal overgrowth: furry tongue, color changes of tongue, glossitis, stomatitis; vaginitis, curd-like milky vaginal discharge; proctitis. Treatment with a candidacidal agent may be indicated.

GENERIC NAME BRAND NAME CLASSIFICATIONS

PRESCRIBED AND RECOMMENDED DOSAGE, FREQUENCY, AND ROUTE OF ADMINISTRATION

MECHANISM OF ACTION

` Penicillin G 5, 000, 000 “u” Bactericidal: Brand Name: IVTT q 6H Inhibit Pfizerpen ANST synthesis of Classifications cell wall of : sensitive Antibiotic microorganis Penicillin ms, causing cell death.

INDICATION

Indicated to treatment of severe infections caused by sensitive microorganis ms. Treatment to syphilis, gonococcal infections

CONTRAINDICATI ON

ADVERSE REACTION

NURSING RESPONSIBILITIE S

Contraindicate d with allergy to penicillins, cephalosporin s,imipinem, beta-lactinase inhibitors and other allergens, Use cautiously with renal diseases, pregnancy, lactation, (may cause diarrhea or candidiasis of the infant)

CNS: Lethargy, Hallucinations, seizures GI: Glossitis, stomatitis, gastritis, sore mouth, furry tongue, black hairy tongue, nausea, vomiting, diarrhea, abdominal pain, bloody diarrhea, enterocolitis, pseudomeme branous colitis, nonespecific hepatisis

~ Assess for patient’s history with allergies to penicillins, cephalosporin s, procaine, other allergies, renal disorders, pregnancy and lactation. ~ Do physical assessment by culturing infection, skin color, lesions, adventitious sounds, bowel sounds.

GENERIC NAME BRAND NAME CLASSIFICATIONS

PRESCRIBED AND RECOMMENDED DOSAGE, FREQUENCY, AND ROUTE OF ADMINISTRATION

Penicillin G ` Brand Name: Pfizerpen Classifications : Antibiotic Penicillin (CONTINUATI ON)

MECHANISM OF ACTION

INDICATION

CONTRAINDICA TION

ADVERSE REACTION

NURSING RESPONSIBILITIE S

GU: Nephritis--oliguria, proteinuria, hematuria, casts, azotemia, pyuria Hematologic: Anemia, thrombocytopen ia, leucopenia, neutropenia, prolonged bleeding time Hypersensitivity reactions: Rash, fever, wheezing, anaphylaxis Local: Pain, phlebitis, thrombosis at injection site, JarischHerxheimer reaction when used to treat syphilis

~ Administer by IM route only. ~ Continue therapy for at least 2 days after infection has disappeared, usually 7 to 10 days. ~Administer IM injection in upper outer quadrant of buttock. In infants and children, midlateral aspect of the thigh may be preferred.

GENERIC NAME BRAND NAME CLASSIFICATIONS

PRESCRIBED AND RECOMMENDED DOSAGE, FREQUENCY, AND ROUTE OF ADMINISTRATION

Chloramphen 1 g IVTT q 8H icol ANST Brand Name: Chloromycetin Classifications : Antibiotic

MECHANISM OF ACTION

Bacteriostatic effect against susceptible bacteria; prevents cell replications.

INDICATION

Systemic: ~ Serious infections for which no antibiotic is effective ~ Acute infections caused by Salmonella typhi ~ Serious infections caused by Salmonella, Haemophilus influenza and lymphogranuloma.

CONTRAINDIC ATION

ADVERSE REACTION

NURSING RESPONSIBILITIE S

Contraindic ated to allergies to chloramphe nicol Use cautiously with renal failure, hepatic failure, G6PD deficiency, intermittent porphyria, pregnancy and lactation.

CNS: headache, mild depression, mental confusion, delirium GI: Nausea, vomiting, stomatitis, glossitis, diarrhea Hematologic: Blood dyscariasis Other: Fever, Macular rashes, urticaria, anaphylaxis, gray baby syndrome ( abdominal distention, pallid cyanosis), superinfections

~ Assess patient for allergies to chloramphenic ol, renal or hepatic failure, pregnancy and lactation. ~ Observe for side effects such as nausea, vomiting, diarrhea, headache, confusion, and superinfection s.

GENERIC NAME BRAND NAME CLASSIFICATIONS

Chloramphen icol Brand Name: Chloromycetin Classifications : Antibiotic (CONTINUATI ON)

PRESCRIBED AND RECOMMENDED DOSAGE, FREQUENCY, AND ROUTE OF ADMINISTRATION

MECHANISM OF ACTION

INDICATION

CONTRAINDICATI ON

ADVERSE REACTION

NURSING RESPONSIBILITIE S

~ Report sore throat, tiredness, unusual bleeding or bruising, numbness, tingling, pain in the extremeties, pregnancy and discomfort at IV site. ~ Reduce dosage in patients with renal or hepatic disease. ~ Monitor serum levels periodically as indicated in the dosage section.

GENERIC NAME BRAND NAME CLASSIFICATIONS

PRESCRIBED AND RECOMMENDED DOSAGE, FREQUENCY, AND ROUTE OF ADMINISTRATION

Nalbuphine 5 mg IVTT q 4 Brand Name: H (then 6 Nubain doses) Classifications : Opioid agonistantagonist analgesic

MECHANISM OF ACTION

INDICATION

CONTRAINDICATI ON

ADVERSE REACTION

NURSING RESPONSIBILITIE S

Binds with opiate receptors in the CNS, altering perception of and emotional response to pain.

~Management of moderate to severe pain ~ Preoperative and postoperative analgesia supplement to balanced anesthesia ~ Obstetrical analgesia during labor and delivery

Contraindicate d in patients hypersensitive to drug Use cautiously in patients with history of drug abuse and in those with emotional instability, head injury, increased ICP, impaired ventilation, MI accompanied by N/V, upcoming biliary surgery, and hepatic or renal disease

CNS: Sedation, dizziness, vertigo, headache, agitation, confusion, crying, depression, dysphoria, euphoria, faintness, floating feeling, hallucinations, heaviness feeling, hostility, nervousness, numbness, restlessness, seizures, tingling, unreality, unusual dreams

~ Reassess patient’s level of pain at least 15 and 30 minutes after parenteral administration ~ Nalbuphine acts as an opioid antagonist and may cause withdrawal syndrome. For patients who have received log-term opioids, give 25% of the usual dose initially. Watch for sings of withdrawal.

GENERIC NAME BRAND NAME CLASSIFICATIONS

Nalbuphine Brand Name: Nubain Classifications: Opioid agonistantagonist analgesic (CONTINUATIO N)

PRESCRIBED AND RECOMMENDE D DOSAGE, FREQUENCY, AND ROUTE OF ADMINISTRATI ON

MECHANISM OF ACTION

INDICATION

CONTRAIN DICATION

ADVERSE REACTION

NURSING RESPONSIBILITIES

CV: Bradycardia, hypertension, hypotension, tachycardia EENT: Blurred vision, dry mouth GI: Nausea, vomiting, biliary tract spasms, constipation cramps, dyspepsia GU: Urinary urgency Respiratory: Respiratory depression, asthma, dyspnea, pulmonary edema Skin: Burning, clamminess, diaphoresis, pruritus, uticaria

~Alert: Drug causes respiratory depression, which at 10mg is equal to respiratory depression produced by 10 mg of morphine ~ Monitor circulatory and respiratory status, bladder and bowel function. If respirations are shallow or rate is below 12 breaths/minute, withhold dose and notify prescriber ~ Constipation is often severe with maintenance therapy. Make sure stool softener or other laxative is ordered. ~ Psychological and physical dependence may occur with prolonged use. ~ Remind patient not to confuse Nubain with Navane.

GENERIC NAME BRAND NAME CLASSIFICATIONS

PRESCRIBED AND RECOMMENDED DOSAGE, FREQUENCY, AND ROUTE OF ADMINISTRATION

Vitamin K 1 amp (IM) q Brand Name: 12 H AquaMephyto n Mephyton Classifications : Clotting Agent

MECHANISM OF ACTION

Vitamin K is required for synthesis of prothrombin and three other clotting factors.

INDICATION

CONTRAINDICATI ON

ADVERSE REACTION

NURSING RESPONSIBILITIE S

~Vitamin K deficiency ~Those with bruising and bleeding. ~Vitamin K is routinely given to newborn infants to prevent bleeding problems.

~In patients receiving anticoagulants (blood thinners) as vitamin K decreases the effects of these drugs. ~ Pregnancy —Vitamin K has not been reported to cause birth defects or other problems in humans. ~When taken during pregnancy jaundice and other problems in the baby.

Decreased appetite; decreased movement or activity; difficulty in breathing; enlarged liver; general body swelling; irritability; muscle stiffness; paleness; yellow eyes or skin.

~ If pt. take warfarin (a blood thinner), you should know that vitamin K or foods containing vitamin K can affect how the drug works. ~ Vitamin K deficiency is very rare. It occurs when the body can't properly absorb the vitamin from the intestinal tract.

GENERIC NAME BRAND NAME CLASSIFICATIONS

Vitamin K Brand Name: AquaMephyto n Mephyton Classifications : Clotting Agent (CONTINUATI ON)

PRESCRIBED AND RECOMMENDE D DOSAGE, FREQUENCY, AND ROUTE OF ADMINISTRATI ON

MECHANIS M OF ACTION

INDICATIO N

CONTRAINDICATION

ADVERSE REACTION

NURSING RESPONSIBILITIES

.Breast-feeding— Vitamin K taken by the mother has not been reported to cause problems in nursing babies. You should check with your doctor if you are giving your baby an unfortified formula. In that case, the baby must get the vitamins needed some other way. Children—Children may be especially sensitive to the effects of vitamin K, especially menadiol or high doses of phytonadione. This may increase the chance of side effects during treatment.

Less common: Difficulty in swallowing; fast or irregular breathing; lightheadedness or fainting; shortness of breath; skin rash, hives and/or itching; swelling of eyelids, face, or lips; tightness in chest; troubled breathing and/or wheezing. Blue color or flushing or redness of skin; dizziness; fast and/or weak heartbeat; increased sweating; low blood pressure (temporary). Rare: Flushing of face; redness, pain, or swelling at place of injection; skin lesions at place of injection (rare); unusual taste.

~ Vitamin K deficiency can also occur after long-term treatment with antibiotics. ~ If pt. are taking anticoagulant medicine (blood thinners), the amount of vitamin K in your diet may affect how well these medicines work. The doctor or health care professional may recommend changes in your diet to help these medicines work better.

GENERIC NAME BRAND NAME CLASSIFICATIONS

PRESCRIBED AND RECOMMENDED DOSAGE, FREQUENCY, AND ROUTE OF ADMINISTRATION

Ferrous 500 mg tab Sulfate BID Brand Name: Ferrous sulfate (Feosol, FerIron) Ferrous gluconate (Fergon, Fertinic) Ferrous fumarate (Feostat, Fumerin) Classifications :

MECHANISM OF ACTION

INDICATION

*Mineral for antianemia *Vital for hemoglobin regeneration, specifically it enables the RBC development and oxygen transport via hemoglobin It elevates the serum iron concentration, which then helps to form Hgb or trapped in the reticuloendoth elial cells for storage and eventual conversion to a usable form of iron.

Preventing or treating low levels of iron in the blood. It also may be used for other conditions as determined by your doctor.

CONTRAINDICATI ON

Allergy to any ingredient in Ferrous Sulfate High levels of iron in your blood

ADVERSE REACTION

NURSING RESPONSIBILITIE S

Constipation, upset stomach, black or darkcolored stools, temporary staining of the teeth. Signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat.

Administer vitamins with food to prevent GI upset. *Caution on intake of chamomile, feverfew, peppermint and St. John’s wort for it interfere with the absorption of iron and other minerals. *Increadead effect of iron with viatmin C; decreaded effect of tetracycline, antacids, penicillamine

GENERIC NAME BRAND NAME CLASSIFICATIONS

Ferrous Sulfate Brand Name: Ferrous sulfate (Feosol, FerIron) Ferrous gluconate (Fergon, Fertinic) Ferrous fumarate (Feostat, Fumerin) Classifications : (CONTINUATI ON)

PRESCRIBED AND RECOMMENDED DOSAGE, FREQUENCY, AND ROUTE OF ADMINISTRATION

MECHANISM OF ACTION

INDICATION

CONTRAINDICATI ON

ADVERSE REACTION

NURSING RESPONSIBILITIE S

*Inform clients of side-effects like nausea and vomiting, diarrhea, constipation,e pigastric pain and refer to the attending nurse upon occurrence for management. *Monitor for adverse reactions like pallor and drowsiness.

SUMMARY OF

INTRAVENOUS FLUID

Date Started 8 - 21- 09 | 9:00 PM 10: 20 PM

IV Fluids, Volume, Drop Rate #1 D5LR; 1L @ 30 drops/min # 2 PNSS; 1L @ 40 drops/min

Indication

For fluid and electrolyte replenishment and caloric supply 8 - 22- 09 | 12:25 AM To replace fluids in | 10:00 AM dehydration, go with | 4:10 PM #3 PNSS; 1L @ 40 blood transfusions, drops/min hyponatremia, and burn 8 - 23 - 09 | 9:30 PM #4,5 PNSS; 1L @ 40 victims. It is isotonic,( drops/min same osmolarity as our 8 - 24- 09 | 10: 45 AM #6 PNSS; 1L @ 40 body fluids) | 6:45 PM drops/min To replace fluids in dehydration, go with 8 - 25- 09 | 7:00 PM #8,9,10 PNSS; 1L @ 40 blood transfusions, drops/min hyponatremia, and burn 8 - 25- 09 | 12:50 AM BT S# 0908-186 A+ WB victims. It is isotonic,( 8 - 25- 09 | 3:30 PM #11 PNSS; 1L @ 40 same osmolarity as our drops/min body fluids) To replace clotting factors BT S# 0908-183 A+ WB (e.g after multiple D5LR; 1L @ 30 drops/min transfusions or reverse BT S# 0908-187 A+ WB the effects of Coumadin) BT S# 0908-193 A+ WB For fluid and electrolyte replenishment and caloric

LABORATORY & DIAGNOSTIC PROCEDURE

HEMATOLOGY NORMAL VALUES Hemoglobin

RESULT

IMPLICATION

August 21,’09

Explain test purpose and procedure

120-150 g/L Hematocrit 0.37-0.45 WBC 5-10 x109/L Neutrophil 0.55-0.65 Lymphocyte 0.25-0.40 Eosinophil 0.01-0.05 Bleeding Time Up to 6 mins. Clotting Time 5-8 mins. Platelet Count

Hgb Hct WBC

35

Decreased

.10

Decreased Normal

9.2 Neutrophil 0.59 Lymphocyte 0.29 Eosinophil 0.12 Platelet 228

NURSING RESPONSIBILITIES

Normal Normal Increased

-Interpret test outcome and monitor appropriately -Watch carefully for signs and symptoms. -Have the patient avoid excessive exercise before the test. -Avoid over hydration or dehydration. -Note any medication the patient is taking.

HEMATOLOGY(cont…) NORMAL VALUES Hemoglobin 120-150 g/L

RESULT

IMPLICATION

8-24-09 Hgb 54

Decreased

Hct

Decreased

Hematocrit 0.37-0.45 WBC 5-10 x109/L Neutrophil 0.55-0.65

WBC

0.16 10.60

Neutrophil 0.46

Eosinophil 0.01-0.05 Bleeding Time Up to 6 mins. Clotting Time 5-8 mins.

Decreased Normal

Lymphocyte 0.25-0.40

Normal

Lymphocyte 0.38 Eosinophil 0.16

Increased Normal Normal

Bleeding time 2’

Platelet Count

Clotting time

Normal

NURSING RESPONSIBILITIES

HEMATOLOGY(cont…) NORMAL VALUES Hemoglobin 120-150 g/L Hematocrit 0.37-0.45

RESULT

IMPLICATION

8-25-09 Hgb 8-26-09 Hgb

71

Decreased

100

Decreased

Hct

0.30

Decresaed

WBC 5-10 x109/L Neutrophil 0.55-0.65 Lymphocyte 0.25-0.40 Eosinophil 0.01-0.05 Bleeding Time Up to 6 mins. Clotting Time 5-8 mins. Platelet Count

NURSING RESPONSIBILITIES

Hgt/ Blood Glucose Test NORMAL VALUES

Hgt 72-128 mg/dL

RESULT

8-21-09 8:25pm Hgt 120 mg/dL 11:00pm Hgt 115 mg/dL 5:00am Hgt 116 mg/dL 8-24-09 5:00pm Hgt 101 mg/dL

IMPLICATION

Increased Increased Increased

Normal

NURSING RESPONSIBILITIES

-Explain test purpose and blood drawing procedure. -Tell patient that the test requires an overnight fast; water is permitted. -Note the last time the patient ate in the record and on the laboratory requisition. -Tell the patient that she may eat and drink when blood is drawn. -Interpret result and monitor appropriately for hyperglycemia

Cross Matching 8-22-09/ 10:00pm 

Blood Type “A”



RH (+)



Extract Date 8-10-09



Expire Date



Volume 250, Whole Blood



Slide Method, Compatible

9-13-09

8-24-09 

Blood Type “A”



RH (+)



Extract Date 8-22-09



Expire Date



Volume 250, Whole Blood



Slide Method, Compatible

9-14-09

8-26-09  Blood Type “A”  RH (+)  Extract Date 8-2509  Expire Date 9-19-09  Volume 500, Whole Blood  Slide Method Compatible

Ultrasound of Abdomen 8-26-09  Sonography normal liver, gallbladder, biliary ducts, pancreas, spleen, urinary bladder and uterus.  Normal sized kidneys with suggestive pyelonephrotic changes.  No definite intrauterine gestation.  Presence of a small (3.9cm) complex mass at the left adnexal area. This may suggest a small ovarian mass- however ectopic gestation with intraperitoneal blood cannot be

Ultrasound of Abdomen (cont…) Minimal pleural fluid, bilateral. May be due to reactive pleurons. Suggest chest xray.  Noted is a small complex mass seen left supero-lateral to the uterus. Measures 3.5 x 3.9 x 3.9 cm. no significant tenderness noted. However 1 moderate to massive intraperitoneal fluid was noted. 

Pregnancy Test 8-23-09 RESULT: positive 

ANATOMY & PHYSIOLOGY

OF THE FEMALE INTERNAL REPRODUCTIVE SYSTEM



The internal reproductive anatomy includes the uterus, two ovaries, two fallopian tubes. The ovaries are the female reproductive glands where the 400,000 ova or egg cells are stored. The fallopian tubes tube-like a structure that convey the ovum from the ovaries to the uterus and provides a place for fertilization of ovum by sperm.



It is divided into four parts the interstitial portion that lies within the uterine wall, the isthmus that is cut or sealed during BTL, the ampulla where fertilization of an ovum occurs and the infundibular portion which is funnel-shaped structure and its rim is covered by fimbria(small hairs) that helps to guide the ovum into the fallopian tube. The lining of entire fallopian tube is composed of mucous membranes which contains both mucussecreting and ciliated (hair-covered)cells.



The uterus is a hollow, muscular pear-shaped organ located at the lower pelvis posterior to the bladder and anterior to the rectum. It receives ovum from the fallopian tube and provide place for implantation and nourishment during fetal growth.



It has three divisions the corpus (body) which the lining of the cavity is continuous with the fallopian tube which enter the upper aspect (cornua), the isthmus which enlarges greatly to aid in accommodating the growing fetus during pregnancy, the cervix the lower portion of the uterus which contains a small opening called the os. Semen travels through the os into the uterus and the fallopian tubes following ejaculation



Fertilization is the meeting of sperm cell and the fertilized ovum. It can only occur if intercourse takes place before the time of ovulation that usually occurs mid-cycle or about 14 days before the woman's next menstrual period. At the time of ovulation, the ovum is released from the ovary and transported in the fallopian tube where it remains for about 24-48 hours.



Sperm cells remain viable within the female reproductive tract for about 72 hours. Only a single sperm cell is needed to fertilize the ovum, even though the average ejaculation contains approximately 300 million sperm.



During fertilization, the sperm enters the cell membrane of the ovum so the nuclei of the sperm and egg cells combine to form a zygote. The zygote will remain in the fallopian tube for approximately three days before it travels to the uterus through the help of the hair like structures called cilia where it will remain for approximately four to five days before implantation or

PATHOPHYSIOLOGY

Predisposing

Precipitating

Age: Above 25 PID; Infertility; Use of Gender: IUD; Female Tubal Surgery; Previous Smoking; Tubal Ectopic Ligation Signs and symptoms: Pregnancy

Clinical presentation of ectopic pregnancy occurs at a mean of 7.2 wks. After the last menstrual period with range of 5-8 wks.   Pain in the lower Abdomen and inflammation Pain while urinating Pain and discomfort. A corpus luteum on the ovary In a normal pregnancy mat give very similar symptoms. Vaginal bleeding, usually mild. An ectopic pregnancy is usually a failing pregnancy and falling levels of progesterone from the corpus luteum on the ovary cause withdrawal bleeding. Pain while having a bowel movement.

Patients with a late ectopic pregnancy typically experience pain and bleeding, this bleeding will be both vaginal and internal and has two discrete pathophysiologic mechanism. 1. External bleeding- due to falling progesterone levels. 2. Internal bleeding- due to hemorrhage from the affected tube.     Severe internal bleeding may cause: Lower back, abdominal, or pelvic pain. Shoulder pain, This is caused by free blood tracking up the abdominal cavity and irritating the diaphragm, and is an eminous sign. Cramping or even tenderness on one side of the pelvis. Can mimic diseases such as appendicitis

MANAGEMENT

MEDICAL MANAGEMENT IDEAL

Another option administer methrotrexate -Pt. must be hemodymically stable, have no active renal or hepatic disease, have no evidence of thrombocytopenia or leukopenia, and have a very small, unruptured ectopic pregnancy on ultrasound -no fetal cardiac activity, no active bleeding, and a beta-hCG level of < 2000 mIU per ml -administered intramuscularly or orally, maybe treated with intratubal injection of methotrexate Side effects: Abdominal cramping, mucositis, and renal and hepatic damage, allergic reactions have occurred in pt. receiving high dosages

ACTUAL

August 21, 2009; 9PM Please admit under the Dep’t of surgery NPO V/S q 4hours Administer: # 1 P5NSS ; 1L @ 40 drops/min #1 D5LR; 1L @ 30 drops/min LABS: CBC U/A XRAY- Abdomen flat plate and epigastric UTZ whole abdomen MEDS: Ranitidine 200mg Cefuroxime 50mg Insert NST and open to drain 10:15 AM Check HGT q 6 hours (3AM-11AM-6PM-11PM) 10:20 PM Change present IVF to # 2 PNSS; 1L @ 40 drops/min

MEDICAL MANAGEMENT(cont…) IDEAL

Complete Blood Count Renal and hepatic function tests Blood typing Pt is advised to refrain from alcohol, intercourse and vitamins containing folic acid because it may exacerbate the adverse effects of methotrexate Pt. may expect abdominal which occurs within 5 to 10 days, it indicates termination of pregnancy Serum level of beta-hCG should gradually decreased upon monitoring Ultrasound should also be used for monitoring

ACTUAL

August 22, 2009; 12:35 AM IVF TF c #3 PNSS; 1L @ 40 drops/min 10:00AM Pregnancy test IVF TF #4,5 PNSS; 1L @ 40 drops/min 4:10PM IVFTF c #6 PNSS; 1L @ 40 drops/min Paracetamol 500mg IVTT q 4 hours 7:20PM May have DAT No dark colored foods Stop when abnormal when abdominal pain recurs August 23,2009; 9:30PM IVFTF c #8,9,10 PNSS; 1L @ 40 drops/min Follow up pregnancy test

MEDICAL MANAGEMENT(cont…) IDEAL

ACTUAL

August 24, 2009; Refer to OB-Gyne (r/t EP) 8:10PM For 2nd UTZ now Request CBC, Platelet, Bleeding time, Clotting time *** UTZ – (+) pregnancy test for transfer of service to OB 10:00AM May transfer to OB-Gyne WARD 10:45AM Follow up blood Request HGT Lab today Schedule for Pelvic Lap Secure Consent Request RBC NPO for 4hours 6:45PM Keep NPO Request HGT level IVFTF #11 PNSS; 1L @ 40 drops/min Follow up blood

MEDICAL MANAGEMENT(cont…) IDEAL

ACTUAL

August 25, 2009 Prepare for Pelvic Lap Keep NPO 1 Ranitidine 50 mg q 8hours IVTT 3:45PM For Culdocentesis now Follow up blood 1 Vit K 1 amp IM for 12hours *** (-) abdominal pain, (+) distension fallopian tube, (+) direct tenderness 7:00 PM UTZ – upper abdomen & transvaginal IVFTF D5LR; 1L @ 30 drops/min Culdocentesis *no blood withdrawn 10:00PM Keep NPO Metronidazole 1 gm Suppository

MEDICAL MANAGEMENT(cont…) IDEAL

ACTUAL

August 26, 2009 Follow-up UTZ (abdominal & transvaginal) Repeat hgb and hct 6 hours post bilateral tubal ligation Keep NPO Continue meds Refer to OB – on call in case of fluctuation *** abdomen: distended, non-tender, soft, tympanic, (-) vaginal bleeding 9:30am UTZ of whole abdomen now FBC attached to urobag - For bladder filling prior to UTZ 11:00am Repeat hgb, hct count @ outside lab Repeat pregnancy test 11:20am For paracentesis, Please secure consent for explore lap/pelvic lap Secure blood for OR use

SURGICAL MANAGEMENT IDEAL

Resection of the involved fallopian tube with End to end Anastomosis “Milking” an ectopic pregnancy from the tube Salvaging the tube with a salpingotomy which involves opening and evacuating the tube and controlling bleeding salpingectomy Salpingo-oophorectomy After surgery pt. is given methotrexate to treat any remaining embryonic or early pregnancy tissue as indicated by a persistent or increasing beta-hCG level Repeat beta-hCG test every two weeks after surgery to ensure that the level is decreasing

ACTUAL

PREOP CHECKLIST: Informed consent (BTL and pelvic lap) Sponge bath done Jewelry : dentures, prosthesis removed Proper attire: Hospital gown without underwear Nails cleaned and polish removed FBC inserted Operative record AUGUST 26,2009 Pre Dx: acute abdomen t/c ectopic pregnancy, ruptured Post Dx: Left cornual pregnancy, ruotured,hemorrhage secondary to severe anemia Operation performed: repair of the ruptured left cornua,BTL

SURGICAL MANAGEMENT(cont…) IDEAL

ACTUAL

Surgical interventions: Preoperative Interventions 1. Check vital signs as indicated (depending on severity). 2. Check amount of vaginal bleeding. 3. Check for signs of shock such as tachycardia, drop in blood pressure, and cool clammy skin. (During pregnancy, signs of shock are not manifested until there has been at least a 40 % blood volume loss. 4.Check state of mental acuity/level of consciousness. 5.Keep an accurate record of intake and output. •Urinary output during pregnancy is the best noninvasive indicator of circulatory volume. •Diminished cardiac output causes a shunting of blood away from the skin, kidneys, and skeletal muscles in order to ensure blood delivery to heart and brain. 6.Start an intravenous infusion with an 18gauge intracatheter and maintain as ordered.

Surgical techniques/ findings Induction of spinal anesthesiaasepsis/antisepsis. Midline infraumbilical incision , deepened down  Intra Op: Hemoperitoneum = 2L (suction), the left cornua has point of rupture = 1-2 cm with desidual time/ blood noted; active bleeding at the site. Cornual resection at the left is started with double osshner clamp, rescted and excised then sutured using chromic 2-0, hemostasis is observed.BTL done. Abdominal wall is closed layer by layer.

SURGICAL MANAGEMENT(cont…) IDEAL

7.      Obtain blood as ordered for • a complete blood count, • prothrombin time, • partial thromboplastin time, • Rh antibody screen, and • type and cross match for 2 to 4 units of blood. 8.      Administer oxygen at 8 to 10 L by mask as needed. 9.      Carry out such preoperative protocol as giving the patient • nothing by mouth, • giving no enemas or cathartics since they could stimulate a tubal ectopic pregnancy to rupture, •being prepared to insert a Foley catheter as ordered, and •get the permit signed for surgery. 10.  Notify the attending physician of any changes in •vital signs, •decreasing urinary output, •blood pressure that falls 10 mmHg or

ACTUAL

Blood loss(hemoperitoneum) = 2L Transported to PACU per gurney in semi conscious state Post Op: spinal anesthesia (+) spinal headache (+) prolonged motor blockade (+) paralysis (+) lumbar / back pain

SURGICAL IDEAL MANAGEMENT(cont…) 11.  If the patient presents in shock, be prepared to assist with central line placement. The internal

jugular and subclavian veins are less likely to collapsed. 12.  Be prepared to administer blood replacement therapy if •the hemoglobin level is below 7 g/dl or •the patient is manifested signs of shock. Postoperative Interventions 1. Check blood pressure, pulse, and respiration •every 15 minutes, eight times; •every 30 minutes two times; •every hour, two times; •every 4 hours, two times; and then routinely. 2. Assess vaginal bleeding by pad count. 3. Check dressing •every hour four times and then •every shift for bleeding 4. Refer to laboratory work, such as hemoglobin and hematocrit. 5. Keep an accurate intake and output records. 6. Assess for cyanosis. 7. Reinforce or change dressing as needed.

ACTUAL

SURGICAL MANAGEMENT(cont…) ACTUAL IDEAL 9. Once the gastrointestinal tract resumes normal function, instruct regarding the importance of •a high protein, •high-iron diet for body repair and replacement of blood loss. 10.  Notify physician if blood pressure drops to less than 90 systolic, •pulse rises to greater than 120 bpm, or •anemia develops.

NURSING MANAGEMENT IDEAL

Nursing Diagnoses with corresponding interventions Acute pain r/t progression of the tubal pregnancy •Relieving pain by providing preanesthetic medications if the pt. is to undergo surgery •Postoperatively analgesic agents are administered liberally Anticipatory grieving r/t loss of pregnancy and effect on future pregnancies •Supporting the grieving process by listening and providing support and encouraging pts partner to participate in this process Deficient knowledge r/t treatment and effect on future pregnancies •Teaching patient self-care by explaining the procedures in terms that the distressed and apprehensive pt can understand including the pts partner when possible •Addressing pts. Questions and

ACTUAL

NURSING MANAGEMENT(cont…) IDEAL

•Instruct to report early signs and symtoms of recurrence •Review signs and symptoms with the pt and instruct her to report abnormal menstrual period promptly •Pt. teaching is based on the needs of the pt and partner and must take into considerations their distress and grief. Monitoring and managing potential complications by assessing carefully to detect the development of this complications (shock and hemorrhage) •by continuous monitoring of v/s, level of consciousness, amount o bleeding, intake and output •bed rest is indicated •monitor hematocrit, hemoglobin and blood gas levels to assess hematologic status and adequacy of tissue perfusion •blood component therapy may be required if blood loss has been rapid and extensive

ACTUAL

PLS. REFER TO OUR NURSING CARE PLANS

NURSING CARE PLAN

Identified Problem: Nursing Diagnosis: secondary to anemia

Activity Intolerance r/t generalized weakness

CUES

OBJECTIVES

Subjective Cues: “Maglisod ko ug lihok sa laing posisyon,” as verbalized by patient.     Objective Cues:   Dyspnea Pallor Increased heart rate Level 4 functional level evidenced by dyspnea and fatigue at rest

Short term Objectives:   Within 8 hours of nursing interventions, patient will be able to demonstrate identified techniques to enhance activity tolerance such as proper positioning every after 2 hours, balancing rest periods and progressively increasing activity level

INTERVENTIONS

Monitor Vital signs regularly. Check patency of IV. Monitor intake and output. Note client’s reports of weakness, fatigue, pain and difficulty of accomplishing tasks. Assess cardiopulmonary response to physical activity. Assess emotional/ psychological factors affecting current situation.

RATIONALE

To provide baseline data. To prevent complications. Symptoms may be result of/or contribute to intolerance of activity. To determine effect of activity. May be increasing the effects of an illness or might be the result of being forced into inactivity. To determine current status and needs associated with participation in needed/ desired

EVALUATION

CONTINUATION Nursing Diagnosis: secondary toOBJECTIVES anemia CUES Long Term Objectives:   Within 3 days of nursing interventions, patient will report measurable increase in activity tolerance.

Activity Intolerance r/t generalized weakness INTERVENTIONS

RATIONALE

Ascertain ability to stand and move about and degree of assistance necessary/use of equipment. Increase exercise/ activity level gradually by taking frequent rests and asking SO to assist patient in performing ADLs. Raise the side rails. Adjust level of activities by reducing intensity level or discontinue activities that cause undesired physiological changes. Plan care to carefully balance rest periods with activities. Perform passive

To provide safety. To prevent over exertion of effort. To reduce fatigue. To enhance ability to tolerate activities. Prevent bed sores and promote activity. To determine current status and needs associated with participation in needed/ desired activities. To conserve energy and promote rest. To provide safety. To prevent over exertion of effort. To reduce fatigue. To enhance ability to tolerate activities. Prevent bed sores

EVALUATION

Identified Problem: Nursing Diagnosis: Acute Pain r/t abdominal pressure secondary to distention tube CUES of fallopian OBJECTIVES INTERVENTIONS RATIONALE EVALUATION Subjective Cues: “Sakit akong puson,” as verbalized. P- distension of fallopian tube Q- Sharp stabbing pain R- Pain at McBurney’s point. S- Pain scale of 10 T- Intermittent; felt most when moving. Objectives Cues: Facial grimace Guarding behavior Irritability and restlessness

Short term objectives: Within 8 hours of rendering nursing care, patient will be able to verbalize nonpharmacolog ic methods that provide relief.   Long term objectives: Within 3 days of nursing care, patient will be able to report that pain is

 Monitor vital signs regularly.  Check IV fluids and regulate at prescribed rate.  Monitor intake and output.  Assess patients past coping mechanisms to wards pain.  Observe nonverbal cues/pain behaviors and other objective defining characteristics, as noted  Assess patient’s

To provide baseline data. To prevent complications. To determine what measures worked best in the past. Observations may/may not be congruent with verbal reports or may be only indicator present. This will impact on patient’s perception of the effectiveness of the treatment modality and willingness to

CONTINUATION Nursing Diagnosis: Acute Pain r/t abdominal pressure secondary to distention of fallopian tube CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION  Accept client’s description of pain and acknowledg e the pain experienced and convey acceptance of client’s response to pain.  Encourage use of relaxation techniques such as breathing exercises, and

Pain is a subjective experience and cannot be felt by others. To distract attention and release tension. To prevent pain in the affected part. To promote nonpharmacologica l pain management. To relieve pain. To prevent fatigue.

CONTINUATION Nursing Diagnosis: Acute Pain r/t abdominal pressure secondary to distention of fallopian tube CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION  Limit movement and support patient.  Provide comfort measures such the use of therapeutic touch and repositionin g every 2 hours.  Administer medications such as analgesics, prn.  Encourage

Identified Problem: Nursing Diagnosis: Self-care deficit [hygiene] r/t decreased energy level secondary to anemia CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION Subjective Cues: “Dili nako kaya maligo,” as verbalized by patient. Objectives Cues: •Inability to bathe and groom independently •Inability to put clothing on upper and lower body independently. •Inability to ambulate independently. •Foul body odor •Unkempt hair

 Monitor vital Short term signs objectives: regularly. Within 8 hours  Check of caring, patency of IV  Note patient will verbalize concomitant understanding medical of the need to problems or maintain existing proper conditions hygiene. that may be Long term factors for objectives: care such as Within 3 days increased BP of nursing and pain.  Note whether interventions, patient will be deficit is able to perform temporary or self-care permanent,

To provide baseline data. To prevent complications. To know barriers to activity tolerance. To measure whether care needs to be stressed longer or amount of care needed. Enhances commitment to plan, optimizing outcomes, and supporting recovery and/or

CONTINUATION Nursing Diagnosis: secondary to anemia CUES OBJECTIVES

Self-care deficit [hygiene] r/t decreased energy level INTERVENTIONS

RATIONALE

 Promote client’s/SO’s participation in problem identification and desired goals and decision making.  Provide privacy and equipment within easy reach during personal care activities.  Assist with necessary adaptations to accomplish ADLs. Begin with familiar, easily accomplished tasks.  Advise SO to provide

To encourage client and build on successes To promote hygiene. To enhance proper grooming.

EVALUATION

Identified Problem: Nursing Diagnosis: Sleep deprivation r/t prolonged physical discomfort CUES INTERVENTIONS RATIONALE EVALUATION secondary to pain OBJECTIVES Subjective cues: “Dili ko katulog tungod sa kasakit,” as verbalized by Patient. Objective cues: •Restlessness •Irritability •Slowed reaction •Prominent eyebags noted •Frequent yawning

Short-term objectives: Within 8 hours of nursing care, patient will be able to participate in ways to promote sleep such as balancing rest periods, proper positioning, and adequate exercise. Long-term objectives: Within 3 days of nursing care, patient will be able to report

 Monitor vital signs regularly.  Check IV fluids and regulate at prescribed rate.  Determine client’s usual sleep pattern and expectations .  Encourage client to restrict caffeine, alcohol and other stimulating

To provide baseline data. To prevent complications. Provides comparative baseline. These factors are known to disrupt sleep patterns. Enhances expenditure of energy/ release of tension so that client feels ready for sleep. Because they impair ability to sleep at night.

CONTINUATION Nursing Diagnosis: Sleep deprivation r/t prolonged physical discomfort secondary to pain CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION  Promote adequate physical exercise activity during the day.  Suggest abstaining from daytime naps.  Recommend quiet activities such as reading, listening to soothing music.  Determine client’s intervention that has been tried in the past.  Distinguish client’s beneficial

To reduce stimulation and promote relaxation. Helps identify appropriate interventions. To promote sleep. To monitor effect of interventions.

Identified Problem: Nursing Diagnosis:

Ineffective breathing pattern r/t body position

CUES

OBJECTIVES

INTERVENTIONS

RATIONALE

Subjective cues: “Kung maghayang ko kay maglisod ko ug ginhawa,” as verbalized by patient. Objective cues: •Dyspnea •Alterations in depth of breathing •Tachypnea •Difficulty breathing in supine position •Pallor

Short-term objectives: Within 8 hours of nursing care, patient will be able to participate in techniques to improve breathing by proper positioning and breathing exercise. Long-term objectives: Within 3 days of nursing care, patient will be able to establish

 Monitor vital signs regularly.  Check patency of IV.  Note concomitant medical problems or existing conditions that may be factors for care such as pain and respiratory deviation.  Assess for respiratory rate and depth by listening to breath sounds at least every

To obtain baseline data. To prevent complications. To monitor barriers for effective breathing. Respiratory rate and rhythm changes are early warning sign of impending respiratory distress. For optimal breathing pattern. So that the appropriate

EVALUATION

CONTINUATION Nursing Diagnosis: CUES

OBJECTIVES

Ineffective breathing pattern r/t body position INTERVENTIONS

RATIONALE

 Position patient with proper body alignment  Ensure that oxygen delivery system is applied to the pt .  Pace and schedule activities providing adequate rest periods.  Teach pt the significance of appropriate breathing, coughing, and splinting techniques.  Teach pt. when to inhale and exhale while doing active

To prevent dyspnea resulting from fatigue. To facilitate adequate clearance of secretions. Appropriate breathing techniques during exercise are important in maintaining adequate gas exchange. Pt will then know when to limit activities in terms of her

EVALUATION

Identified Problem: Nursing Diagnosis: Deficient knowledge [Learning Need] regarding condition r/t inadequate understanding of disease process CUES

Subjective cues: “Wala ko’y hanaw sa akong kahimtang karon,” as verbalized by the patient. Objective cues: •Questioning members of the health care team •Verbalizes inaccurate information •Refusal to follow

OBJECTIVES

Short-term objectives: Within 8 hours of nursing care, patient will be able to exhibit increase interest for more information by asking more questions. Long-term objectives: Within 3 days of nursing care, patient will be able to identify relationship of signs and symptoms to the

INTERVENTIONS

RATIONALE

 Determines client’s ability/ readiness and barriers to learning.  Assess ability to learn or perform desired health-related care.  Be alert to signs of avoidance.  Assess motivation and willingness of pt or SO to learn.

Individual may not be physically, emotionally, or mentally capable at this time. Cognitive or physical impairments need to be identified so an appropriate teaching plan can be designed. Client may need to suffer consequences of lack of

EVALUATION

CONTINUATION Nursing Diagnosis: Deficient knowledge [Learning Need] regarding condition r/t inadequate understanding of disease process CUES

OBJECTIVES

INTERVENTIONS

RATIONALE

 Provide positively enforcement and avoid criticisms.  Provide an atmosphere of respect, openness, trust and collaboration.  Give clear and thorough explanation and demonstration. Encourage questioning  Discuss one topic at a time. Avoid giving too much information in one session.  Include emotional counseling in the teaching if necessary.  Provide information about reproductive health, family planning,

To prevent information overload. To encourage continuation of efforts. To promote understanding. To prevent confusion and misinterpretati on. To enhance emotional understanding. Such information is necessary for the client’s situation.

EVALUATION

Identified Problem: Nursing Diagnosis: Ineffective tissue perfusion [cardiopulmonary and peripheral] r/t decreased hemoglobin concentration in blood secondary to CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION anemia Subjective cues: •“Maglisod ko ug ginhawa,” as verbalized by patient. •Chest pain Objective cues: •Capillary refill time of >4 seconds •Nail beds are pail •Edema on face, legs and hands of edema grade 2.

Short-term objectives: Within 8 hours of nursing care, patient will be able to participate in ways to promote circulation such as proper positioning, active ROM and relaxation techniques.

 Monitor vital signs  Check IVF and regulate it at prescribed rate.  Monitor intake and output.  Identify underlying conditions involve in tissue injury.  Note poor hygiene and health practices.  Identify changes related to

To obtain baseline data. For hydration Suggest treatment options. That may be impacting tissue health. Improve tissue perfusion/ organ function. Conserves energy/ lowers tissue oxygen demands. Enhances venous return. To increase gravitational

CONTINUATION Nursing Diagnosis: Ineffective tissue perfusion [cardiopulmonary and peripheral] r/t decreased hemoglobin concentration in blood secondary to CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION anemia • •

• • •

Weak pulses Decreased blood pressure. Pallor Altered sensations Altered respiratory rate outside of acceptable parameter s

 Evaluate for Long-term objectives: signs and Within 3 days infection of nursing especially care, patient when immune will be able to system is maintain compromised. optimal tissue  Investigate perfusion in reports of chest peripheral and pain; note cardiopulmon precipitating ary as factors; evidenced by changes in strong characteristics peripheral of pain pulse, episodes.  Determine absence of edema, alert cardiac rhythm LOC, and note decreased presence of

When at risk for embolus. Drugs used to improve tissue perfusion also carry risk of adverse responses.

CONTINUATION Nursing Diagnosis: Ineffective tissue perfusion [cardiopulmonary and peripheral] r/t decreased hemoglobin concentration in blood secondary to anemia CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION  Assist with treatment of underlying conditions as indicated.  Encourage quiet restful atmosphere.  Note signs of ischemia secondary to drug effects.  Perform assistive/ active ROM exercises.  Encourage early ambulation when possible.  Discourage sitting/standing for long periods, wearing constrictive clothing, crossing legs.  Elevate HOB at night

DISCHARGE PLAN

MEDICATION

EXERCISE

DIET

Instruct pt to take medication within prescribed time and dosage religiously to maintain health improvement. Encourage pt to exercise as tolerated. Educate pt on the benefits of exercise towards health particularly to improvement of tolerance activities. A high-protein, high-calorie diet is recommended for the patient as well as iron-rich foods. Patient should also avoid foods that are high in sodium. Patient’s Name: Condition upon Discharge:

Date of Discharge:

HEALTH TEACHING

Educate the pt on the nature of Ectopic pregnancy

SCHEDULE FOR NEXT VISIT

Instruct pt to return 1 week after discharge for follow up check-up. Emphasize importance of follow up check ups.

SPIRITUAL

Encourage pt to continue trusting God, to pray. Explain to pt that everything happens for a reason and they’re still alternatives to having children.

LIFESTYLE

Encourage pt to take adequate rest and take proper meals. Socializing with people and having a healthy relationship with friend may help divert patient’s attention from his vices, and restore her love for life. Reuniting with her family may also help her psychological condition. Refer to a female reproductive specialist such as obstetrician or gynecologist for further consultation or go to a nearest health center or hospital.

REFERRAL