Ectopic pregnancy

STI College of Nursing Sta. Cruz, Laguna

Submitted to: Ms. Aurea Celino, RN, MAN Clinical Instructor Submitted by: GROUP II Members: Bernardino, Michelle S. Bernas, Nikki Lou Ching, Judith U. De Ramos, Robert Immanuel Ingalla, Charmaine Matienzo, Evangeline N. Monteseña, Roselle Ann Sotomayor, Karen July 2010

TABLE OF CONTENTS 1

I. Introduction ------------------------------------------------------------------------------------2 A. Objectives -------------------------------------------------------------------------------3 B. Background of the Study ------------------------------------------------------------3 C. Rationale for Choosing the Case --------------------------------------------------4 D. Significance of the Study ------------------------------------------------------------4 E. Scope and Limitations ----------------------------------------------------------------4 II. Clinical Study ------------------------------------------------------------------------------------5 A. Demographic Data ----------------------------------------------------------------------5 B. Physical Assessment -------------------------------------------------------------------7 C. System Affected --------------------------------------------------------------------------9 D. Laboratory and Diagnostic Exam ----------------------------------------------------9 III. Clinical Discussion ----------------------------------------------------------------------------11 A. Anatomy and Physiology -------------------------------------------------------------11 B. Pathophysiology ------------------------------------------------------------------------14 C. Nursing Care Plan ----------------------------------------------------------------------15 D. Drug Study -------------------------------------------------------------------------------20 E. Course in the Ward --------------------------------------------------------------------29 F. Discharge Plan --------------------------------------------------------------------------30 G. Evaluation --------------------------------------------------------------------------------32 H. Summary ----------------------------------------------------------------------------------33 I. Recommendation -----------------------------------------------------------------------34 J. Bibliography ------------------------------------------------------------------------------35

I. Introduction 2

ECTOPIC PREGNANCY The BSN level III students were given the opportunity to have a hospital exposure at Laguna Provincial Hospital – Delivery Room; and on that day found a commendable case reasonable to be presented for case study. The patient, to be mentioned in this paper as J.S, housewife, G2P1 (T1-P0-A0-L1), was one of the patients admitted to the Delivery Room. She was 33 years of age. Her LMP is June 10, 2010 and her EDC is March 17, 2011. She was admitted due to ectopic pregnancy. An ectopic pregnancy occurs when the baby starts to develop outside the womb (uterus). The most common site for an ectopic pregnancy is within one of the tubes through which the egg passes from the ovary to the uterus (fallopian tube). However, in rare cases, ectopic pregnancies can occur in the ovary, stomach area, or cervix. Ectopic Pregnancy occurs in about 1 in 250 pregnancies amounting to approximately 70 000 cases annually, 5,833 per month, 1,346 per week, 191 per day, 7 per hour. In the Philippines, unpublished reports have estimated the incidence to be just about 22, 194 each year. An ectopic pregnancy is commonly referred to as a tubal pregnancy because 95 percent occur in a fallopian tube. An ectopic pregnancy needs to be treated immediately to avoid fallopian tube damage or life threatening blood loss. When identified early, ectopic pregnancies are treatable with medication that stops the pregnancy. If the pregnancy is further along, laparoscopy is usually performed to remove the ectopic tissue and repair the fallopian tube. If the ectopic pregnancy has ruptured or bleeding persists, salpingectomy is a very common option. This procedure involves excision of segment of the Fallopian tube involved in the ectopic pregnancy. The tubal segment to be removed is coagulated and cut off with bipolar forceps. The group chose J.S. as our subject primarily because her case posed as a very intricate case requiring due understanding and knowledge. The group recognizes their partial knowledge about ectopic pregnancy and the surgical

3

procedures involved in such condition, thus making this case a good avenue to broaden the proponents’ knowledge about the disease and the surgical procedures involved.

A. OBJECTIVES •

To define what ectopic pregnancy is, trace the pathophysiology and enumerate the signs and symptoms of ectopic pregnancy.

•

To identify and understand different types of medical treatment necessary for the treatment of ectopic pregnancy.

•

To formulate and apply nursing care plan utilizing nursing process.

•

To learn new clinical skills, as well as sharpen our current clinical skills required in the management of the patient with ectopic pregnancy.

•

To develop our sense of unselfish love and empathy rendering nursing care to our patient so that we may be able to serve future clients with higher level of holistic understanding, as well as individualized care.

B. BACK GROUND OF THE STUDY This is a case of a patient, named J.S, 33 years old from Binan Laguna, who has been diagnosed with Ectopic Pregnancy.

The patient has a maternal history of

G2P1T1P0A0L1. The patient was complaining from pain in right lower quadrant of her abdomen. The patient has been admitted at the Delivery Room then transferred to OB – Gyne Ward last July 22, 2010 at 5:30am. Upon internal examination there was

a

tenderness also the patient experienced scanty vaginal bleeding. The result of her ultrasound indicates Ectopic Pregnancy. She has undergone series of diagnostic tests and

undergone

operation

for

Exploratory

Laparatomy

(EXLAP)

and

right

salphingectomy. We decided to present this case due to our eagerness to learn and explore new knowledge and information about this type of condition. Our group wants to formulate a correlation among the conditions that manifests in patient JS. We believe that this can be of great help in performing appropriate nursing interventions to the 4

patient. Our group also wants to focus on ectopic pregnancy, which is uncommon among pregnant mothers. It is a significant topic for the mothers especially those who are in their pregnancy stage. It is of great advantage that they have knowledge on this condition. C. RATIONALE OF CHOOSING THE CASE This case has been chosen by the group due to the following reasons: A. To conduct further studies about Ectopic Pregnancy. B. To have a further knowledge about this complication and how it can occur. C. To know the possible risk of the one who has this kind of complication and how it can be treated. D. To be able to present the case study of our chosen client that would provide a comprehensive discussion of the pathological mechanism of the complication to yield significant information for the case study. D. SIGNIFICANCE OF THE STUDY This study is done for the benefits of the following: •

To the relatives and client – to help them to understand the present condition and its complication.

•

Student Nurse – to enhance the level of our knowledge and appropriate nursing care about Ectopic Pregnancy

•

Reader – acquire more understanding about Ectopic Pregnancy and its sign and symptoms.

E. SCOPE AND LIMITATION This study covers and focuses on the following: 

A brief discussion of the disease and its pathophysiology



A drug study of medications prescribed to patient



Nursing Care Plans which would present nursing analysis, diagnosis, plan, and appropriate interventions that would aid in patients recovery. 5



Discharge plan which presents follow-up care and treatment after confinement.

II. Clinical Study A.DEMOGRAPHIC DATA Patient Name:

Ms. JS

Age:

33 years old

Birth Date:

April 9, 1977

Civil Status:

Single

Occupation:

None

Address:

Binan, Laguna

Maternal history: LMP:

June 10, 2010

EDC:

March 17, 2011

G2P1 T1P0A0L1 Clinical/ Admitting Data: CC:

Abdominal pain

Internal Examination:

with tenderness, with scanty vaginal bleeding

Date of Admission:

July 22, 2010

Time of Admission:

5:30am

Attending Physician:

Dra. Estela Galvez

Admitting Diagnosis:

Ectopic pregnancy G2P1 T1P0A0L1

Proposed Surgical procedure: EXLAP and Right Salpingectomy Vital Signs on admission: T= 37.2 °C PR= 105bpm RR= 22cpm 6

BP= 90/60mmHg Family Background:  2nd among 5 children

 With 2 year old baby girl  Partner: Mr. EP  Partner is a smoker History of Past Illness  She seldom get sick but experiences fever sometimes due to weather conditions 

No information about her immunizations.

 No known allergy

History of Present Illness  The patient is not aware of her pregnancy.  During the 6th week of pregnancy, the patient experienced scanty vaginal

bleeding and abdominal pain which made her seek for medical help.  She went to one of the hospital in Binan, Laguna, she was advised to have an ultrasound.  The findings of the ultrasound indicate that the patient has ectopic pregnancy and they were referred in LPH.

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B. PHYSICAL ASSESSMENT

General Appearance

Head

Hair

Eyelids Sclera Iris

Pupils

Ears

Nose

-

with facial grimace

-

with guarding behavior

-

weak and pale looking

-

with foul breath

-

conscious and coherent

-

with IVF hooked on right hand

-

on NPO normocephalic

-

symmetrical in shape

-

no masses, no lesions evenly distributed over the scalp

-

with black, straight and thick hair

-

dandruff is present lids close symmetrically

-

no edema, and no discharges whitish symmetrical in size

-

round and dark brown Symmetrical in movement

-

round and dark brown in color

-

PERRLA (Pupils Equally Round And React To

-

Light and Accommodation) equal in size

-

auricles are smooth and symmetrical

-

pinna recoils after it is folded

-

with dry cerumen the external nose is symmetrical and straight

-

color is the same with the entire face

-

lesions and tenderness were both absent

-

nasal mucosa was pinkish

-

both left and right nares were patent 8

-

the nasal septum is intact and in midline without deviations

-

cilia present in internal nares

-

absence of nasal discharge appear dry and pale

Mouth

slightly dry and furry with whitish coating -

tounge moves freely

-

uvula is in midline neck movement was coordinated and difficulty in

Neck

moving was not noted -

Thorax

Breast

Abdomen

Upper extremities

tongue was located at the midline, pink in color,

-

free from lumps and no tenderness no masses and tenderness upon palpation no adventitious breath sounds upon auscultation on

-

both left and right lung fields round in shape, no lumps, no masses

-

areola dark brown in color

-

nipples round, equal in size same color of the body

-

with presence of stretch marks

-

with throbbing pain in RLQ good range of motion was noted

-

no lesions, no presence of abnormalities, no tenderness

-

can extend arms without difficulty skin uniform in color

Lower extremities

-

no varicose

Genitalia

-

with limited movement With scanty vaginal bleeding

C. SYSTEM AFFECTED  Reproductive System

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D. LABORATORY AND DIAGNOSTIC EXAM Complete Blood Count July 22, 2010 BLOOD COMPONENTS Hemoglobin

RESULT

White Blood Cells (WBC) Hematocrit

NORMAL VALUE 13-19g/dl

INTERPRETATION

11.8 K/uL

4.1 – 10.9 k/uL

Increase

32.8%

35 – 45%

Decrease

11.0 g/dl

Decrease

SIGNIFICANCE Decrease hemoglobin will result to bleeding Increase WBC signifies infection in the body. Decrease hematocrit indicates that the mass of RBC is decrease

July 24, 2010 BLOOD COMPONENTS Hemoglobin

RESULT

White Blood Cells (WBC)

11.3 K/uL

4.1 – 10.9 k/uL

Increase

35%

35 – 45%

Normal

Hematocrit

11.5 g/dl

NORMAL VALUE 13-19g/dl

INTERPRETATION SIGNIFICANCE Decrease

Decrease hemoglobin will result to bleeding Increase WBC signifies infection in the body.

Ultrasonography D

DIAGNOSTIC

NORMAL

RESULT 10

IMPRESSION

A EXAM T E J Obstetric u ultrasonol graphy y 2 1 , 2 0 1 0

RESULT No anatomic or functional abnormalities exist. The organs are normal in shape, size, contour and position. The internal structures of the organs and nearby tissues are within normal limits.

The uterus is anteverted measuring about 8.01 cm in length x 7.0 cm in width x 5.3 cm in thickness. The endometrial stripe is about 1.4 cm in thickness. A complex mass measuring about 5.12 cm x 5.12 cm is seen at the right adnexae.

III. CLINICAL DISCUSSION

A. ANATOMY AND PHYSIOLOGY 11

ENLARGED UTERUS. THICKENED ENDOMETRIAL STRIPE COMPLEX MASS RIGHT ADNEXAE CONSIDERATION S ARE: TUBO-OVARIAN OATHOLOGY RIGHT EXTRA-UTERINE CONCEPTION RIGHT

The female reproductive organs consist of the ovaries, uterine tubes (or fallopian tubes), uterus, vagina, external genitalia, and mammary glands.

Ovaries – the two ovaries are small organs suspended in the pelvic in the pelvic cavity by ligaments. Ovaries are the female reproductive glands where the 400,000 ova or egg cells are stored. The outer part of the ovary is made up of dense connective tissue and contains ovarian follicles. Fallopian tubes – the uterine tubes extend from the area of the ovaries to the uterus. They open directly into the peritoneal cavity near each ovary and receive the oocyte. The opening of each uterine tube is surrounded by long, thin processes called 12

fimbrae. It is a 4 inches long from each side of the uterus (fundus). It transports the mature ova form the ovaries to the uterus and provide a place for fertilization of the ova by the sperm in it’s outer 3rd or outer half. Parts: •

Isthmus – portion that is cut or sealed in a tubal ligation.

•

Ampulla – widest, longest portion that spreads into fingerlike projections/fimbriae and it is where fertilization usually occurs.

•

Infundibulum - rim of the funnel covered by fimbriated cells (hair covered fingerlike projections) that help to guide the ova into the fallopian tube. Uterus - is as big as a medium-sized pear. The part of the uterus superior to the

entrance of the uterine tubes is called fundus. The uterine wall is composed of three layers: •

The outer layer called the serous layer or perimetrium of the uterus

•

The middle layer called the muscular layer or myometrium

•

The innermost layer of the uterus is the endometrium.

The uterus is supported by the broad ligament and the round ligament Vagina – is a female organ of copulation and functions to receive the penis during intercourse. It also allows menstrual flow and childbirth. The superior portion of the vagina is attached to the sides of the cervix so that a part of the cervix extends into the vagina.

External Genitalia – also called vulva or pudendum of the vestibule and its surrounding structures. The vestibule is the space into which the vagina and urethra open. The vestibule is bordered by a pair of thin, longitudinal skin folds called the labia 13

minora. A small erectile structure called clitoris. The two labia minora unite over the clitoris to form a fold skin called the prepuce. Lateral to the labia minora are two prominent, rounded folds skin called labia majora. The space between the labia majora is called the pudendal.

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.

B. Pathophysiology

Predisposing Factor: Female, 33 years of age Matured ovum release from ovary ready for fertilization Matured egg pick-up by fallopian tube 14

Sperm Single Division cell cell Fision and become ofegg cellscell zygote fused

Sperm cells enter to uterine cavity and migrate to fallopian tube Only one best & healthiest sperm will reach the ovum

Cluster of cell Morula Blocks movement of fertilized egg to the uterus Fertilized egg attaches and implants in the fallopian tube Moderate amount, dark red vaginal bleeding

Distention and irritation of fallopian tube

Ectopic Pregnancy

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Abdominal pain

A. Nursing Care Plan Subjective

Objective

Analysis

Planning

Intervention

Rationale

Evaluation

“Sumasakit ang puson ko” as verbalized by the patient.

- with pain scale of 8 out of 10 -with facial grimace -irritable -with weak and pale looking - with guarding behavior - with limited movement

Acute pain related to distention of the fallopian tube as evidenced by verbal reports of discomfort and pain

After 8 hours of nursing intervention, the patient will verbalize and show relief of pain lessened from 8/ 10 to 6/ 10 in pain scale

Used pain rating scale appropriate for age/ condition .

To assess the rate of the intensity, quality and frequency of pain.

Obtained client’s assessment of pain to include location, characteristics, onset/duration, frequency, quality, intensity, and precipitating factors. Reassessed each time pain occurs/is reported.

To rule out worsening of underlying condition/developme nt of complications.

Goal met. After 8 hours of nursing interventions, the patient able to verbalized and showed relief of discomfort, pain lessened from 8/10 to 6/10 in pain scale

V/S: BP-90/60 mmHg RR- 22 bpm T- 37.2 C

Provided comfort To promote measures such nonpharmacological as touch, pain management. repositioning, use of cold packs, nurse’s presence and quiet environment and calm activities.

16

Instructed and encouraged use of relaxation techniques such as focused breathing, imaging.

To distract attention and reduce tension.

Administered analgesics, as ordered.

To decrease pain at tolerable level. Notify physician if regimen is inadequate to meet pain control goal.

DAY 1: JULY 22, 2010

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Subjective

Objtive

Analysis

Planning

Intervention

“Namumula ang tahi ko”, as verbalized by the patient.

- with reddish 4 inches surgical incision due to exploratory lapatoromy. - with unhealthy environment for postoperative patient wound - with pale and weak looking - incision site is warm to touch -no swelling

Risk for infection related to inadequate primary and secondary defenses secondary to exploratory laparotomy as evidenced by reddish incision site.

After 8 hours of nursing interventions, the patient will be able to identify interventions to prevent or reduce risk of infection.

Noted risk factors for infection including skin integrity, environmental exposure and laboratory results.

To serve as basis in providing preventing actions.

Observed for localized signs of infection as the surgical wound.

To assess physical signs that manifest infection.

Maintained clean technique when doing wound dressing.

To prevent bacterial colonization.

Cleansed incision sites daily and as needed with appropriate cleaning solution.

To maintain a clean surgical wound and reduce the risk of infection.

V/S: -RR= 22 bpm -Temp.= 37.2 C -Hgb= 11.3g/dL

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Rationale

Evaluation After 8 hours of nursing interventions the patient was able to identified the health teachings given to prevent or reduce risk of infection.

Changed dressings as ordered

To maintain adequate protection and prevent contamination.

Encouraged the client to take nutritious foods and increase fluid intake such as meat and fish.

To strengthen the patient’s immune system this decreasing the patient’s susceptibility to infection.

Maintained a clean and healthy environment.

To promote an environment for faster wound healing.

Administered antibiotics as ordered.

To prevent infection and fast healing of wounds.

DAY 2: JULY 23, 2010

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Subjective “Hindi ko alam kung mabubuntis pa ako uli” as verbalized by the patient.

Objective -asking questions about her condition -anxious

Analysis Knowledge deficit related to the treatment and effect on future pregnancies as evidenced by verbal reports of the patient.

Planning After 8 hours of nursing interventions, the patient will be able to increase knowledge about Ectopic pregnancy and treatment.

Intervention Determined client’s ability/readiness and barriers to learning.

Rationale Client’s readiness will help the barriers to learning.

Provided information relevant only to the situation.

To prevent overload of information

Listened to client’s perception of need. Relate information to client’s personal desires/needs and values/beliefs. Begun with information the client already knows and move to what the client does not know, progressing from simple to complex. DAY 3: JULY 24, 2010 20

So that client feels competent and respected.

Can arouse interest/limit sense of being overwhelmed.

Evaluation After 8 hours of nursing interventions the patient was able to verbalized understanding of her condition.

B. DRUG STUDY Drug Name

Dosage

Generic Name: 45mg IV CEFUROXIME q 8 hours SODIUM x 4 doses (-) ANST Brand Name: (After Zinacef Negative Skin Test)

Classification

Mechanism of Action

Indication

Secondgeneration Cephalospho rin

Bactericidal: Periinhibits operative synthesis of prophylaxis bacterial cell wall, causing cell death

Contraindication

Adverse Effects

Nursing Responsibilities

with allergy to cephalosporins or penicillins

Headache, dizziness, lethargy, abdominal pain, flatulence, decreased WBC and hematocrit inflammation at IV site

Advise patient receiving IV drug to report any discomfort in the injection site to check if there is a problem on the site. Inform the patient that this drug is given to treat infection. Follow the ten rights of the medication and administration. Skin test of IV drug before administration. Advice patient to report signs of hypersensitivity such as itchiness and rashes.

21

Drug Name

Dosage

Generic Name: CEFTRIAXONE SODIUM

1g IV q 12 hours (-) ANST

Brand Name: Rocephin

Classification

Mechanism of Action

Indication

Contraindication

ThirdBactericidal: Peri-operative with allergy to generation inhibits prophylaxis cephalosporins Cephalosphorin synthesis of for patients or penicillins bacterial undergoing cell wall, potentially causing cell contaminated death surgical procedures

Adverse Effects Headache, dizziness, diarrhea, lethargy, abdominal pain, flatulence, decreased WBC and hematocrit inflammation at IV site

Nursing Responsibilities Advise patient receiving IV drug to report any discomfort in the injection site to check if there is a problem on the site. Do not mix ceftriaxone with any other antimicrobial drug. Skin test of IV drug before administration.

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Drug Name

Dosage

Classification

Generic Name: 50mg IV Analgesic TRAMADOL q 6 hours HYDROCHLORIDE Brand Name: Ultram

Mechanism of Action

Indication

Contraindication

Binds to muopioid receptors and inhibits the reuptake of norepinephrin e and serotonin; causes many effects similar to the opioids – dizziness, somnolence, nausea, constipation – but does not have the respiratory depressant effects

Relief of moderate to moderately severe pain

With allergy to tramadol or opioids or acute intoxication with alcohol, opioids, or psychoactive drugs

Adverse Effects Vertigo, headache, confusion, sweating, tachycardia, bradycardia, pallor, constipation

Nursing Responsibilities Control environment (temperature, lighting) if sweating or CNS effects occur. Advise patient to report severe nausea, dizziness, severe constipation. Withdrawal symptoms may occur if drug is stopped abruptly. Reduce dosage gradually. Inform patient the side effects that he may fall asleep/ lethargic

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Drug Name

Dosage

Generic Name: COAMOXICLAV

625mg cap BID per orem

Brand Name: Amoclav Augmentin Augmex

Classification Combination with betalactamase inhibitor

Mechanism of Action Combination of amoxicillin, a βlactam antibiotic; with clavulanic acid, β lactamase inhibitors results in an antibiotic with an increased spectrum of action and restored efficacy against β lactamase producing amoxicillinresistant bacteria

Indication For postsurgical infections, prophylaxis against infectious associated with major surgical procedures

Contraindication Hypersensitivity to penicillin, possible cross sensitivity with other β-lactams

Adverse Effects

Nursing Responsibilities

Indigestion, rash, StevensJohnson syndrome, erythema

Obtain patient’s history of allergy. Inform patient that amoxicillin may cause side effects. Assess patient for previous sensitivity reaction to penicillin or other cephalosporin to determine any allergic reactions. Assess for allergic reaction during treatment: rash, urticaria, pruritus, chills and fever. Assess bowel pattern and sign of dehydration. If severe diarrhea occurs drug should be discontinued. Advise patient to discontinue drug if hypersensitivity reaction occurs.

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Drug Name Generic Name: IBUPROFEN Brand Name: Advil Genprin Ibutab Menadol Midol Motrin

Dosage

Classification

Mechanism of Action

500mg cap BID per orem

Analgesic NSAID Propionic acid derivative

Anti-inflammatory, analgesic, and antipyretic activities largely related to inhibition of prostaglandin synthesis; exact mechanisms of action are not known. Inhibits both cyclooxygenase (COX) 1 and 2. Ibuprofen is slightly more selective for COX-1

Indication Relief of mild to moderate pain

Contraindication with allergy to ibuprofen, salicylates, or other NSAIDs

Adverse Effects Somnolenc e, fatigue, tiredness, palpitations, arrhythmia, pruritus, rash, sweating

Nursing Responsibilities Be aware that patient may be at increased risk of GI bleeding. Advise patient to administer drug with food or after meals if GI upset occurs. Advise patient to discontinue drug if hypersensitivity reaction occurs. Assess for allergic reaction during treatment: rash, urticaria, pruritus, chills and fever.

25

Drug Name Generic Name: FERROUS SULFATE Brand Name: Feozol Fer-gen-sol Fer-in-sol

Dosage

Classification

500mg 1 Iron cap OD Preparation per orem

Mechanism of Action Elevates the serum iron concentration, which then helps to form Hgb or trapped in the reticuloendothelial cells for storage and eventual conversion to a usable form of iron

Indication Prevention and treatment of irondeficiency anemias Dietary supplement for iron

Contraindication With allergy to any ingredient; hemolytic anemias With normal iron balance

Adverse Effects Acidosis, anorexia

Nursing Responsibilities Confirm that patient does have iron deficiency anemia before treatment. Advise patient to give drug with meals (avoiding milk, eggs, coffee, and tea) if GI discomfort is severe. Inform patient that stool may be dark or green. Advice patient to arrange for periodic monitoring of Hct and Hgb levels.

26

Drug Name Generic Name: Promethazine Hydrochloride Brand Name: Phenadoz Phenergan

Dosage

Classification

25mg IM Antiemetic Antihistamine (Pre-Op Anti-motionsickness drug Meds.) Dopaminergic blocker Phenothiazine Sedativehypnotic

Mechanism of Action

Indication

Contraindication

Blocks cholinergic receptors in the vomiting center that are believed to mediate the nausea and vomiting caused by gastric irritation, by input from the vestibular apparatus (motion sickness, nausea associated with vestibular neuritis), and by input from the chemoreceptor trigger zone (drugand radiationinduced emesis)

Prevention and control of nausea and vomiting associated with anesthesia and surgery

with hypersensitivity to antihistamines or phenothiazines

27

Preoperativ e, postoperati ve, or obstetric sedation

Adverse Effects Dizziness, headache, vertigo, dry mouth

Nursing Responsibilities Give IM injections deep into muscle. Do not administer subcutaneously; tissue necrosis may occur. Do not administer intra-arterially; arteriospasm and gangrene of the limb may result.

Drug Name Generic Name: Nalbuphine Hydrochloride Brand Name: Nubain

Dosage

Classification

10mg IM Opioid agonist(Pre-Op antagonist analgesic Meds.)

Mechanism of Action Acts as an agonist at specific opioid receptors in the CNS to produce analgesia and sedation but also acts to cause hallucinations and is an antagonist at mu receptors

28

Indication

Contraindication

Prewith operative hypersensitivity analgesia, to nalbuphine as a supplement to surgical anesthesia

Adverse Effects Sweating, headache, confusion, vertigo, floating feeling, numbness

Nursing Responsibilities Keep opioid antagonist and facilities for assisted or controlled respiration available in case of respiratory depression.

Drug Name Generic Name: SIMETHICONE Brand Name: Disflatyl Degas Flatulex Mylanta Gas Mylicon Phazyme

Dosage

Classification

40mg Antiflatulent 2 tabs after meal now per orem BID

Mechanism of Action Defoaming action disperses and prevents the formation of mucussurrounded gas pockets in the GI tract; changes the surface tension of gas bubbles in the stomach and small intestine, enabling the bubbles to coalesce, allowing gas to be more easily freed by belching or flatus

29

Indication

Contraindication

Relief of With allergy to symptoms components of and the product pressure of excess gas in the digestive tract; postoperati ve gaseous distention and pain

Adverse Effects Nausea, vomiting, belching, passing of flatus, constipation

Nursing Responsibilities Give after each meal and at bedtime. Advise patient that she may experience increases belching and passing of flatus as gas disperses.

C.COURSE IN THE WARD Date

Time

Vital Sign

July 22, 2010

6:30am

T – 37.2 oC P – 105 bpm R – 22 cpm BP– 90/60 mmHg

Observation - with pain scale of 8 out of 10 -with facial grimace -irritable -with weak and pale looking - with guarding behavior - with limited movement - with foul breath - conscious and coherent - with IVF hooked on right hand - on NPO

7:30am

T – 37.3 oC P – 80 bpm R – 20 cpm BP– 110/70 mmHg

8:30am

T – 36.5 oC P – 89 bpm R – 22 cpm BP– 100/70 mmHg

9:30am

T – 37 oC P – 88 bpm R – 23 cpm BP– 110/60 mmHg

10:30am

T – 36 oC P – 85 bpm R – 25 cpm BP– 100/70 mmHg 30

11:30am

T – 37.2 oC P – 91 bpm R – 22 cpm BP– 110/70 mmHg

12:30nn

T – 37.2 oC P – 91 bpm R – 22 cpm BP– 110/70 mmHg

1:30pm

T – 36.8 oC P – 87 bpm R – 24 cpm BP– 110/60 mmHg

DISCHARGE PLAN Medications: 

Take ferrous sulfate 500mg 1 tablet each day for 6 months preferably before bed time; Co-amoxiclav 500mg 2 times a day for seven days every 12 hours, 1 tablet 7AM and 1 tab in 7PM, do not take with empty stomach; Ibuprofen 500mg 1tab for 3 days for pain only

Exercise and Environment: 

Do light exercises like stretching or walking slowly and carefully; seek assistance for safety measure



Encouraged the mother to keep an environment clean and conducive to health for her rapid recovery and to avoid infection and keep environment quiet to make the patient comfortable

Treatment: 

Explain to the client that becoming pregnant again may be difficult because fertilization takes place only on the side of the remaining tube after ovulation of

31

the remaining tube of the ovary on the same side and at higher risk for a subsequent ectopic pregnancy as well as infertility. 

Emphasized to the mother the importance of regular follow-up check-ups and as instructed by physician



Advised the mother to seek medical advice if any strange arises



Encouraged the mother to let her be monitored by the health care provider until complete recovery is met

Health Teachings:  Emphasized to the mother the importance of proper hand washing and proper hygiene  Educate the client to recognize some signs and symptoms of pregnancy if occurs, aside from the absence of menstrual period and morning sickness she should visit her OB or nearest health center for proper assessment & check-ups.  Advice the client to engage in safe sexual practices like proper hygiene before intercourse to prevent from STDs and pelvic infections that could cause further damage to the fallopian tubes.  Refrain from sexual intercourse for at least 6 weeks until the follow-up appointment with the physician. Out Patient: 

Reminded the mother that even though she feels better, it is important to have the doctor monitor her progress. The patient is scheduled for her follow up check up one week after her discharge from the hospital in Out-Patient Department in Laguna Provincial Hospital (LPH) to evaluate her recovery.

Diet: 

Encourage to eat nutritious food and drink natural fruit juices for fast recovery.



Get plenty of rest. Increase fluid intake. Keep the incision clean.

Spirituality: 

Encouraged the mother to continue to seek God’s guidance and to continue to have a positive outlook in life



Emphasized the importance of prayers in healing 32



Encouraged the mother to pray for her fast recovery and gave words of encouragement

EVALUATION

A pregnant woman with vaginal bleeding must be evaluated promptly. Once a diagnostic of ectopic pregnancy is made and surgery is scheduled, start an IV as ordered and begin preoperative teaching. Immediately report the signs of developing shock. If the patient experiences severe abdominal pain administer analgesics and evaluate the effectiveness and patient’s response.

Regardless of the treatment used, the prescribed therapy for the post operative procedure such underwent Salphingectomy operation, the patient should be at complete bed rest, abstinence from sex, religious intake of medication and emotional support from the family.

However, though the group had rendered not enough time to handle the case completely because of conflicting schedule, the nursing intervention we had during the confinement for the patient like aseptic wound cleansing of the incision site, mild assistance in ambulation and health teaching with regards to continuous prescribed meds, proper hygiene, eat well and strengthens faith in God provided the client with much ease and comfort that the client exhibits early recovery and may go home order.

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SUMMARY Our patient Ms. JS, 33, a G2P1, plain housewife, was admitted on July 22, 2010 @ 8:00 in the morning with the chief complaint of abdominal pain. She obtained medical consultation in Binan Hospital, Binan, Laguna and then was advised/referred to Laguna Provincial Hospital, Sta. Cruz, Laguna for prompt surgery. Upon assessment Ms. JS happened to have scanty vaginal bleeding, pale and weak. She presented an UTZ result which came out to her to undergo Salphingectomy (excision of segment of the Fallopian tube) that is involved in the ectopic pregnancy. Ms. JS has no family or past history of present illness, no known history of illness, no known allergies and reportedly without recognizing that she was 6th weeks pregnant. Her husband is a driver and they were blessed with a 2-year old female child. Her husband known to be a responsible and good provider but a chain smoker, they were not married. At the course of the ward, necessary surgical procedure was done, consent letter was signed, IVF hooked such as 1L D5LR; Voluven 500ml (side drips); 1L D5 NSS; prescribed medication such as antibacterial (Co-amoxiclav, Cefuroxime, Ceftriaxone); Analgesic (Tramadol & Ibuprofen); Pre-Op anesthesia (Promethazine & Nalbuphine); For iron supplement (Ferrous sulfate); Anti-flatulence (Disflatyl); For laboratory study: CBC, urinalysis and “For Exlap”. Post-Op: sponge bath, apply abdominal binder and clear liquid tee and crackers for diet then diet as tolerated once bowel movement occur; Ambulate; change of dressing or wound care. Upon interviewing the client, other concerns we gather, she was not a stressful housewife and only do light household chores. Though their budget is limited they still manage to eat a balanced diet and able to provide their child’s needs. The etiology of ectopic is unknown but then our case has revealed that an aging woman is prone for this kind of condition and if not prompted damage of fallopian tube will occur or life threatening blood loss is at risk.

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RECOMMENDATION This case study has provided us with important information about the patient’s ectopic pregnancy condition and its proper nursing care intervention prior to pre-andpost surgical procedure. In order to ensure that optimal health is restored and maintained, the group would like to recommend the following: To the patient: Whenever there is, the onset of a certain condition it implies one to contribute her cooperation and willingness to be responsible for her own health, such as: •

The patient must be sensitive of her own needs and be able to expect liability for her actions.

•

She is also encouraged to verbalize her own thoughts and feelings concerning how she perceives her condition affect her life and her expected duration of her recovery.

•

She is advised to take part in complying with therapeutic regimen designed for her recovery.

•

She should realize the importance of complying with her medication and the benefits this practice would bring to the improvement of her well-being. Moreover, she must not hesitate on seeking medical assistance whenever she feels signs and symptoms, which may be due to other health illness.

To the patient’s family: The patient’s family plays an important role in the patient’s recovery. •

The family should make themselves physically present so that the patient would somehow feel their support and concern.

•

They are encouraged to be the patient’s source of strength and inspiration as she undergoes painful, traumatic and harrowing procedures. In addition, it is of prime importance that they are oriented and educated basic facts regarding the patient’s condition so that they will understand her even better and assist him in his daily activities. 35

To our fellow nursing students: It is encourage as much as possible to have a complete nursing care in the span of confinement of your client, it starts from the assessment, admission and up to the full recovery of the client that includes the discharge or may go order and follow-up checkups so that every actual scenario can be studied and experienced of the given appropriate nursing intervention done. Since the goal of giving nursing care is promote wellness, prevent from or further illness and restore health, thorough handling for this kind of case must be given prior attention, time and effort. For Future Researcher: It is recommend that you must have an actual case handle because every patient has a case-to-case basis nevertheless this case may guide you to have comparison although case-to-case basis but then depending on how and what kind of person is giving care to a certain patient to have a fulfilled nursing care.

BIBLIOGRAPHY Medical-Surgical Nursing, Brunner and Suddarth’s, 12th ed., Vol. 1, p. 299 Medical-Surgical Nursing, Brunner and Suddarth’s, 12th ed., Vol. 2, p. 1432 Fundamental of Nursing, Kozier and Erb’s, 8th ed., Vol. 2, p. 1455 Nursing Drug Guide, Lippincott’s, 2009, pp. 259, 257, 998, 832, 1170, 607, 508, 1074

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