Ectopic Pregnancy

Prepared by: Adrillano, E.J Bernales, J.P Centeno, Lily Ebron, Don Nocos, Sharm Peria, Paolo Romero, Charm Silay , Anne

Introduction

The BSN students were given the opportunity to have a hospital exposure at Ospital ng Cabuyao; and on that day found a commendable case reasonable to be presented for case study. The patient, to be mentioned in this paper as Patient X, housewife, G2P1 (T1-P0-A0-L1), was one of the patients admitted to the Emergency Room. She was 34 years of age. Her LMP is July 30, 2012. 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 In the Philippines, unpublished reports have estimated the incidence to be just about 22, 194 each year.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. Currently, laparotomy is the preferred technique when the patient is hemodynamically unstable, the surgeon has not been trained in laparoscopy, physical facilities and supplies to perform laparoscopic surgery are lacking or technical barriers to laparoscopy are present.

Currently, laparotomy is the preferred technique when the patient is hemodynamically unstable, the surgeon has not been trained in laparoscopy, physical facilities and supplies to perform laparoscopic surgery are lacking or technical barriers to laparoscopy are present. 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 their 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 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.

The first warning signs of an ectopic pregnancy are often pain or vaginal bleeding. You might feel pain in your pelvis, abdomen, or, in extreme cases, even your shoulder or neck (if blood from a ruptured ectopic pregnancy builds up and irritates certain nerves). Most women describe the pain as sharp and stabbing. It may concentrate on one side of the pelvis and come and go or vary in intensity. Any of the following additional symptoms can also suggest an ectopic pregnancy: vaginal spotting dizziness or fainting (caused by blood loss) low blood pressure (also caused by blood loss) lower back pain

Abstract
This is a case of a patient who has been diagnosed with Ectopic Pregnancy. The patient was complaining from pain in right lower quadrant of her abdomen. In an ectopic pregnancy, a fertilized egg has implanted outside the uterus. The egg settles in the fallopian tubes in more than 95% of ectopic pregnancies. This is why ectopic pregnancies are commonly called "tubal pregnancies." The egg can also implant in the ovary, abdomen, or the cervix, so you may see these referred to as cervical or abdominal pregnancies. None of these areas has as much space or nurturing tissue as a uterus for a pregnancy to develop. As the fetus grows, it will eventually burst the organ that contains it. This can cause severe bleeding and endanger the mother's life. A classical ectopic pregnancy does not develop into a live birth. Ectopic pregnancy can be difficult to diagnose because symptoms often mirror those of a normal early pregnancy. These can include missed periods, breast tenderness, nausea, vomiting, or frequent urination.

Patients Profile: Name: Patient X Address: Nia Road Sala, Cabuyao, Laguna Birthdate: March.18,2012 Age: 34 Birthplace: Mindanao Religion: Roman Catholic

Nationality: Filipino Civil Status: Single Admission: Aug. 23,2012 Time: 12:15 am Discharge: Aug. 28, 2012 Time: 8:00pm Final Diagnosis: Tubal pregnancy, right completely ruptured G2P1 (1001) right partial salpingectomy

Nursing Assessment

Review of Reproductive System

Gynecological

Gravida\ para Obstruction LMP(frequency,duration) Age of menarchy Menopause Dysmenorrhea Contraception Discharge Itchiness Dysparunia

Hematological

Anemia Bleeding Bruising Malignancy Transfusion

Physical Examination
Skin-Pale

skin Chest- SCE no retraction Heart- AP no murmur nrrr Abdomen- flabby soft (+) hypogastric tenderness Pelvic Exam- (+) wriggling tenderness
Eyes

Pale palpebral conjuctiva

Nose

(-) NAD

Assessment findings :

Amenorrhea Abnormal menses (after fallopian tube implantation) Slight vaginal bleeding Unilateral pelvic pain over the mass If fallopian tube ruptures, sharp lower abdominal pain, possibly radiating to the shoulders and neck. Possible extreme pain when cervix is moved and adnexa palpated. Boggy and tender urine Possible enlargement of adnexa

Chest- SCE no retraction Heart- AP no murmur nrrr Abdomen- flabby soft (+) hypogastric tenderness Pelvic Exam- (+) wriggling tenderness
Eyes

Pale palpebral conjuctiva

Nose

(-) NAD

Drug Study

DRUG NAME

ACTIO N AND THERA PEUTIC EFFEC T

SEMISY THETIC, FIRST GENER ATION CEPHAL OSPORI NC WITH LIMITED ACTIVIT Y AGIANS T GRAMNEGATI VE ORGANI SMS

CONT RAIND ICATI ON

ADVERSE EFFECT

NURSING IMPLICATION

CEFAZOLIN SODIUM CLASSIFIC ATION: ANTIBIOTIC , FIRST GENERATI ON CEPHALOSPORIN ROUTE, DOSAGE, FREQUENC Y AND ADMINISTR ATION: -ADULT: IV/IM 250mg-2g Q8

HYPER SENSI TIVITY TO ANY CEPHA LOSPO RIN AND RELAT ED ANTIBI OTICS

BODY: ANAPHYLA XIS, FEVER, EOSINOPHI LIA, SUPERINFE CTIONS, SEIZURE, GI: DIARRHEA, ANOREXIA, ABDOMINA L CRAMPS SKIN: MACULOPA PULAR RASH, URTICARIA

-DETERMINE HISTORY OF HYPERSENSITIVITY TO CEPHALOSPORINS, PENICILINS, AND OTHER DRUGS BEFORE THERAPY IS INITIATED -LAB TEST: PERFORM CULTURE AND SENSITIVITY TESTING PRIOR TO AND DURING THERAPY. THERAPY MAY BE INITIALED PENDING RESULTS -MONITOR I & O RATES AND PATTERNS, BE ALERT TO CHANGES IN BUN, SERUM CREATINIRE -PROMT ATTENTION SHOULD BE GIVEN ONSET SIGNS OF HYPERSENSITIVITY PROMPTLY REPORT THE ONSET OF DIARRHEA, PSEUDOMEMBRANOUS COLITIS, A POTENTIALLY LIFE THREATENNG CONDITION, STARTS WITH DIARRHEA

DRUG

ACTION AND THERAPE UTIC EFFECT CENTRAL LY ACTING OPIATE RECEPT OR AGONIST THAT INHIBITS THE UPTAKE OF NOREPIN EPHRINE AND SEROTO NIN, SUGGES TING BOTH OPIOIDLIKE EFECTS, BUT CAUSE LESS RESPIRA TORY DEPRESS ION THAN

CONTRAIN DICATION S

ADVERSE EFFECT

NURSING IMPLICATION

TRAMA DOL CLASSI FICATI ON: ANALG ESIC, NARCO TIC ROUTE, DOSAG E, FREQU ENCY AND ADMINI STRATI ON: PO IMMEDI ATE RELEA SE: 25mg DAILY, TITRAT ED UP TO DOSE OF

HYPERSE NSITIVITY TO TRAMADO L OR OTHER OPIOID ANALGESI CS, SEVERE RESPIRAT ORY DEPRESSI ON, SEVERE OR ACUTE ASTHMAS, PATIENS ON MAO INHIBITOR S, SUBSTAN CE ABUSE, ALCOHOL INTOXICAT ION, LACTATIO N, CHILDREN YOUNGER

CNS: DROWSINESS, DIZZINESS, VERTIGO, FATIGUE, HEADACHE, SOMNOLENCE, RESTLESSNESS, EUPHORIA, CONFUSION, ANXIETY COORDINATION DISTURBANCE, SLEEP DISTURBANCES, SEIZURES CV: PALPITATION, VASO-DILATION GI: NAUSEA, CONSTIPATION, VOMITING, XEROSTOMIA, DYSPEPSIA, DIARRHEA, ABDOMINAL PAIN, ANOREXIA, FLATULENCE BODY: SWEATING, ANAPHYLACTIC RAECTION, WITHDRAWAL SYDROME w/ ABRUPT DISCONTINUATION SKIN: RASH SPECIAL SENSES: VISUAL DISTURBANCES UROGENITAL: URINARY RETENTION/FREQUENCY, MENOPAUSAL SYMPTOMS

-ASSESS FOR LEVEL OF PAIN RELIEF AND ADMINISTER PRN DOSE AS NEEDED BUT NOT TO EXCEED THE RECOMEMDED TOTAL DAILY DOSE -MONITOR VITAL SIGNS AND ASSESS FOR ORTHOSTATIC HYPOTESION OR SIGNS OF CNS DEPRESSION -WITHHOLD DRUG AND NOTIFY PHYSICIAN IF S/S OF HYPERSENSITIVITY OCCUR -ASSESS BOWEL AND BLADDER FUNCTION; REPORT URINARY FREQEUNCY OR RETENTION -USE SEIZURE PRECAUTIONS FOR PATIENTS WHO HAVE A HISTORY OF SEIZURES OR WHO ARE CURRENTLY USING DRUGS THAT LOWER THE SEIZURE THRESHOLD -MONITOR AMBULATION

DRUG

ACTION AND THERAPEUTI C EFFECT

Diclofenac competitively inhibits both cyclooxygenase isoenzyme, COX-1 and COX-2, by bloking arachidonic acid conversion to other chemicals, thus leading to its analgesic,antipyretic and antiinflammatory effect. It appear to be a potent inhibitor of cyclooxygenase,the reby decreasing the synthesis of prostaglandin

CONTRAIN ADVERSE EFFECT DICATIONS

NURSING IMPLICATION

Dieclofena c Classificati on: Nonsteroid al analgesic,a ntiinflammator y drug Route,dose , frequency and administrati on:adultapply one patch to most painful area B.I.D.

Hypersensitivity to diclofenac,NSAI DS, or salicylate; patients in whom asthma,urthicari a,angioedema,b rochospasm,se vere rhinitis,history of bleeding; hepatic porhpyria;shock or other sensitivity reaction is presipitated by aspirin or other NSAIDS, post operative CABG pain.

CNS: Dizziness, headache, drowsiness Special senses: Tinnitus Skin: Rash, pruritus GI: Dyspepsia, nausea, vomting, abdominal pain, cramps, constipation, diarrhea, indigestion, abdominal distention, flatulence, peptic ulcer, liver enzyme, transaminases,increased liver test abnormalities CV: Fluid retention, hypertention, CHF. RESPIRATORY: Asthma BODY AS A WHOLE: Back, leg, or joint pain. ENDOCRINE: hyperglycemia HEMATOLOGIC: prolonged bleeding time; inhibits platelet aggregation

-observe and report signs of beeding -Monitor blood pressure for hypertension and blood sugar for hyperglycemia -Monitor diabetics closely for loss of diabetic control -monitor for increased serum sodium and potassium in patient receiving potassuim sparing diuretics - Monitor for S&S of CHF, including weight gain greater than 1kg -monitor for signs and symptoms of GI irritation and

DRUG

ACTION AND THERAPEUTIC EFFECT AN ANTISECRETO RY COMPOUND THAT IS A GASTRIC ACID PUMP INHIBITOR. SUPPRESSES GASTRIC ACID SECRETION BY INHIBITING THE H+, K+, ATPase ENZYME SYSTEM ACID IN THE PARIETALCELL S. SUPPRESSES GASTRIC ACID SECRETION RELIEVING GASTROINTES TINAL DISTRESS AND

CONTRAINDIC ATION LONG TERM USE FOR GASTROESOP HAGEAL REFLUX DISEASE, DOUDENAL ULCERS, PROTON PUMP INHIBITORS, HYPERACTIVIT Y, BLEEDING, LACTATION, USE OF ZEGERID IN METABLOLIC ALKALOSIS, HYPOGLYCEMI A, VOMITING

ADVERSE EFFECT CNS: HEADACHE, DIZZINESS, FATIGUE GI: DIARRHEA, ABDOMINAL PAIN, NAUSEA, MILD TRANSIENT INCREASES IN LIVER FUNCTION TESTS UROGENITAL: HEMATURIA, PROTEINURIA SKIN: RASH

NURSING IMPLICATION -LAB TESTS: MONITOR URINALYSIS FOR HEMATURIA AND PROTEINURIA, PERIODIC LFTS w/ PROLONGED USE -REPORT ANY CHANGES IN URINARY ELIMINATION SUCH AS PAIN AND DISCOMFORT ASSOCIATED w/ URINATION -REPORT SEVERE DIARRHEA, DRUG MAY NEED TO BE DISCONTINUE

OMEPRAZOLE CLASSIFICATI ON: PROTON PUMP INHIBITOR, ANTISECRETO RY ROUTE, DOSE, FREQUENCY AND ADMINISTRATI ON: PO 20-40mg ONCE A DAYFOR 4-5 WEEKS

DRUG

ACTION ANF THERAPE UTIC EFFECT STANDAR D IRON PREPARA TION THAT CORREC TS ERYTHR OPOIETIC ABNORM ALITIES INDUCED BY IRON DEFICIEN CY BUT DOES NOT STIMULA TE ERYTHR OPOIESIS

CONTRAINDI CATION

ADVERSE EFFECTS

NURSING IMPLICATION

FERROU S SULFATE CLASSIFI CATION: IRON PREPARA TION ROUTE, DOSAGE, FREQUE NCY AND ADMINIST RATION: PO SULFATE 7501500mg PER DAY IN 1-3 DIVIDED DOSES

PEPTIC ULCER, REGIONAL ENTERITIS, ULCERATIVE COLITIS, HEMILYTIC ANEMIAS, HEMOCHRO MATOSIS, HEMOSIDER OSIS, PATIENTS RECEIVING REAPETED TRANSFUSI ONS, PYRIDOXINE RESPONSIV E ANEMIA, CIRRHOSIS OF LIVER

GI: NAUSEA, HEARTBURN, ANOREXIA, CONSTIPATION, DIARRHEA, EPIGASTRIC PAIN, ABDOMINAL DISTRESS, BLACK STOOLS SPECIAL SENSES: YELLOW-BROWN DISCOLORATION OF EYES AND TEETH LARGE CHRONIC DOSES IN INFANTS: RICKETS MASSIVE OVERDOSAGE: LETHARGY, DROWSINESS, NAUSEA, VOMITING, ABDOMINAL PAIN, DIARRHEA, LOCAL CORROSION OF STOMACH ANF SMALL INTESTINE, PALLOR OR CYANOSIS, METABOLIC ACIDOSIS, SHOCK, CARDIOVASCULAR COLLAPSE, CONVULSION, LIVER NECROSIS, RENAL FAILURE, DEATH

-LAB TEST: MONITOR HIGH Hgb AND RETICULOCYTE VALUES DURING THERAPY. INVESIGATE THE ABSENCE OF SATISFACTORY RESPONSE AFTER 3 WEEKS OF DRUG TREATMENT -CONTNUE IRON THERAPY FOR 2-3 MONTHS AFTER THE HEMOGLOBIN LEVEL HAS RETURNED TO NORMAL -MONITOR BOWEL MOVEMENTS AS CONSTIPATION IS A COMMON ADVERSE EFFECT

DRUG

ACTION AND THERAPEUT IC EFFECT SEMISYNTH ETIC SECOND GENERATIO N CEPHALOSP ORIN BETALACTAM ANTIBIOTIC. PREFERENT IALLY BINDS TO ONE OR MORE OF THE PENICILIN BONDING PROTEINS LOCATED ON CELL WALLS OF SUSCEPTIBL E ORGANISMS , THUS KILLING THE BACTERIUM

CONTRAIN DICATION

ADVERSE EFFECT

NURSING IMPLICATIONS

CEFUROX IME SODIUM CLASSIFI CATION: ANTIBIOTI C, SECOND GENERAT ION CEPHALO SPORIN ROUTE, DOSAGE, FREQUEN CY AND ADMINIST RATION: ADULT: PO 250500mg Q12 IV/IM 7501.5g Q6-8

HYPERSE NSITIVITY TO CEPHALO SPORINS AND RELATED ANTIBIOTI CS; VIRAL INFECTION S

BODY: THROMBOPHLEBITIS, PAIN, BURNING, CELLULITIS, SUPERINFECTIONS, POSITIVE COOMBS TEST GI: DIARRHEA, NAUSEA, ANTIBIOTIC ASSOCIATED COLITIS SKIN: RASH, PRURITUS, URTICARIA UROGENITAL: INCREASED SERUM CREATININE AND BUN, DECREASED CRAETININE CLEARANCE

-DETERMINE HISTORY OF HYPERSENSITIVIT Y REACTIONS TO CEPHALOSPORIN S, AND HISTORY OF ALLERGIES, PARTICULARLY TO DRUGS, BEFORE THERAPY IS INITIATED -LAB TESTS: PERFORM CULTURE AND SENSITIVITY TESTS BEFORE INITIATION OF THERAPY. THERAPY MAY BE INSTITUTED PENDING TEST RESULTS. MONITOR PERIODICALLY BUN AND CREATININE

DRUG

ACTION AND THERAPEUTIC EFFECT Relief of mild to moderately severe pain with or without accompanied inflammation. Relief of pain associated with post-partum cramping and dysmenorrhea.

CONTRAINDIC ATION Hypersensitivity. Active peptic ulcer. Children <16 yrs

ADVERSE EFFECT Abdominal discomfort, epigastric distress, headache, nausea, vertigo, tinnitus, peripheral edema.

NURSING IMPLICATION -History of GI (gastrointestinal ) disease, edema, sodium intake, hematological, anaphylactoid/ti c reactions, ocular effects. Impaired renal or hepatic functions. Elderly. Pregnancy. NSAIDs/steroid combinations. Pregnancy Risk Category B but D in 3rd trimester or near delivery.

FLANAX FORTE CLASSIFICATI ON: Analgesics, Antipyretics & Muscle Relaxants/ Analgesics, Non-Narcotic/ Non-Steroidal AntiInflammatory Drugs (NSAIDs) ROUTE, DOSAGE, FREQEUNCY AND ADMINISTRATI ON: PO Non-Rx: Flanax 275mg; Rx: Flanax Forte BID

DRUG

ACTION AND THERAPEUTIC EFFECT HYPERTONIC SOLUTIONS ARE THOSE THAT HAVE AN EFFECTIVE OSMOLARITY GREATER THAN THE BODY FLUIDS. THIS PULLS THE FLUID INTO THE VASCULAR BY OSMOSIS RESULTING IN AN INCREASE VASCULAR VOLUME. IT RAISES INTRAVASCULA R OSMOTIC PRESSURE AND PROVIDES FLUID, ELECTROLYTE S AND

CONT RAIND ICATI ON HYPE RSEN SITIVI TY TO ANY OF THE COMP ONEN TS

ADVERSE EFFECT

NURSING IMPLICATION

D5LRS(DEXTRO SE 5% IN LACTATED RINGERS SOLUTION) CLASSIFICATIO N: HYPERTONIC, NONPYROGENIC, PARENTERAL FLUID, ELECTROLYTE, NUTRIENT REPLENISHER ROUTE, DOSAGE, FREQUENCY AND ADMINISTRATIO N: IV SINGLE DOSE OF 5001000mL @ 30 gtts/min OR AS

The most frequently reported side effects for patients taking D5 Lrs are: hypotension , pneumonia respiratory syncytial viral, hypernatrae mia. They are followed by: acute respiratory distress syndrome, pneumonitis , blood bilirubin increased.

-DO NOT ADMINISTER UNLESS SOLUTION IS CLEAR AND CONTAINER IS UNDAMAGED -CAUTION MUST BE EXERCISED IN THE ADMINISTRATION OF PARENTERAL FLUIDS, ESPECIALLY THOSE CONTAINING SODIUM IONS TO PATIENTS RECEIVING CORTICOSTEROIDS OR CORTICOTROPHINSOLUTION CONTAINING ACETATE SHOULD BE USED WITH CAUTION AS EXCESS ADMINISTRATION MAY RESULT IN METABOLIC ALKALOSIS -SOLUTION COINTAING DEXTROSE SHOULD BE USED WITH CAUTION IN PATIENTS WITH KNOWN CUBCLINICAL OR OVERT DIABETES MELLITUS

Assessment Diagnosis Subjective: Masakit ang tiyan ko ( My tummy hurts ) as verbalized by patient . Objective: Facial mask of pain. Guarding behavior Acute pain related to distention or rupture of fallopian tube

inference Ectopic pregnancy is gestation located outside the uterine cavity. The fertilized ovum implants outside of the uterus, usually in the fallopian tube .

Planning

Intervention Rationale Monitor mat ernal vital signs. Monitor for presence and amount of vaginal bleeding. Monitor for increase and pain and abdominal distention and rigidity. Monitor co mplete blood count(CBC) To determine presence of hypotensi on and tachycardia caused by rupture or hemorrha ge.

evaluation After 8hours of nursing interventions , the patient was relieved or cont rolled

After 8 hours of nursing interventions, the patient will be relieved or controlled Independent:

Assessment

Diagnosis

inference
Predisposing factors Include Adhesions of the tube, salpingitis, congenital and developmental anomalies of the fallopian tube, previous ectopic pregnancy ,use of an intrauterine device for more than 2years,multipl einducedabort ions,menstrual reflux , and decreased tuba lmotility

Planning

Intervention
Provide comfort measure like back rubs, deep breathing. Instruct in relaxation or visualization exercises. Provided diversional activities Collaborative : Administer analgesics as indicated

Rationale
To further assess the present situation indicating hemorrhage Provide comfort measure like back rubs, deep breathing. Instruct in relaxation or visualization exercises. Diversional activities aids in refocusing attention and enhancing coping with limitations. To maintain acceptable level of pain

Evaluation