c
c

c  

ECTOPIC
PREGNANCY
(S/P BTL 1 YEAR)

BY: Mr. Bucare Manarondong RN

V V
V

Ectopic pregnancy presents a major health

problem for women of childbearing age. It is
the result of a flaw in human reproductive
physiology that allows the conceptus to implant
and mature outside the endometrial cavity,
which ultimately ends in death of the fetus.
Without timely diagnosis and treatment, ectopic
pregnancy can become a life-threatening
situation.
Ectopic pregnancy currently is the leading
cause of pregnancy-related death during the
first trimester in the country, accounting for
9% of all pregnancy-related deaths. In
addition to the immediate morbidity caused
by ectopic pregnancy, the woman's future
ability to reproduce may be adversely
affected
as well.
Ectopic pregnancy is derived from the Greek
word —
 meaning out of place, and it
refers to the implantation of a fertilized egg in a
location outside of the uterine cavity, including
the fallopian tubes, cervix, ovary, cornual region
of the uterus, and the abdominal cavity. This
abnormally implanted gestation grows and draws
its blood supply from the site of abnormal
implantation. As the gestation enlarges, it
creates the potential for organ rupture because
only the uterine cavity is designed to expand
and accommodate fetal development. Ectopic
pregnancy can lead to massive hemorrhage,
infertility, or death.
2ultiple factors contribute to the relative risk of ectopic
pregnancy. In theory, anything that hampers the migration
of the embryo to the endometrial cavity could predispose
women to ectopic gestation. The most logical explanation for
the increasing frequency of ectopic pregnancy is previous
pelvic infection; however, most patients presenting with an
ectopic pregnancy have no identifiable risk factor. It has
been observed that women diagnosed with pelvic
inflammatory disease, those with history of prior ectopic
pregnancy, of tubal surgery and conception after tubal
ligation are at risk of ectopic pregnancy. It has also reported
that smoking, the use of fertility drugs or reproductive
technology, intrauterine device and increasing age, T-shaped
uterus and ruptured appendix may predispose a woman to
such conditions.
Ê
  
   
     

 

 
 

 V
  

    

 
V


 

    

    

    
The classic clinical triad of ectopic pregnancy is pain,
amenorrhea, and vaginal bleeding. Unfortunately, only 50% of
patients present typically. Patients may present with other
symptoms common to early pregnancy, including nausea, breast
fullness, fatigue, low abdominal pain, heavy cramping, shoulder
pain, and recent dyspareunia. Astute clinicians should have a
high index of suspicion for ectopic pregnancy in any woman who
presents with these symptoms and who presents with physical
findings of pelvic tenderness, enlarged uterus, adnexal mass, or
tenderness. The result of the ultrasound is tge most reliable
indicator that a woman is suffering from ectopic pregnancy.
Early detection means saving the woman from blood loss and
death.
m 2
 
 


  2

 


  
 
          

 
  ! 
 "
#  
 
    "
$
 
       "   "
" %   !
!
m #  

 
  
 
 
 
  % "
   
 
 
    

 


  & 
   !
m '     (  
  " 

 )  %   "
 



" 
  
  
      " %     
  

m *
" 

   +
  
%
      
  & 
&   
 # ,-
,- .,/,   



 &% #  
0  
 "
  % % 
   "
 
"

   
    12 

 "  
  %!
%! 2
 
"  
& 

 

  

 " 
% &  



    " 
 
  VÊÊ

  

  






 
  


 

  


  
 


  
  




 


 
  


 
 
  

 



 
 V
 

 


 

 
   


 




 





 
 




 


 V
Ê V
   


%3#

3

%3#

3 
 " 
c  %
3 
  34 
c
 (&  3
31%
1% -333
# %& % 4 %

  

 # 3

   


  (35,,,63

 
 0  

 c  c
/-.,/,
 /,73,,3
( 3"3*

73333333333331
73333333333331  (   3# 
4
 ÊV VÊ
m *3 73.,3%
3 
m  7353
7353 #73/83
%
3 
m (7393:/3
  3.3 % 
  ;
m 2739
m (73,
m *& 73.3:/
  <3.,,/39 &
.,,5;
m  & 
7393

7393
m 
3= %73*
3/93.,,>3 % 3 3  
m 3"  3

73%

m *3 
33%3&%73
*3 
33%3&%731%
1% #  "
m ( 
3 

6%731  32& 3  3
:03  3#

3&%3# 3

3

0 ;
m =73#3,-3.,/,
m ( 734 %3 3"" 3# %& %
3# %& %
m 
3
 3 73?
'
73?
' .>3.,/,3:.
.>3.,/,3:.93%
;
c c  c
   



 9@!A34
 
   &





  


73
 

73 /9,6-,3

!
 5+,++
!
 !53

"#!53
"# 

!  
 33""3   3
&  3"33%
3 
%
   

c

     $

 
 
%     

 
 
 
 c
 &  $
 



 

   ! 


   !  =!3 

=!3 
' 
 ( c
 ' 2cc2
% 
 c
m  )
 2   *


!

m 23 3"3
3%3
3"33  3"3  3 3
 "
3
 "
3
33 
33  33  3 3
!3B33

3
3
3%3 "3 3
 "
3
 "3&?33  3
 33 
3
3
33"  !3333  3
3  3 3
 "
3
 "33
3&3 3
3"  3
&    %3
%&  %33
  %33   
33"
3

 "3  
33
633& "3 3   3 "3 3

 "
3 & !
3
m 2
3
 "3  
3 3 3 33
2
3
 "
"3   3 %33
3
 33
  3
 3)
33 "33 
"33 & 33& 3
 !323 3"33
3 3
3 3
33 3



33 " 3 +
3  3 3  3
3  3   3"3
 "
 3   3"3
 "!33
3  3" 3
 3%
3"3


 3 
33 3 3
 "
3
 "
3"  3
3
73 3"33 3"3  3

 3  33   3 33
 3 3 
33 
33
 " 3

!
m
@
m 23
33"3
3 3
3
333%3  )3&%3
=3
=3 !!

@

%
2c c
 ( %  

2 %
   

     

  ""   &     &% %
 
 !
! %
    


   
 *
 /> /> .,/,  1(#41(#4
(=  

 "  
  
   

     %!
%! 




  &%      


 
   
    &

 
  

 
 )
 

!
! *
 "
  

   
    " &%


  
 ! 2       
 

" 264 '  (%  1(#4 # %& %
 
 " '% (  %
 c

(  ( %

 
c
(

           
  
      "  
 

B'

 & &    

" )   " 

   "   &
!
&
!


YISK30*42
FACTOYS
VÊ ÊV

X



V VV
  
 


XPelvic Inflammatory Disease

XEndometriosis X 


 
XCongenital anomalies of the  
fallopian tubes XV 
XT-shaped uterus
XÊ  
XYuptured appendix
XPrevious tubal surgery or
tubal pregnancy
  Ê
TYPES

 
VÊV
 cc
m
c m %2c
m

c m c 2c
Dysfunction of the cilia which usually propel
The fertilized ovum through the tube into the
uterine cavity

Disruption or scarring of the fallopian tube

Blocks or slows the movement of a fertilized

Egg through the fallopian tube to the uterus

Fertilized egg attaches to an area outside of

The uterus(ampullary area of the fallopian
Tube) wher it implants and
 SIGNS & SY2PYO2S

Sudden severe Transvaginal/

Amenorrhea Abdominal ultrasound
Abdominal/
Abnormal bleeding Findings:
Hypogastric pain
From the vagina (+) positive embrio sac
Usually unilateral
Usually scanty No intauterine sac
In nature
Amounts or Identified; suggestive
spotting Of ruptured
Ectopic pregnancy
 OUTCO2E

Internal hemorrhage
On the tube as the
Affected area starts to
rupture

Profound drop on
cardiac output

S/sx: <BP
Hypovelemic Shock >HY,YY,sweating
DOB
Yestlessness
and other signs

DEATH
(may occur)
ëII. MEDICAL MANAGEMENT

Ê
DATE/TI2E V

‡For medical/surgical
Please admit to ward management
August
19,2010
Secure consent to care ‡To obtain patient
10:00 am
permission to conduct
B/P ± 130/90
treatment
HY ± 101
‡ To prevent aspiration and
YY ± 22
NPO other complications
T ± 37.6
during/after the operation

‡Baseline purposes in
TPY q 4 hrs determining any deviation
from normal reading

Start IVFluid of D6LY 1 L ‡Hypertonic solution

And regulate at provides accessible means
36gtts/min for emergency drug therapy
DATE/TI2E Ê V


LABS:
‡Determining hemoglobin
CBC stat
hematocrit count
BT stat
‡To identify the patient¶s
blood type for possible blood
transfusion intra and post
operatively
HBSAG det stat
‡To determine if reactive to
hepatitis B and if so to
execute strict isolation
techniques/procedures
Urinalysis stat
‡To detect any abnormalities
Start D5LY 1L at
‡Hypertonic solution that
40gtts/min
provide accessible means
for emergency drug therapy
 Ê
DATE/TI2E V

2EDS:
Cefazolin 1g IVTT q 8 ‡ Act as prophylaxis
hrs ANST ( )

For ³E´ Pelvic

Laparotomy Ye: Ectopic X Desired procedure to
Pregnancy prevent hypovemic shock
and other complications

Please secure consent for ‡To obtain permission for

sugery surgery and attest
understanding about the
procedure
DATE/TI2E Ê V


Please inform
OY/Anesthesiologist on ‡For the staff to prepare
call materials/instruments for
the specified operation

For pre op order please ‡

To secure 2 ³U´ of WB
with proper typing and
Xfor cases of massive blood
cross- matching- standby
loss during the operation
for OY use
and possible blood
transfusion
Start bloodline of
XHypotonic solution for
PNSS1L
possible BT
DATE/TI2E Ê V


Please inform Dr.

11:30 am X Consultant on on call. For
Buenaventura of this
further management and
admission
evaluation
Please insert FBC F16 XTo monitor fluid balance or
and attach to UB state of hydration and renal
function

Yefer for BP < 90/60

mmHg pressure,SOB and XÊ 
any signs of shock

Please facilitate meds X   
 



 

Dr. Galang
DATE/TI2E Ê V


PYE-OP OYDEYS
11:00am

XTo prepare the patient for

NPO 6-8 hours
surgery and prevent
complication suring the
operation
Secure consent

XTo obtain permission for

On call meds:
surgery and attest
understanding about the
procedure
Yanitidine 0 mg IVTT X Inhibits action of histamine
on the H2 receptor sites of
parietal cells and decrease
gastric secretions.
DATE/TI2E Ê V


2etoclopromide 1o mg ‡ to prevent vomiting during

1 :18pm
IVTT the operation

Yefer accordingly ‡To measure accurate intake

and output and determine
Dr. Estopia untoward effects brought by
anesthesia

‡To evaluate patient and

provide appropriate
measure
DATE/TI2E Ê V


POST OP OYDEYS
‡For close monitoring of
To PACU patient¶s vital signs
1:40pm

NPO XTo prevent aspiration

EST: 900cc
2onitor V/S q 14 mins XTo evaluate status and
For 2 hours then hourly detect abnormal vital signs
until stable

2onitor I and O q hour XTo measure accurate intake

until stable and output and assess renal
perfusion functioning

O2 at 2-3 liters via N.C. X to provide adequate tissue

perfusion
Transfuse 1 u of WB with
PTX2 and regulate at XTo replace the blood loss
KVO rate for the 1st hour brought by surgery and
and 30gtts/min prevent complication
DATE/TI2E Ê V


‡To prevent spinal

Flat on bed due 6 hours
headache
post op
‡Hypertonic solution that
IVF: D5LYiL at 30gtts/
provide accesible means
min(L)
for emergency drug
PNSSiL at KVO
therapy
2edications:
‡To prevent infection
1. Cefazolin 1gm IVTT
q 8h ANST ( )
2. Ketorolac 30 mg
‡For relief of pain
IVTT q 8h x 3 doses
DATE/TI2E Ê V


‡To prevent gastric acid

secretion.

4. Famotidine 20 mg
ho IVTT q 12h x 2 doses
DATE/TI2E Ê V


6. Paracetamol 300 mg ‡ analgesic for signs of

IVTT q 4h for hyperthemia
T>37.8C

Yepeat HGb and Hct 6h post ‡To monitor the normality

op of blood count and
determine the need for
another transfusion
Yefer accordingly ‡ to evaluate patient¶s
condition

Dr. Estopia
 DATE/TI2E
Ê V


August 20,
Please remove FBC X to prevent infection
2010

6:00 A2
2ay have clear liquids then X facilitate normal intake
(+) flatus
soft diet of foods gradually

Place abdominal binder

‡To prevent dehiscence or

evisceration while patient
is ambulating
DATE/TI2E Ê V


Encourage ambulation X 


 

  


Continue Cefazolin 1 gm IVTT

x 2 more days then shift to
Cefuroxime 600 mg BID x 7
days ‡ 
 

   



 
DATE/TI2E DOCTOY¶s Order V


‡ relief of post op pain

2efenamic Acid 600mg q 8h
for pain

FESO4 OD x 1 mo
‡For prevention of anemia
and to provide dietary
supplements
Dr.Galang
DATE/TI2E IVTFF: V

D6LY 1L at 30gtts/ min
August
21,2010 ‡Provide accessible means
for emergency drug
8:00am Cont meds
therapy
Yefer
‡ for continued care and
determine any
complications
Dr.Chavez
DATE/TI2E Terminate IVF V


2GH anytime
X

XFor compliance of drug

Continue p.o meds at home
therapy and prevent
infection/complications
Dr.Chavez
Ô
  
      
Date: August 19,2010
 
 


  V
 

 V  

  
 
White Cell 11.1 5.0 ± 10 Inflammatory process
Count Elevated results in leukocytosis
Hemoglobin 11.22 13.7-16.7 decreased Yeduced YBC production

Hematocrit 38.22 40.5-49.7 Decreased Yeduced YBC

productions
Platelet Adequate 144,000 to Within normal Normal
count 372,000 range
DifferentiaL
count: 67 % 43.4- Normal Normal
Segmenters 28% 76.2% Normal Normal
Lymphocyte 05% 17.4 ± decreased decreased
s 2onocyte 46.2 4.5%
- 10.5
Bleeding 3 mins &10 1-3 mins Normal Normal
Time
Clotting 4 mins 3 ' 5 mins Normal Normal
time
Date: August 19, 2010
11:00pm YEPEAT HGB
and HCT Yesult

 
 


  V
 

 V  

  
 
White Cell 5.0 ± 10 Elevated
Count
Hemoglobin 12.9 13.7-16.7 normal Below normal

Hematocrit 39.42 40.5-49.7 Normal below normal

Platelet 144,000 to normal range Normal

count 372,000
DifferentiaL
count: 80 % 43.4-76.2% increased
Segmenters 16% 17.4 ± 46.2 decreased
Lymphocyte 04% 4.5 - 10.5 decreased
s 2onocyte

Bleeding 1 min 1-3 mins Normal Normal

Time
Clotting 3 ' 5 mins
time
  

 Color: yellow

 pus cells: 5 ± 10 hpf

 Transparency: clear

 YBC 0-2/hpf
 Specific gravity: 1.025

 epithelium: occasional
 Yeaction: 6.0
 Sugar (-)
 Albumin (+)
 V
 Control: 15.1 secs
 Patient: 20.5 secs
 % activity 48%
 INY 1.48
 




  


   
Findings: in line of positive pregnancy
 suggestive of ruptured ectopic pregnancy
 


 
 

 VS before BT: T:36.0C
 HY: 68bpm
 YY: 20cpm
 Time transfuseD:
transfuseD: 12:30pm ended: 4:49pm
 Blood Type: ³O´
 Unit: 1 or 500cc
 Component: Whole blood
 Serial number: BPH2690
 Adverse Yeaction: none
 VS After BT: T:36.0C YY:19cpm
=32=C

 " =7

=7 4'0*D
:D4'0;6 4'0E#' 5,,
5,,
  1=
:* .,
.,.,/,
.,/,;;
= 7
7 *
 /-
/- .,/,

4 

"  7

7 4'(*(

=
60%
=
6 0%6
677 /  F22 :  
%;  % >

*
2 : ;

#
 " * 7

7 & &    & 
   
"
    
  
 &   & % "
&   %   &%   
 &  " & 
%
)  
" "    

  &
 

 
  " 
  

      !
 !
 "    : % 
;
;77 "   "
" 

 &%

 &  &   

 % 
    % & % 
& ?  %  " 

 



4   7

7
   & 
    
  
  
  
 
   
&
 




 % " 
!



! #
 
 & 
  
    
   "   
  
!!
  '""
62  '""
7
'""
7

#
 7
7  2
 

     
&       "  



7
7 (&
 

4

%
    )) 


%  



( & 


 ( 
77
G4   

 % 

 
 

  "   " 
 

G #   "  

       %

  %   "   

  

G3'
333 3 
33" 3
3"3
 
 3
3
 &3 333 333
3 
3"" 

333
33
3"3


3
 

G3# 33
3"3 " 33
 3

3

%
333
3"3%!30 3

 3
3

3  3333 
3333  3



G3 3
 3"3
3
3 3"
333 3 
33
 

3%33
3 "

 
3
333& 
33  3

"333 3  333"  

G3( 3
"%3



 " =7
=7 *
2=
'6 0*#2=
'

= 7
7 *
 /-
/- .,/,

4 

"  7

7 
  . *


=
60%6
=
60%677 /  F22   
 .,
.,
 F22  /.
/.


 .



#
 " * 7

7 &  . 

&  . 


 
     
   
    
   
  
!!

 "    : % 
;

;77 (% 
"







       &    " "
%

" &    
  

!

!

4   7

7
 
   
    % " 

 

!! 4 
  & 
  %    
 


 
      %
" 
!!
m   '""
62  '""
7
'""
7
H   
  
H )) 


H
H"
!
!

m

 ( 
77
H#    

    : " " 
%
  
     " 

 "  ;!
 ;!
H#  "  
 ""
: )) 

 "
    
 
  
   % 


 %
 %
  ;;!
H'   "" 

"     :    
 
  
 ""
  " 
 "  


    
""
I;!
""
I;!
H#  "" 

" " 

    
 !
!
Name of Drug: KETOYOLAC (Ketomed)/2EFENA2IC ACID 500mg
Date Ordered: August 19 , 2010
Classification: NSAID
Dose/Fequency/Youte:30 mg IVTT (intravenously) every 8hours
2echanism of Action: The anti-inflammatory, analgesic, and antipyretic
effects of the NSAIDs are largely related to inhibition of
prostaglandin synthesis.
Specific indication (why drug is ordered): Short-term management of
pain; topically to relieve ocular itching.
Adverse effects: Adverse effects associated with acetaminophen use
include headache, hemolytic anemia, renal dysfunction, skin
rash, and fever. Hepatotoxicity is a potentially fatal adverse effect
that is usually associated with chronic use and overdose and is
related to direct toxic effects on the liver.
Nursing Precaution:
*Administer with food if GI occurs.
U2onitor for adverse effects: CNS changes, rash, GI upset, CHF,
liver dysfunction, asthma.
UEvaluate drug effects
UEvaluate effectiveness of patient teaching program.
Name of Drug: FEYYOUS SULFATE
Date Ordered: August 20 , 2010
Classification: IYON PYEPAYATION
Dose/Fequency/Youte:1 tab OD
2echanism of Action: Iron preparation elevate the serum iron
concentration. They are then either converted to hemoglobin
or trapped in reticuloendothelial cells for storage and eventual
release for conversion into a useable form of iron for YBC
production.
Specific indication (why drug is ordered): Treatment of iron deficiency
anemia
Adverse effects:
*GI irritation
*anorexia
*nausea
*vomiting
*diarrhea
*dark stools
*constipation
Nursing Precaution:
*Confirm iron defiency anemia before administering drugs to
ensure proper use of the drug.
*Consult with the physician to arrange for treatment of the
underlying cause of anemiaif possible, as iron replacement will not
correct the cause of the iron loss.
*Caution the patient that stool may be dark or green to prevent
undue alarm if this occurs.
*Arrange for hematocrit and hemoglobin levels before
administration and periodically during therapy to monitor drug
effectiveness.
 c '
c c


    

3 3%3&3 33 33
33

  3

c
33%3&3 33 3333




 
&
*    *

' 3 3
33
3
3


' 0

3

' 3 
33 3 3  

' 4
33
31(


 

± ( 3 3 & )3 "3 3"3 
± =
3
3"3  3 

± =
 %33
3 33
3"3 
 V

V
Ê V


  

/! & 3" 3
  3"3 3"3 m ( 3
33
&? 3 33
3

 3   3  3 
%3:,
%3:, &3
 &3&%33 !3*


3
/,;3 J3 %3: 6
 ;J3  33 "%3 3&%3 3 3
3   33 
!

.! 
3 333 3 m = %3 3 3 3 
3 3

  %  "63%3 3 
3
3"3
  33  3 "!33  3

 3 3%3 3
3&%3

   33
% 3 
3

%
3&%3 3"3
33 " 3 3 

3
3 "3"3 !

9! ( 3 3 3 3 m =

3 3
  3 3%3

  
33"3

3:!!3  3 %33 3
 33
%63  K
 K"3 
3&&;!3  3 3&  
33?
33
*33 3  %33 3
 !
"  %
 V

V
Ê V

8! *


63 
3 3  3 
3!

3!3
3 m  " 3 3
3 3"63

33
63
3& 3
 3& 
3  !3( 
33

3"3 3
3 3 3

 ) 3 3 % 3
 3 
3 3
 3 !

='('
='
27

/!3* 
3 3  3
3 m 033 "3"3 



   


——
 
  ——
—

—
 — 
—   —— ——

—

—

POSSIBLT EVIDENCED BY:

hypotension
Thirst
Increase pulse rate
Decreased skin turgor
Change in mental state
Increased body temperature
Low CBC result
 

 
± patient have attain normal vital signs and negative of
symptoms of hypotension
± CBC result reveal a normal result
  *2
*'

m 
='('
='
2
/!3*



6 3  3

333333333333333G3 3

3"3  33

.!3
3
3"3%
 3

3333333G33  "%3

3"3


9!3 3 &%33!3133423 G33 3

3"3

 333"312

m ='('
='
2
/!3* 
3F3"  
3
3

3
3  G 3
33"3"  3 
/("31 32
"
3(
3( 3
3G33 3%  
3
3G33 3%    
3  
÷



Ê ³sakit kaau akong pus-on, musamot kun magtakilid ko´

 facial grimaces
changes in vital signs, baseline:   

 Acute pain related to distention/rupture of fallopian tube

At the end of 30 minutes, patient will be able to verbalize relief of

pain, display reduced tension, relaxed manner and ease of movement

Desired ³Outcome: patient will verbalize deminished hypogastric pain

 V

V
Ê
V

 
1. Obtained full description of pain from
patient including location, intensity (0-
10), duration, quality and radiation.
2. Positioned patient comfortably, in
moderate high back rest
3. Instructed patient in relaxation
techniques, i.e., deep/slow breathing
V

‡ Pain is a subjective experience and must
be described by the pt. Assist pt. to
quantify pain by comparing it to other
experiences.
‡ This allows for lung expansion by
lowering the diaphragm
‡ Helpful in decreasing perception of/
response to pain. Provides a sense of
having some control over the situation,
increase in positive attitude.
 V

V
Ê V

R

 

Ò. Administered supplemental oxygen by ‡ Increases amount of oxygen available

means of nasal cannula @ 3L/min. for adequate tissue perfusion




 

 !   
Ê ³mura ko ug gakalumos and lipong NG AKONG
Paminaw´

 facial grimaces
changes in vital signs, baseline: 
  
HGB nd HCT result

 High Yisk for fluid Volume Deficit Y/T

hemorrhage losses and restricted intake

At the end of 3-8hours, patient will be able to

maintain fluid volume at a functional level as evidenced by normal
vital signs and relief of discomfort
        Ô
V








 
 !  
 
   

   
  
  
  ! 
 

     
 
 " !

 
# 
 
 

$ V 
 % !











   

   &
 

  
#


  !
"# $!%$!

& '''''''''''''''''''''''''''''''''''''''''''''''''''''
( )'
 
'
   ' ( )  ÷  $ >!?@
 

   
 #   
     *

 
  
      
    + 
  
 *
 !
  +   #

+ 
 
   
& & #    

+   
 &  ! 
 
 , 

+   
     +




V  
     
 &   

&   *
  
+! !     - ./ "
 '0 


              "     


   # 

   

    
  %   





 


(      &   
   
  &     !
  
 1    

&   #     !   

 
 
&

 

2    


&    
  *
 '0  #
   !   
 2
   
  

 V #
   2  

   # '
   &
  3 
   


 
 
  
  # &    # 
   
>AA !
     
 

&   #  
    ! 

    
 0 


 




 0  
 
   & 0 
  !  
 
 !  & 
  #  

 
     



 
 
 
  " 
    
   

 "  
 
 VV 

Smeltzer.Bare. Textbook on 2edical-Surgical Nursing (10th

edition) Lippincott-Yaven Publisher.Copyright 1996

Wilson, Billie Ann Nurse¶s Drug Guide (vol. 1 & 2) Pearson

Education Inc.,Copyright 2000

2osby¶s Pocket Dictionary of 2edicine, Nursing and Allied Health

(4th edition) Elsevier(Singapore) PTE LTD> Copyright 2002

Doenges, 2arilynn Nursing Care Plans, Guidelines for

Individualizing Patient Care(6th edition) F.A Davis Company.
Copyright 2000

Kozier. Erb. Blais. Wilkinson. Fundamentals in Nursing (5th

Edition). Addison esley Longman Inc. 1998.

2ac2ahon, S. Blood pressure and the risk of cardiovascular

disease. N Engl J 2ed 2000; 342:50

HT2L1Yollins Gina. "With smoking cessation drugs, dosing is

key", ACP-ASI2 Observer, 22(4); 1,16-17.
 V 

http://biology.clc.uc.edu/courses/bio105/circulat.htm

wwwmedlib.med.utah.edu\webpath\TUTOYIAL\ECTPY
EG.com
 BCD  E EÔ  Ô C Ô 
B F

# 4