University of San Jose Recoletos

COLLEGE OF NURSING
Cebu City, Philippines

A Study on the Case of

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

In Partial Fulfillment of the Requirements in NCM

102 RLE

Perpetual Succour Hospital

Station 3B, Sto. Nio & St. Elizabeth Wards
Third Rotation

(Feb 15-19, March 1-5, 2010)

Presented to the Faculty of

the University of San Jose Recoletos College of
Nursing

Submitted to Gonzalve, Ronnie, Jr, BSN, RN

5 March 2010

A Study on the Case of

Obstetric Client F.B.M., Female, 25 Years Old,

Diagnosed with Ruptured Ectopic Pregnancy,

Right Uterine Tube, undergone Exploratory
Laparotomy, Right Salpingo-oophorectomy

conducted by BSN II Block II Group I

TABLE OF CONTENTS

Contents

Introduction

Objectives

Nursing Assessment
Clients Profile

Physical Assessment

Gordons Functional Health Patterns

Laboratory Findings

Anatomy and Physiology of the Female Reproductive System

10

Pathogenesis of Ectopic Pregnancy

12

Nursing Care Plans

13

Discharge Plan

16

Drug Study

17

Bibliography

21

Appendix

22

I. INTRODUCTION (lacking of statistical data/ epidemiology Philippines-/

literature)

An ectopic pregnancy is one in which implantation occurs outside the uterine cavity. The
implantation may occur on the surface of the ovary or in the cervix. The most common
site (in approximately 95% of such pregnancies) is in the uterine tube. Of these uterine
tube sites, approximately 80% occur in the ampullar portion, 12% occur in the isthmus,
and 8% are interstitial or fimbrial.

With ectopic pregnancy, fertilization occurs as usual in the distal third of the uterine tube.
Immediately after the union of the ovum and the spermatozoon, the zygote begins to
divide and grow normally. Unfortunately, because an obstruction is present, such as
adhesion of the uterine tube from a previous infection (chronic salpingitis or pelvic

inflammatory disease), congenital malformations, scars from tubal surgery, or a uterine

tumor pressing the proximal end of the tube, the zygote cannot travel the length of the
tube. It lodges at the strictured site along the uterine tube and implants there instead of in
the uterus.

Approximately 2% of pregnancies are ectopic; ectopic pregnancy is the second most

frequent cause of bleeding in early pregnancy. The incidence is increasing because of the
increasing rate of pelvic inflammatory disease, which leads to tubal scarring. Ectopic
pregnancy occurs more frequently in women who smoke compared to those who do not.
There is some evidence that intrauterine devices (IUDs) used for contraception may slow
the transport of the zygote and lead to an increased of tubal or ovarian implantation. The
incidence also increases following an in vitro fertilization. Women who have one ectopic
pregnancy have a 10% to 20% chance that a subsequent pregnancy will also be ectopic.
This is because salpingitis that leaves scarring is usually bilateral. Congenital anomalies
such as webbing (fibrous bands) may also be bilateral. Surprisingly, oral contraceptives
may reduce the possibility of ectopic pregnancy. (3 classification of ectopic pregnancy
pain, bleeding and abd tenderness)

Assessment

With ectopic pregnancy, there are no unusual symptoms at the time of implantation. The
corpus luteum of the ovary continues to function as if the implantation were in the uterus.
No menstrual flow occurs. A woman may experience the nausea and vomiting of early
pregnancy, and pregnancy test for human chorionic gonadotrophin (hCG) will be positive.

At weeks 6 to 12 of pregnancy (2 to 8 weeks after a missed menstrual period), the zygote

grows large enough to rupture the slender uterine tube or the trophoblast cells break
through the narrow base. Tearing and destruction of the blood vessels in the tube result.
The extent of the bleeding that occurs depends on the number and size of the ruptured
vessels. If implantation is in the interstitial portion of the tube (where the tube joins the
uterus), the rupture can cause severe intraperitoneal bleeding. Fortunately, the incidence
of tubal pregnancies is highest in the ampullar area (the distal third), where the blood
vessels are smaller and profuse hemorrhage is less likely. However, continued bleeding
from this area may in time result in a large amount of blood loss. Therefore, a ruptured
ectopic pregnancy is serious regardless of the site of implantation.

A woman usually expediencies a sharp, stabbing pain in one of her lower abdominal
quadrants at the time of the rupture, followed by scan vaginal spotting. With placental
dislodgement, progesterone secretion stops and the uterine decidua begins to slough,
causing additional bleeding. The amount of bleeding evident with a ruptured ectopic
pregnancy often does not reveal the actual amount present, however, because the
products o conception from the ruptured tube and the accompanying blood may be
expelled into the pelvic cavity rather than into the uterus. Therefore, this blood does not
reach the vagina to become evident. If internal bleeding progresses to acute hemorrhage,
a woman may experience lightheadedness and rapid pulse, signs of shock.

When helping determine the possibility of an ectopic pregnancy, ask a woman whether

she has pain or vaginal bleeding. Any woman with sharp abdominal pain and vaginal
spotting needs to be evaluated by her health care provider to rule out the possibility of
ectopic pregnancy. Occasionally, a woman will move suddenly and move and pull one of
her round ligaments, the anterior uterine supports. This can cause a sharp, but
momentarily and innocent, lower quadrant pain. However, it would be rare for this
phenomenon to be reported in connection with vaginal spotting.

By the time a woman with a ruptured ectopic pregnancy arrives at the hospital of
physicians office, she may already be in severe shock, as evidenced by rapid, thready
pulse, rapid respirations, and falling blood pressure. Leukocytosis may be present, not
from infection but from trauma. Temperature is usually normal. A transvaginal sonogram
will demonstrate the ruptured tube and blood collecting in the peritoneum. Either a falling
hCG or serum progesterone suggests that pregnancy has ended. If the diagnosis of ectopic
pregnancy is in doubt, a physician may insert a needle through the postvaginal fornix into
the cul-de-sac under sterile conditions to see whether blood can be aspirated. A
laparoscopy or culdoscopy can be used to visualize the uterine tube if the symptoms alone
do not reveal a clear picture of what has happened. However, sonography alone usually
reveals a clear-cut diagnostic picture.

If a woman waits before seeking help, gradually her abdomen becomes rigid from
peritoneal irritation. Her umbilicus may develop a bluish tinge (Cullens Sign). A woman
may have continuing extensive or dull vaginal and abdominal pain; movement on the
cervix on pelvic examination my cause excruciating pain. There may be pain in her
shoulders from blood in the peritoneal cavity causing irritation to the phrenic nerve. A
tender mass is usually palpable in Douglas cul-de-sac on vaginal examination.

Therapeutic Management

Although some ectopic pregnancies spontaneously end and then reabsorbed, requiring no
treatment, it is difficult to predict when this will happen, so when an ectopic pregnancy is
revealed by an early sonogram, some action is taken. If an ectopic pregnancy can be
diagnosed before the tube has ruptured, it can be treated medically by oral administration
of methotrexate and leucovorin. Methotrexate, a folic acid antagonist chemotherapeutic
agent that attacks and destroys fast-growing cells. Because trophoblast and zygote growth
is rapid, the drug is drawn to the site of ectopic pregnancy. Women are treated until a
negative hCG titer is achieved. A hestrosalpingogram or sonogram is usually performed
after the chemotherapy to assess whether the tube is fully patent. Mifepristone, an
abortifacient, is also effective at causing sloughing of the tubal implantation site. The
advantage of these therapies is that the tube is left intact, with no surgical scarring that
could cause second ectopic implantation.

If an ectopic pregnancy ruptures, it is an emergency situation. Keep in mind that the

amount of blood evident is a poor estimate of the actual blood loss. A blood sample needs
to be drawn immediately for hemoglobin level, tying, and cross-matching, and possibly
hCG level for immediate pregnancy testing, if pregnancy has not yet been confirmed.
Intravenous fluid using a large-gauge catheter to restore intravascular volume is begun.
Blood then can be administered through this same line when matched.

The therapy for ruptured ectopic pregnancy is laparoscopy to ligate the bleeding vessels
and to remove or repair the damaged uterine tube. A rough suture line on the uterine tube
may lead to another tubal pregnancy, so either the tube will be removed or suturing on
the tube is done with microsurgical technique.

If a tube is removed, a woman is theoretically only 50% fertile, because every other
month, when she ovulates next to the removed tube, sperm cannot reach the ovum on
that side. However, this is not reliable contraceptive measure. Research in rabbits has
shown that translocation of ova can occur that is, an ovum released from the right ovary
can pass through the pelvic cavity to the opposite (left) uterine tube and become fertilized
and vice versa.(salphigictomy-removal of the fallopian tube.)
As with miscarriage, women with Rh-negative blood should receive Rh (D) immune
globulin (RhIG) after an ectopic pregnancy fro isoimmunization protection in future
childbearing.

(See Appendix for illustrations)

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

8) map out and explain the disease process of ectopic pregnancy.

9) identify and describe the various managements especially nursing
management for ectopic pregnancy.
10)
gather again as a group for pointers and reactions from each member
and from the clinical instructor after the case presentation.

III. NURSING ASSESSMENT

Client in Context

Client F.B.M., 25 years old, female, 5 weeks age of gestation; admitted to Perpetual
Succour Hospital for
the first time on March 02, 2010 at 8:58 A.M., accompanied by
her husband; in for complaints of right, lower abdominal pain; pre-operative diagnosis

ectopic pregnancy; operative diagnosis ruptured ectopic pregnancy, right uterine tube;
undergone major operation on March 02, 2010 at 10:00 A.M. exploratory laparostomy,
right salpingo-oophorectomy; under the services of Dr. Lyn Alana Busa of the Department
of Obstetrics; with hospital number 219923.

Biographical Data

Name of Client: F.B.M.

Sex: Female

Age: 25

years old
Civil Status: Married
Religion: Kristohanon

Nationality: Filipino

Address: Holy Name, Mabolo, Cebu City

Contact No: 0926

Birthdate: October 6, 1984

Birthplace: Ipil, Zamboanga Sibugay

Education: College Graduate

Occupation: Stocks In-charge, Ever Care

Health Insurance: PhilHealth

Date and Time of Admission: March 02, 2010 at 8:58 A.M.

Informant / Relation to Client: U.R.M. / Husband
Reliability: Reliable

Chief Complaints and History of Present Illness

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

Past Health History

Childhood Illness: Fever, Cough, Cold

Surgeries: None
Serious Injuries: None
Immunizations: Cant recall
Allergies: No known food, drug, dust allergies
Blood Transfusions: None
Hospitalizations:

CONDITION

INSTITUTION

DATE

None

Medications before Admission

Medication
Name

Dose/Frequency

Time of
Last
Dose

Medication Name

Dose/Frequency

Time
of Last
Dose

None

PHYSICAL ASSESSMENT
General appearance
Client F.M, 25 years old married and resident of holyname mabolo cebu city. She
was seen grimacing once in awhile. She can now move minimally with assistant and was
able to turn sides occasionally. She was still pale and weak.
Vital signs

Temperature: 36.8C
Pulse: 79 bpm
Respiration: 20 cpm
Blood Pressure: 90/60 mmHg

Height: 5 feet
Weight: 47kg
Integumentary
Skin is fair colored, warm, soft, and smooth, with moles at the right lower face, left upper
face behind the left nares and freckles around the left upper forehead; trauma in the right
dorsal part of the hand; hairs is thick, long, wavy, without parasites nor flakes on the
scalp; no clubbing present, negative capillary test (3 sec)
HEENT
Head/face normocephalic; no tenderness or masses; facial features symmetrical. Vision
was not assessed, extraocular muscles intact, visual fields normal by confrontation, cornea
and iris are intact, sclera is white, conjunctivae clear and pale pink, PERRLA, positive
constriction and convergence. External ear canals clear without redness, swelling, lesions,
and tympanic membrane intact, gray. Nares patent, no sinus tenderness present; nasal
mucosa pink, cilia noted; septum intact, no deviation. Lips dry; oral mucosa and gingivae
pink and moist without lesions; 32 ivory colored teeth, dental cary noted at the upper left
canine; tonsils are not assessed; tongue is smooth pink, symmetrical, no lesions.
Neck and Axillae
Positive swallow reflex
Thorax
Breasts symmetrical; light brown areolas and nipples with no masses or discharges;
normal spinal curvatures
Abdomen
Sutures seen in the abdomen, Wasnt able to auscultate abdomen due to abdominal binder
present and the client felt the pain when binder was loose
Musculoskeletal System and Extremities
Full ROM of lower extremities (patient was sitting with her legs dangling), upper
extremities are not fully movable because of the IVF at the right arm and the left arm is
still in trauma; skin is warm, hairs are visible in both legs; wasnt able to assess gait, heelto-toe walk and the likes because client is still lethargic and still needs assistance in
moving.

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

Health Perception Health Management

Health is wealth. Importante ni aron mabuhi, so that we could do everything we
want as verbalized by the patient. She scaled her health as 7/10. Patient said that
if ever she or a member of her family is sick, they usually buy OTC drugs. They dont

really go to health center because they are renting an apartment far from a health
center. They sometimes use herbal medicine such as kalabo w/c can be used for
treatment of cough.

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

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

Activity Exercise

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

Sleep Rest
Patient usually wakes up at 6-7 in the morning and sleep at around 10:30 in the
evening. She can only take a nap sometimes. So far she doesnt talk while sleeping
but hagok if shes very stress from work. She also mentioned that previously she
treat her insomnia by means of taking 4G but as of now she takes ferrous sulfate
to treat her insomnia. During her admission, patient sleeping pattern was different
because patient doesnt have enough sleep due to some noise in the ward.

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

Role Relationship
Patient aware that her responsibilities in the family is to be a good, loving, caring,
understanding wife to her husband and to their future children. As a wife, she said
that she takes care of her husbands needs like cooking him for breakfast, preparing
his food for work. She is very close to her husband, she even ask advices from her
husband. She is not very close to her siblings because its been long time since
theyve seen each other. In work, she believes that shes almost responsible to all.
She defines roles and responsibilities in life as a law and is to be followed
accordingly. The client felt sadness after knowing that her baby has already gone.
Her husband is always at her side to comfort her
.

Value Belief
Patient doesnt believe on horoscope as well as fortune/palm reading because she

believes that we are the one making our future by means of self-decision making.
She also believes that God has already planned our individual life. Patient is a
protestant but considered herself as a catholic in general because she is one of the
Christ believers but in terms of religious beliefs, she doesnt worship saints and do
the sign of the cross. During assessment, we observed that patient is religiously
active.

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

Coping Stress
Patient stated that, A problem is part of our lives. It molds us to become stronger.
For her, problem is like a challenge that if without it; a person wont fully enjoy and
feel lifes accomplishments and satisfaction. She also mentioned during assessment
that problems gives stress and makes a person very depress unless that certain
person knows how to handle it. Her ways in coping up with problems/stressors are
to always pray and ask Gods guidance; Work on it in order to solve it whether by
herself or with the help of others.

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

IV. LABORATORY FINDINGS

Exam date: March 02, 2010

URINALYSIS

MACROSCOPIC
Color (Urine)
Appearance
Glucose
Protein
pH
Specific gravity
Bilirubin

Umol/ L

Urobilinogen

Mg/ dl

Urine ketone
Nitrite
Leukocytes
Blood
/hpf
MICROSCOPIC

/hpf

RBC/ hpf
WBC/ hpf
Epithelial cells
Mucus threads
Amorphous material
Bacteria

LEGEND
NEG= Negative

BLOOD

POS= Positive

+ = 0.03mg/dl
+ = 30mg/dl

TNTC= Too numerous to count

++ = 100mg/dl

++ = 0.2mg/dl

PROTEIN

OCC= Occational

+++ = 1.0mg/dl
+++ = 300mg/dl
++++ =

2000mg/dl

BILIRUBIN

GLUCOSE
UROBILINOGEN

+ = 1mg/ dl

+ =50mg/dl
+ = 2mg/dl

++ = 2mg/ dl

++ = 150mg/dl
++ = 4mg/dl

+++ = 4mg/ dl

+++ = 500mg/dl
+++ = 8mg/dl
++++ = 1000mg/dl
++++ = 12mg/dl

SCLOUD= Slightly Cloudy

KETONE
LEUKOCYTES

LTYLW= Lightly yellow

+ = 25mg/dl
+ = 25wbcs/ ul

DKYLW= Dark yellow

++ = 100mg/dl
++ = 75 wbcs/ul

LTORNG= Light orange

+++ = 300mg/dl
+++ = 500wbcs/ul

Exam date: March 02, 2010

COMPLETE BLOOD COUNT
RESULT
White Blood Cells

UNITS
X10^9/L

REFERENCE RANGE

4.50- 13.0
Neutrophils

25.0- 70.0

Lymphocytes

20.0- 65.0

Monocytes

0.00- 9.00

Eosinophils

0.00- 8.00

Basophils

0.00-3.00

Hemoglobin

g/ dL

12.0- 16.0

Hematocrit

36.0- 49.0

Mean Corpuscular vol.

10^12/ L

78.0- 102.0

Mean Corpuscular Hgb

Fl

25.0- 35.0

Red Blood Cells Dist. Width

Pg

31.0- 36.0

( % ) x 10^9/ L

140.0- 440.0

Platelet Count

MANUAL PLATELET COUNT: 50,000/ cumm

Exam date: March 02, 2010

HEMATOLOGY

Test Name

Result

Units

Reference Range

Clotting Time LW

1330

min sec

7.0-15

Bleeding Time
IVY

430

min sec

2.0-8.0

Exam date: March 02, 2010

CHEMISTRY

Test
Name

Results

Units

Referenc
e Range

Results

Units

Referenc
e Range

Creatinin
e

0.86

mg/dL

0.60-1.50

76.02

mg/dL

53.4132.6

Sodium

134

mmol/L

133-146

134

mmol/L

133-146

Potassiu
m

3.46

mmol/L

2.4-5.2

3.46

mmol/L

3.4-5.2

Exam date: March 02, 2010

PREGNANCY
Result

POSITIVE

V. ANATOMY AND PHYSIOLOGY

(Female Reproductive System)
The system consists of external and internal genitalia, which develop and function
according to hormonal influences that affect fertility and childbearing. It also consists of
urinary structures.

External genitilia include the mons pubis, clitoris, vestibule, labia majora, labia minora,
vaginal introitus, hymen, Bartholins gland, Skenes gland, and the urethral meatus.
Internal genitalia include the vagina, cervix, uterus, adjacent structures (adnexa), ovaries,
and uterine tubes. Internal urinary structures include the ureters, bladder, and urethra.

The functions of the female reproductive system are:

Manufacturing and protective ova for fertilization

Transporting the fertilized ovum for implantation and embryonic/fetal development
Housing and nourishing the developing fetus.
Regulating hormonal production and secretion of several sex hormones.
Providing sexual stimulation and pleasure
Providing a drainage route for the excretion of urine (urinary structures)

Structures and Functions of the Female Reproductive System

STRUCTURE

DESCRIPTION/PRIMARY FUNCTION

Mons Pubis

- Pad of subcutaneous fatty tissue lying over

anterior symphysis

pubis
- Protects pelvic bones during coitus
- Two longitudinal folds of adipose and connective

Labia Majora
tissue

- Extended from clitoris anteriorly and

gradually narrow to

merge and form

posterior commissure of perineum

- Outer surface of the labia majora becomes

pigmented,

wrinkled and hairy at puberty

- Inner surface is smoother, softer, and contains

subcutaneous

glands
- Protects vulva components that it surrounds
- Protects urethra and vagina from infections
- Consists of two thin folds of skin that extend to

Labia Minora
form prepuce

of clitoris anteriorly and a transverse fold

of skin forming

fourchette posteriorly
- Contains sebaceous glands, erectile tissue, blood

vessels, and

involuntary muscle tissue

- Secretions are bactericidal and aid in lubricating

vulval skin

and protecting it from urine

- Protects urethra and vagina from infections
- Erectile body about 2.5 cm in length and 0.5 cm in

Clitoris
diameter

- Contains erectile tissue and has significant supply

of nerve

Vestibule

endings
- Serves as primary organ for sexual stimulation
- Area between two folds of labia minora
- Boat-shaped area containing the urethral meatus,

openings of

the Skenes glands, hymen,

openings of the Batholins glands

vaginal introitus
Skenes Gland

Vaginal Introitus
Hymen
surrounding vaginal

sexual experiences
Bartholins Glands

and

- Surround urethral meatus

- Provide lubrication to protect skin
- Entrance to vagina; size and shape may vary
- Avascular thin fold of connective tissue
introitus in women who have not had
- Small, pea-shaped glands deep in perineal

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

viability and motility of sperm along the

reproductive tract

Perineum

Vagina

- Space between fourchette and anus

- Composed of muscle, elastic fibers, fascia, and
connective

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

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

Cervix
Uterus

through which menstrual flow exists

- End of uterus that projects into vagina
- Pear-shaped, hollow, muscular organ

between bladder neck

and rectal wall

- Mucous membrane lining is the endometrium.

Muscular layer

is the mesometrium. Inferior aspect is

cervix, superior aspect

is fundus
- Major functions include serving as implantation

site of

fertilized ovum as protective sac for

developing embryo and

Uterine Tubes

fetus
- Two 7-10cm long ducts on either side of fundus of

uterus
- Extend from uterus almost to ovaries
- Normally, fertilization takes place within the tubes
- Major functions include serving as fertilization site
and

providing passage way for unfertilized ova

to travel to uterus

Ovaries

- Almond-shaped glandular structures that

produce ova
- Located laterally to uterine tubes
- Major functions include producing ova for
fertilization by

sperm and producing estrogen and

progesterone

(See Appendix for illustrations)

V. PATHOGENESIS

Ectopic Pregnancy in the Uterine Tube

HOST

AGENT
ENVIRONMENT

-Female, 25 y/o
motor-

Unknown

-unaware of pregnancy
hus-

-rides on

cycle with

band

Fertilization

Zygote travels along the uterine tube (UT)

Possible Causes
- adhesion of UT from

Zygote trapped on stinctured site

previous infection
(chronic salpingitis, PID)

Implantation on site

- congenital malformations
pregnancy

- (+)

- scars from tubal surgery

- uterine tumor
- IUD

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

If diagnosed early

- oral meds
(methotrexate, leucovorin,

Mifepristone)
Recovery
ruptures

UT

Destruction of conceptus
- (-) pregnancy

Recovery

Uterine deciduas sloughs off

Additional bleeding

scant vaginal spotting

Bleeding

Pain (RLQ)

Hemoperitoneum
(1500 cc)
- shoulder
pain

Hypovolemia
- tachycardia, thready pulse
- tachypnea
- hyptotension

Total circulatory collapse

Coma

Death

VI. NURSING CARE PLANS

NAME OF CLIENT: F.B.M
PHYSICIAN: Dr. Lyn Alana Busa
AGE:

ATTENDING

25 years old

NEED/NUR
SING
DIAGNOSI
S/CUES
Acute pain
related to
post
operative
surgery as
manifested
by
verbalized
reports.

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

SCIEN
TIFIC
ANALY
SIS

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

OBJECTIV
ES

After 3
days of
nursing
interventi
on the
patient
will be
able to:
-report
pain
-follow
prescribed
pharmacol
ogical
regimen
verbalized
methods
that
provide
relief
demonstr
ate use of
relaxation
skills

NURSING
OBJECTIVES/
NURSING
INTERVENTI
ONS
1. Perform a
comprehensiv
e assessment
of pain to
include
location,
characteristics
,
onset/duration
, frequency,
quality,
severity, and
aggreviating
factors.
2. Perform
pain
assessment
each time
pain occurs.
3. Monitor
vital signs

RATIONALE

-to assess
etiology

-to rule out

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

EVALUA
TION

EVALUA
TION

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

-to be
successful in
alleviating pain
-to promote
wellness and
to prevent
fatigue.

4.Provide
quiet
environment

5. Encourage
adequate rest
periods

SEX:

Female

STATUS:

Married

RELIGION: Kristohanon
COMPLAINT: RLQ abdominal pain
ADDRESS: Holy Name, Mabolo, Cebu City
Pregnancy, Right Uterine Tube

CHIEF

DIAGNOSIS:

Ruptured Ectopic

DATE AND TIME OF ADMISSION: March 02, 2010

PROFILE: Received client on bed,
.
with husband, afebrile, without IVF

08:58 A.M

NEED/ NURSING
DIAGNOSIS/ CUES

SCIENTIFIC
ANALYSIS

OBJECTIVES

Physiologic needs:
Risk for infection
related to tissue
destruction and
increase in
environmental
exposure/vertical
incision

Intact skin and

mucous
membrane are
the bodys first
line of defense
against
microorganisms.
Unless the skin
and mucosa
became crack and
broken, they are
an effective
barrier against
bacteria/
infectious agents.

After 8 hours of nursing

interventions the patient
will be able to:

O: Received pt. on
bed with vertical
incision at lower
abdomen w/binder

a.) Verbalize
understanding of
individual causative
risk factors.
b.) Identify intervention
to prevent/ reduce
risk f infection.
c.) Demonstrate
technique, lifetime
changes to promote
safe environment.

Source:
Fundamentals of
nursing 8th edition
page 673

CLIENT
asleep,

NURSING
OBJECTIVES/
NURSING
INTERVENTIONS
1. Note risk
factors
occurrence of
infection.
2. Clean incision
with betadine
or appropriate
solution.
3. Change
dressing as
needed or
indicated.
4. Provide
perineal care.
5. Monitor for
signs and
symptoms of
sepsis.

RA

Pr
ca
fa
inf

To
sp
inf
to
op
he

To
sk
at
lev

To
we

To
pa
or
pr
fu
inf

NEED/
NURSIN
G
DIAGNO
SIS/

SCIENTIF
IC
ANALYSI
S

OBJECTIVES

NURSING
OBJECTIVES/
NURSING
INTERVENTIO
NS

RATIONA EVALUATION
LE

VALUE
INTEGRA
TION

CUES
Powerle
ssness
related
to early
loss of
pregnan
cy
seconda
ry to
ectopic
pregnan
cy.

Depressio
n is an
illness that
causes a
person to
feel sad
and
hopeless
much of
the time. It
is different

S: Client
states
she
feels
sad at
pregnan
cy loss
but is
able to
deal
with
situatio
n; has
returned
to work
and has
forwardthinking
plans.
O:
Receive
d pt. on
bed
with
grimace
face,
weak ,
conscio
us and
has the
followin
g vital
signs:
T:
P:
R:
BP:

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

from
normal
feelings of
sadness,
grief, or
low
energy.
Anyone
can have
depression
. It often
runs in
families.
But it can
also
happen to
someone
who
doesn't
have a
family
history of
depression
. You can
have
depression
one time
or many
times.
If you think
you may
be
depressed
, tell your

a.) Express
feelings
of
physical
safety.
b.) Use
effective
coping
mechani
sms to
reduce
depressi
on.
c.) Mobilize
support
systems
and
professio
nal
resource
s as
necessar
y.
d.) Reestabli
sh and
maintain
adaptive
interpers
onal
relations
hips.

1. Provid
e the
patien
t with
psych
ologic
al
suppo
rt.
Visit
freque
ntly.
2. Be
availa
ble to
listen.
3. Accept
the
patien
ts
feeling
s and
behavi
ors.
4. Instru
ct the
patien
t in at
least
one
fearreduci
ng
behavi
or,
such
as
seekin
g
suppo
rt
from
others
when
frighte
ned.
5. Help
her
under
stand
the
phase
s of
crisis
and
the
patien

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

These
measur
es help
reduce
anxiety.

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

a.) Express
feelings
of
physical
safety.
b.) Use
effective
coping
mechani
sm to
reduce
depressi
on.
c.) Mobilize
support
systems
and
professio
nal
resource
s as
necessar
y.
d.) Reestabli
sh and
maintain
adaptive
interpers
onal
relations
hips.

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

doctor.
There are
good
treatments
that can
help you
enjoy life
again. The
sooner
you get
treatment,
the sooner
you will
feel better.

VIII. DISCHARGE PLAN

ts
reacti
ons to
the
family
memb
ers.

NAME OF CLIENT:
WARD & BED NO:

F.B.M.
3B-SE7

AGE: 25 years old

SEX:

COMPLAINT:
ADDRESS:
Ever Care

Female

STATUS:

Married

RELIGION:

Kristohanon
CHIEF

RLQ abdominal pain

Holy Name, Mabolo, Cebu City

DIAGNOSIS:

OCCUPATION:

Stocks In-charge,

Ruptured Ectopic Pregnancy, Right Uterine Tube

DATE AND TIME OF ADMISSION: March 02, 2010 08:58 A.M.

TYPE &
DATE OF SURGERY: Exploratory Laparotomy, Right Spingo-oophoretomy 03/02/10

OBJECTIVES

NURSING INTERVENTIONS

By the time the client will be discharged,

she should:

Medications
- take his prescribed drugs unfailingly.

- explain why the drug is prescribed

including side effects and immediate
measure in case
these occur (refer to
drug study)

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

- explain the relation of a well environment

to health
- site ways on how to provide a well
environment

Treatment
- recognize the necessity to comply with
his treatment.

Health Teaching

- advise to follow scheduled checkups (if

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

- learn about ectopic pregnancy

- health teaching session
Observable Signs & Symptoms
- recognize the signs and
symptoms of ectopic pregnancy
- advise for admission when these occur

-encourage prenatal care

Diet
- identify due diet for faster

- encourage to drink fluids as tolerated

(water, fruit juices)

recovery

- encourage to eat fruits and vegetables,

and other nutrient-dense foods
Spirituality
- improve spiritual wellness
- allow to verbalize about personal matters
about faith

IX. DRUG STUDY

NAME OF CLIENT: F.B.M.
CHIEF COMPLAINT: RLQ abdominal pain
AGE:

25 years old

SEX:

Female

STATUS:

Married

RELIGION:

Kristohanon

DIAGNOSIS:

Ruptured Ectopic Pregnancy, Right Uterine Tube

ADDRESS: Nivel Hills, Brgy. Lahug, Cebu City

Ever Care
To lower down fever from 37.8C to at least 37.5C

OCCUPATION: Stocks In-charge,

GOAL:

DATE AND TIME OF ADMISSION: March 2, 2010 08:58 A.M.

PROFILE:
client on bed, asleep, with husband, afebrile, without IVF

DRUG

mefenamic
acid
(Dolfenal)

Tramadol
(TDL)

parecoxib
(Dynastat)

CLASSIFIC
ATION
AND
MECHANI
SM OF
ACTIONS
Mefenamic
acid is a
nonsteroid
al antiinflammato
ry drug
(NSAID)
which is an
anthranilic
acid
derivative.
It exhibits
antiinflammato
ry,
analgesic
and
antipyretic
activity by
inhibiting
prostaglan
din
synthesis
in body
tissues.
Unlike
most other
nonsteroid
al antiinflammato
ry drugs,
mefenamic
acid
appears to
compete
with

INDICATION
S AND
DOSAGE
500mg/tab
Q6 RTC/ prn
for pain
Relief of mild
to
moderately
severe
somatic and
neuritic pain;
headache,
migraine,tra
umatic pain,
post-partum
pain, postop
pain, dental
pain and in
pain and
fever
following
various
inflammatory
conditions;
dysmenorrhe
al,
menorrhagia
accompanied
by spasm of
hypogastric
pain

50mg Q6 prn

CONTRAINDIC
ATIONS

SIDE
EFFECTS

GI ulceration of
inflammation.
Kidney or liver
impairment.

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

Resp
depression,
especially in
presence of
cyanosis and
excessive
bronchial
secretion, and
after op on
biliary tract.
Acute
alcoholism,
head injuries,
conditions in
which
intracranial
pressure is
raised. Attack
of

Nausea,
vomiting,
fatigue,
headache,
constipation,
drowsiness,
confusion,
skin
reactions,
dry mouth,
facial
flushing,
sweating,

CLIENT
Received

NURSING
RESPONSIB
ILITIES
Instruct
patient to
avoid
alcohol
(includes
wine, beer,
and liquor)
when taking
this
medicine
since it can
cause
increases in
stomach
irritation.

Avoid
aspirin,
aspirincontaining
products,
other pain
medicines,
other blood
thinners
(warfarin,
ticlopidine,
clopidogrel),
garlic,
ginseng,
ginkgo, and
vitamin E
while taking.
Talk with
healthcare

cefazolin
(Stancef)

ranitidine(E
ntac)

prostaglan
dins for
binding at
the
prostaglan
din
receptor
site and
thus,
potentially
affect
prostaglan
dins that
have
already
been
formed.

Binds to
mu-opoid
receptors.
Inhibits
reuptake of
serotonin
and
norepineph
rine in the
CNS.

for
painModerat
e to severe
acute and
chronic pain,
painful
diagnostic
procedures
and surgery

Short term
treatment of
acute pain &
post-op pain.
May be used
pre-op to
prevent or
reduce postop pain; can
reduce
opioid
requirements
when used
concomitantl
y.

Therapeuti
c effect:
decreased
pain

bronchospasm.
Heart failure
secondary to
chronic lung
disease.

Hypersensitivit
y to parecoxib
or to any other
ingredient of
Dynastat.
Patients who
have
demonstrated
allergic-type
reactions to
sulfonamides,
acetylsalicylic
acid (aspirin) or
nonsteroidal
antiinflammatory
drugs (NSAIDS)
including other
cyclooxygenas
e-2 (COX-2)
specific
inhibitors;
asthma and
urticaria

vertigo,
bradychardia
, palpitation,
orthostatic
hypotension,
hypothermia,
restleness,
changes in
modod,
miosis.
Rarely,
muscle
weakness,ap
petite
changes,
difficulty in
passing
urine, biliary
spasm.

Body as a
Whole: Back
pain.
Central and
Peripheral
Nervous
System:
Dizziness.
GI System:
Alveolar
osteitis (dry
socket),
constipation
and
flatulence.
Platelet,
Bleeding and
Clotting:
Ecchymosis.

Parecoxib
is a
prodrug of
valdecoxib.
The
mechanism
of action of
valdecoxib
is by
inhibition
of
cyclooxyge
nase-2
(COX-2)mediated

Psychiatric:
Agitation and
insomnia.

500mg
IVTT
Q8H

History of
shock by
cefazolin.

Skin and
Appendages:
Increased
sweating and
pruritus.
Events
Occurring
0.5% and
<1%:

provider

assess type,
location and
intensity of pain
before 2-3 hr
after
administration.
assess BP
and RR. Respi
depression has
not occurred
with
recommended
doses.
advise patient
to change
position slowly
to minimize
orthostatic
hypotension.
do not
confuse
tramadol from
toradol.

prostaglan
din
synthesis.
Cyclooxyge
nase is
responsible
for
generation
of
prostaglan
dins. Two
isoforms,
COX-1 and
COX-2,
have been
identified.
COX-2 is
the isoform
of the
enzyme
that has
been
shown to
be induced
by proinflammato
ry stimuli
and has
been
postulated
to be
primarily
responsible
for the
synthesis
of
prostanoid
mediators
of pain,
inflammati
on and
fever. At
therapeutic
doses,
valdecoxib
is a COX-2
selective
inhibitor of
both
peripheral
and central
prostaglan
dins and
does not
inhibit COX1, thereby
sparing

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

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

Application
Site:
Injection site
pain.

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

Autonomic
Nervous
System: Dry
mouth.
Body as a
Whole:
Asthenia and
peripheral
edema.
Hearing and
Vestibular:
Earache.
Heart Rate
and Rhythm:
Bradycardia.
Give the
Metabolic
medication
and
around the
Nutritional:
Hyperglycem clock at
evenly
ia.
spaced
Musculoskele times and to
finish the
tal System:
medication
Arthralgia.
completely
at directed,
Respiratory
even if
System:
feeling
Pharyngitis.
better.
Skin and
Appendages: Check for
signs of
Rash and
super
skin
infection
postoperativ
(vaginal
e
complication itching/
discharges)
s.
and allergy.
Urinary
System:
Oliguria.

Shock;
hypersensitiv

COX-1dependent
physiologic
al
processes
in tissues,
particularly
the
stomach,
intestine
and
platelets.
COX-2 is
also
thought to
be involved
in
ovulation,
implantatio
n and
closure of
the ductus
arteriosus
and CNS
functions
(fever
induction,
pain
perception
and
cognitive
function).

Bind to
bacterial
cell wall
membrane
causing
cell death.
Therapeuti
c effect:
bactericidal
action
against
susceptible
bacteria.

Inhibits the
action of
histamine

ity reactions;
hematologic
eg
granulocytop
enia,
eosinophilia
or
thrombocyto
penia;
hepatic,
renal
impairment;
GIT disease
eg colitis;
CNS signs
including
convulsions;
alteration in
bacterial
flora; vit
deficiencies
& others eg
headache,
dizziness or
malaise

Confusion,
dizziness,
drowsiness,
hallucination,
headache.
Arrythmiasis,
constipation
and nausea.

Assess
patient for
epigastric or
abdominal
pain and
frank or
occult blood
in the stool,
emesis, of
gastric
aspirate.
Administer
with meals
or
immediately
afterward
and at
bedtime to
prolong
effect.

at the h2receptor
site located
primarily in
gastric
parietal
cells,
resulting in
inhibition
of gastric
acid
secretion.

X. BIBLIOGRAPHY

Dillon, Patricia M. 2007. Nursing Health Assessment, ed. 2. Bangkok, Thailand:

iGroup Press Co., Ltd.

Maried, Elaine N. 2006. Essentials of Human Anatomy & Physiology, ed. 8.

Philippines: Peason Education South Asia Pte Ltd.

Pillitteri, Adele. 2007. Maternal and Child Health Nursing: Care for the Childbearing
and Childbearing Family, ed. 5. Philippines: Lippincott Williams and Wilkins.

XI. APPENDIX