BSN-211

GROUP 5

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 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.

PATIENT S PROFILE

NAME: Glecie Suzanne M. Quinto GENDER: Female BIRTHDAY: October 18, 1989 AGE: 21 NATIONALITY: Filipino RELIGION: Catholic CIVIL STATUS:Married

G 3 Patient has been pregnant thrice. She had her first child when she was 19. P 2 T 1 One child was born @ 37wks. AOG. Now 2 years old (Birthday: December 1, 2008) One child was born @ 28mks. AOG. Now 11 mos. old (Birthday: August 5, 2010)

P 1

A 0 One event of miscarriage at age 18. Fetus was 6wks. AOG. L 2 Patient has two living Girls.

LMP: May 21, 2011

PAST ILLNESS: Patient has a family history of hypertension. Patient s grandfather died of stroke.

PRESENT ILLNESS: 2 days prior to the admission, she had experienced abdominal pain. Consultation was done and she was advised to do a pregnancy test and it showed a positive result. Few hours before admission, the patient has undergone the ultrasound and found out that the embryo was in the left fallopian tube and not in the uterine wall. The patient has decided to remove the embryo.

NURSING ASSESSMENT

GENERAL APPEARANCE Glecie Suzanne Quinto, 21. Weak and pale looking can move minimally with assistance. Have grimace and unwanted breath and with tensing behavior.

HEAD AND FACE Normocephalic, no masses or lesions or tenderness, visual field was normal by interview, cornea and iris are intact, sclera is white, ear canals was clear without redness, no sinus, tenderness present, nasal mucosa is pink, dry lips with lesions, tongue is ruffled and pink and symmetrical with no lesions.

NECK AND AXILLAE Neck movement was coordinating with the pain, no tenderness, no lumps, positive swallow reflex.

THORAX No masses and tenderness after palpation, no adventitious breath sound after auscultation on both lungs.

BREAST Round in shape, no masses, no lumps, nipples is dark brown in color, equal in size, light brown areolas with no masses or discharges.

ABDOMEN Presence of stretch marks, auscultation heard a throbbing sound in LLQ.

UPPER EXTREMITIES Good ROM, no lesions, no tenderness, no abnormalities present, and has pain on the left shoulder.

LOWER EXTRIEMITIES Same color of the body, limited movement, no varicose.

GENITALIA Minimal vaginal bleeding.

ANATOMY AND PHYSIOLOGY

The vagina is a thin-walled tube 8 to 10 cm long. It lies between the bladder and rectum and extends from the cervix to the body exterior. Often called the birth canal, the vagina provides a passageway for the delivery of an infant and for the menstrual flow to leave the body. The cervix (from Latin "neck") is the lower, narrow portion of the uterus where it joins with the top end of the vagina. During menstruation, the cervix stretches open slightly to allow the endometrium to be shed. This stretching is believed to be part of the cramping pain that many women experience. Evidence for this is given by the fact that some women's cramps subside or disappear after their first vaginal birth because the cervical opening has widened.

The portion projecting into the vagina is referred to as the portio vaginalis or ectocervix. On average, the ectocervix is three cm long and two and a half cm wide. It has a convex, elliptical surface and is divided into anterior and posterior lips. The ectocervix's opening is called the external os. The size and shape of the external os and the ectocervix varies widely with age, hormonal state, and whether the woman has had a vaginal birth.

In women who have not had a vaginal birth the external os appears as a small, circular opening. In women who have had a vaginal birth, the ectocervix appears bulkier and the external os appears wider, more slit-like and gaping.The passageway between the external os and the uterine cavity is referred to as the endocervical canal. It varies widely in length and width, along with the cervix overall.

During childbirth, contractions of the uterus will dilate the cervix up to 10 cm in diameter to allow the child to pass through. During orgasm, the cervix convulses and the external os dilates. The uterus is shaped like an upside-down pear, with a thick lining and muscular walls. Located near the floor of the pelvic cavity, it is hollow to allow a blastocyte, or fertilized egg, to implant and grow. It also allows for the inner lining of the uterus to build up until a fertilized egg is implanted, or it is sloughed off during menses.

The uterus contains some of the strongest muscles in the female body. These muscles are able to expand and contract to accommodate a growing fetus and then help push the baby out during labor. These muscles also contract rhythmically during an orgasm in a wave like action. It is thought that this is to help push or guide the sperm up the uterus to the fallopian tubes where fertilization may be possible. The uterus is only about three inches long and two inches wide, but during pregnancy it changes rapidly and dramatically.

During pregnancy the ligaments prolapse due to the growing uterus, but retract after childbirth. In some cases after menopause, they may lose elasticity and uterine prolapse may occur. This can be fixed with surgery. The Fallopian tubes are paired, tubular, seromuscular organs whose course runs medially from the cornua of the uterus toward the ovary laterally. Each tube is about 10 cm long with variations in length from 7 to 14 cm. The abdominal ostium is situated at the base of a funnel-shaped expansion of the tube, the infundibulum, the circumference of which is enhanced by irregular processes called fimbriae. The ovarian fimbria is longer and more deeply grooved than the others and is closely applied to the tubal pole of the ovary.

Passing medially, the infundibulum opens into the thin-walled ampulla forming more than half the length of the tube and 1 or 2 cm in outer diameter; it is succeeded by the isthmus, a round and cord-like structure constituting the medial one-third of the tube and 0.5-1 cm in outer diameter. The interstitial or conual portion of the tube continues from the isthmus through the uterine wall to empty into the uterine cavity. This segment of the tube is about 1 cm in length and 1 mm in inner diameter.

The tubal wall consists of three layers: the internal mucosa (endosalpinx), the intermediate muscular layer (myosalpinx), and the outer serosa, which is continuous with the peritoneum of the broad ligament and uterus, the upper margin of which is the mesosalpinx. The endosalpinx is thrown into longitudinal folds, called primary folds, increasing in number toward the fimbria and lined by columnar epithelium of three types: ciliated, secretory, and peg cells. In the ampullary and infundibular sections, secondary folds of the tubal mucosa also exist, markedly increasing the surface areas of these segments of the tube. The myosalpinx actually consists of an inner circular and an outer longitudinal layer to which a third layer is added in the interstitial portion of the tube.

Peristaltic contraction of the smooth muscle fibers in the tubal wall allows the gametes (the sperm and egg) to be brought together, thus allowing fertilization and subsequent transport of the fertilized ovum from the normal site of fertilization in the ampulla to the normal site of implantation in the uterus. There are fewer ciliated cells in the isthmus than in the ampullary portion of the tube, whereas they are most prominent in the fimbriated infundibulum. Ciliation and deciliation is a continuous process throughout the menstrual cycle. Ciliation is maximum in the periovulatory period, particularly in the fimbria. Estrogen enhances the process of ciliation, whereas progesterone inhibits it, so significant deciliation occurs in atrophic postmenopausal tube.

PATHOPHYSIOLOGY

Actual Laboratory Tests and Diagnostic Examinations

Urinalysis: Urinalysis is performed to screen for urinary tract disorders, kidney disorders, urinary neoplasm and other medical conditions that produce changes in the urine. This test is also used to monitor the effects of treatment of known renal or urinary condition.

Date

Laboratory Test Color Appearance Reaction Specific gravity Albumin Sugar Epithelial CellsSquamous Pus cells Red Blood Cells Mucous Threads

Normal Value/ Results

Result

Clinical Significance

Nursing Interventions Pre test: > Provide patient with urine container with lid. > Instruct the patient to collect sample of urine, preferably on arising in the morning; must not be contaminated by toilet paper, toilet water, feces or secretions. > Women should not collect the urine duringmenstruation. > Instruct the patient to collect a midstream voided specimen. Post test: > The lid must be sealed completely and the container must be labeled properly. > Specimen must be delivered to the laboratory immediately.

Complete Blood Count: The CBC is the series of different tests used to evaluate the blood and the cellular components of RBC s, WBC s and platelets. The CBC is used to assess the Patient for anemia, infection, inflammation, polycythemia, hemolytic disease and the effects of ABO incompatibility, leukemia and dehydration status.

Date

Laboratory test Normal Value Hemoglobin Erythrocytes Leukocytes Neutrophils Lymphocytes Monocytes Eosinophils

Result

Clinical Significance

Nursing Intervention Pretest: > Identify patient and check the requisition form with the patient s identification bracelet. >Inform the patient that blood needs to be drawn from the designated site. Provide reassurance to help limit anxiety. >The patient may be seated or in supine position. The patient s arm is in extension with easy access to the antecubital fossa. Post test:

Basophils Hematocrit MCV >assess the patient s arm to ensure that the bleeding has ceased. Apply adhesive bandage as needed. > If hematoma occurs or if there is still bleeding, ask the patient to continue compression of the site or elevate the arm and rest in top of the head. >Instruct patient to continue compression of the puncture site for 2-5 minutes or until the bleeding stops.

Ultrasonography: A diagnostic technique that uses high-frequency sound to form pictures of the internal structures of the body. Information gained through this test includes measurement of size, determination of shape and location, and actual movement of certain structures.

Date

Diagnost ic Exam Trans vaginal Scan

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

Result

Clinical Significance

Nursing Intervention > Obtain written consent, particularly for any ultrasound procedure that involves insertion of transducer into a body cavity or blood vessel. > The nurse schedules the ultrasound examination before or several days after any barium studies; residual barium blocks the transmission of ultrasound impulse. >Abdominal ultrasound requires fasting from food for 12 hours. > Inform the patient that the examination is safe and painless. > Instruct the patient not to void until after the test is completed. > Remove clothes, jewelry and metallic objects; wear a hospital gown. Post test: > Remove conduction gel from the skin. > assist patient to a comfortable position and getting dressed, as needed.

Laparoscopy: Permits visualization of the peritoneal cavity by the insertion of a small fiber-optic telescope (laparoscope) through the anterior abdominal wall. This surgical technique may be used diagnostically to detect abnormalities, such as cyst, adhesions, fibroids and infection. It can also be used therapeutically to perform procedures such as adhesion lysis; ovarian biopsy; tubal sterilization; removal of ectopic pregnancies, fibroids, hydrosalpinx, and foreign bodies; and fulguration of endometriotic implants.

Purpose: To identify cause of pelvic pain. To detect endometriosis, ectopic pregnancy, or pelvic inflammatory disease (PID). To evaluate pelvic masses. To evaluate infertility. To stage a carcinoma.

Procedure: Preparation 1. Explain the procedure to the patient, and tell the patient that laparoscopy is used to detect abnormalities of the uterus, fallopian tubes, and ovaries. 2. Instruct the patient to fast for at least 8 hours before surgery. 3. Tell the patient who will perform the procedure and where it will take place. 4. Tell the patient whether she ll receive a general anesthetic and whether the procedure will require an outpatient visit or overnight hospitalization. 5. Warn the patient that she may experience pain at the puncture site and in the shoulder.

6. Make sure that the patient or a responsible family member has signed an informed consent form. 7. Check the patient s history for hypersensitivity to the anesthetic. 8. Make sure laboratory work is completed and results are reported before the test. 9. Instruct the patient to empty her bladder just before the test.

Implementation 1. The patient is anesthetized and placed in the lithotomy position. 2. The doctor catheterizes the bladder and then performs a bimanual examination of the pelvic area to detect abnormalities that may contraindicate the test and to ensure that the bladder is empty. 3. The doctor makes an incision at the inferior rim of the umbilicus. He inserts a special needle into the peritoneal cavity and insufflates 2 to 3 liters of carbon dioxide or nitrous oxide. 4. The doctor then removes the needle and inserts a trocar and sheath into the peritoneal cavity.

5. After removing the trocar, the doctor inserts the laparoscope through the sheath to examine the pelvis and abdomen. 6. To evaluate tubal patency, the doctor infuses a dye through the cervix and observes the fimbria (the finger-like extremity of the fallopian tube) for spillage. 7. After the examination, he may perform minor surgical procedures such as ovarian biopsy. 8. The doctor may insert a second trocar at the pubic hairline to provide a channel for inserting other instruments.

Nursing Interventions 1. Instruct the patient to resume her usual diet. 2. Instruct the patient to restrict activity for 2 to 7 days. 3. Explain that abdominal and shoulder pain should disappear within 24 to 36 hours. 4. Provide analgesics. 5. Monitor vital signs. 6. Monitor the patient for adverse reactions to anesthetic. 7. Monitor intake and output. 8. Watch for bleeding and signs and symptoms of infection.

Interpretation: Normal Results The uterus and fallopian tubes are of normal size and shape, free form adhesions, and mobile. The ovaries are of normal size and shape; cysts and endometriosis are absent. Dye injected through the cervix flows freely from the fimbria.

Abnormal Results A bubble on the surface of the ovary suggests a possible ovarian cyst. Sheets of strands of tissue suggest possible adhesions. Small, blue powder burns on the peritoneum or serosa suggest endometriosis. Growths on the uterus suggest fibroids. An enlarged fallopian tube suggests possible hydrosalphinx. An enlraged fallopian tube suggests a possible ectopic pregnancy. Infection or abscess suggests possible pelvic inflammation disease.

Precautions Be aware that laparoscopy is contraindicated in the patient with advanced abdominal wall cancer, advanced pulmonary or cardiovascular disease, intestinal obstruction, palpable abdominal mass, large abdominal hernia, chronic tuberculosis, or a history of peritonitis. During the procedure, check for proper catheter drainage.

Interfering Factors Adhesions or marked obesity which may obstruct to visualization. Tissue or fluid becoming attached to the lens that may also obstruct to visualization.

Complications Punctured visceral organ. Peritonities.

MEDICAL MANAGMENT

Medical management for ectopic pregnancy: Non-surgical Ultrasound showing a gestational sac with fetal heart in the fallopian tube is clear evidence of ectopic pregnancy. Transvaginal ultrasound showing no uterine pregnancy is presumptive evidence. Methotrexate use as treatment is safe & effective for unruptured ectopic pregnancies that satisfy the strict criteria with no side effects and the advantage of avoiding invasive surgery.

Surgical Laparoscopy (laparotomy) to gain access to the pelvis and can either incise the affected fallopian and remove only the pregnancy. Salpingostomy remove the affected fallopian with the pregnancy.

COLLABORATIVE MANAGEMENT

 A thorough assessment of the wellbeing of the mother and fetus, as well as the possible underlying cause is required. Treatment of cause; urgent hospital referral if uncertain cause, and/or maternal or fetal distress. If surgery is required but is considered elective, waiting until after the pregnancy is completed is prudent. If surgery is deemed necessary during pregnancy, perform it in the second trimester if possible; the risk of preterm labor and delivery is lower in the second trimester compared to the third, and the risk of spontaneous loss and risks due to medications such as anesthetic agents are lower in the second trimester compared to the first.

 A pregnancy in a woman with an intra-abdominal inflammatory disease will not be harmed by proper surgical treatment. The fetus is more likely to be damaged if the proper operation is delayed. Laparotomy (or perhaps laparoscopy but not in late pregnancy) is indicated if the diagnosis is in doubt or if there is shock.

DRUG STUDY

Drug Name (Generic) methotrexate

Drug Name (Brand) Rheumatrex, Trexall

Formulations Tablets 2.5 mg; powder for injection 20 mg, 1 g per vial; injection 2, 2.5 mg/mL

Drug Action

Side Effects

Contraindicat ions pregnancy, lactation, alcoholism, chronic liver disease, immune deficiencies, blood dyscrasias, hypersensitivi ty to methotrexate renal disease, infection, peptic ulcer, ulcerative colitis, debility

Nursing Actions Arrange for an antiemetic if nausea and vomiting are severe. Arrange for adequate hydration during therapy to reduce the risk of hyperuricemia. Do not administer any other medications containing alcohol.

Inhibits folic Nausea, acid reductas vomiting, e, leading to diarrhea, inhibition of dizziness DNA synthesis and inhibition of cellular replication; selectively affects the most rapidly dividing cells (neoplastic a nd psoriatic cells).

NURSING CARE PLAN

Cues Subjective: Ang talas ng sakit ng tiyan ko na parang tinutusok, kasama yung balikat ko.

Nursing Problem

Scientific Reasoning

Planning

Implementation Independent: Limit movement and support patient to decrease the discomfort the patient feels.

Evaluation Standard Criteria There is no The patient s abdominal pain discomfort is felt in the left lessening due hypogastric to limitation of region. movements.

Short term goal: Abdominal pain With ectopic To alleviate the related to pregnancy, fertilization patient s discomfort stretching of the occurs as usual in the fallopian tube due distal third of the to improper fallopian tube implantation of the Unfortunately, because zygote. an obstruction is To ease the patient s Mabubuntis pa present the zygote anxiety ba ako nito? cannot travel the length of the tube. It Objective: lodges at the strictured site along the tube and Long term goal: Keeps holding implants there instead To have a safe onto her left termination of of in the uterus. hypogastric pregnancy region. At weeks 6 to 12 of pregnancy, the zygote Client will have On a scale of 1 to successful future grows large enough to 10, 1 as the least pregnancy rupture the slender painful and 10 as fallopian tube the most, the pain was at a 10. Based on the patient s LMP (May 27, 2011 and last check up (July 7, 2011), she was 5-6 weeks pregnant. * Maternal and Child Health Nursing Adele Pillitteri T: 36.4 C P: 90 bpm R: 28 cpm BP: 110/90 mmHg

Provide reassurance to the patient that The patient will theoretically she still can The patient feels confident be able to get pregnant. about having a verbalize any successful uncertainty future about future pregnancy. pregnancy.

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