NURSING CARE PLAN

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Independent:
Subjective: • Acute pain • Ectopic • After 8 hours • Monitor maternal • To determine • After 8
related to of nursing vital signs. presence of hours of
“Masakit ang
pregnancy
distention or interventions hypotension nursing
tiyan ko” (My rupture of is gestation , the patient and tachycardia intervention
tummy hurts) as fallopian tube. located will be caused by s, the
verbalized by outside the relieved or rupture or patient was
patient. uterine controlled. hemorrhage. relieved or
cavity. The • Monitor for • To further controlled.
Objective: presence and assess the
fertilized amount of vaginal present
• Facial mask ovum bleeding. situation
of pain. implants indicating
outside of hemorrhage.
• Guarding the uterus, • Monitor for • Increased pain
behavior. increase and pain and abdominal
usually in
and abdominal distention
• V/S taken as the fallopian distention and indicates
follows: tube. rigidity. rupture and
Predisposin possible intra-
T: 36.4 g factors abdominal
P: 85 include hemorrhage.
R: 22 • Monitor complete • To determine
Bp: 110/90
adhesions
blood count the amount of
of the tube , (CBC). blood loss.
salpingitis, • Provide comfort • Promotes
congenital measure like relaxation and
and back rubs, deep may enhance
developmen breathing. patient’s coping
Instruct in abilities by
tal relaxation or refocusing
anomalies visualization attention.
of the exercises.
fallopian Provide
tube, diversional
activities.
previous
• Provide • Diversional
ectopic diversional activities aids in
pregnancy,
use of an activities. refocusing
intrauterine attention and
enhancing
device for coping with
more than 2 limitations.
years, Collaborative:
multiple • Administer • To maintain
induced analgesics as acceptable
abortions, indicated. level of pain.
menstrual
reflux , and
decreased
tubal
motility.