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. Niño & 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 i

Introduction 1
Objectives 3
Nursing Assessment
Client’s Profile 4
Physical Assessment 5
Gordon’s Functional Health Patterns 6
Laboratory Findings 8
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
physician’s 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 (Cullen’s 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 Nationality: Filipino
Religion: Kristohanon
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 36.4°C, HR 92 bpm, RR 24 cpm, BP 90/60 mmHg.

Past Health History

Childhood Illness: Fever, Cough, Cold

Surgeries: None
Serious Injuries: None
Immunizations: Can’t recall
Allergies: No known food, drug, dust allergies
Blood Transfusions: None
Hospitalizations:
 CONDITION INSTITUTION DATE

None

Medications before Admission

Time of Time
Medication
Dose/Frequency Last Medication Name Dose/Frequency of Last
Name
Dose 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: 36.8°C
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, Wasn’t 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; wasn’t able to assess gait, heel-
to-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;
GORDON’S 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
don’t 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 ½ 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, patient’s 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 doesn’t talk while sleeping
but ‘’hagok’’ if she’s 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 doesn’t 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 husband’s 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 it’s been long time since
 they’ve seen each other. In work, she believes that she’s 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 doesn’t 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 doesn’t 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. She’s emotional, because according to her, she’s very sensitive
(emotionally); hardworking, because she really focuses on her work; lastly, she’s
loving wife, because she still have time for her husband although she’s 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 won’t fully enjoy and
feel life’s 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 God’s 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 PROTEIN
POS= Positive + = 0.03mg/dl
+ = 30mg/dl
TNTC= Too numerous to count ++ = 0.2mg/dl
++ = 100mg/dl
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 UNITS REFERENCE RANGE

White Blood Cells X10^9/L 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

Platelet Count ( % ) x 10^9/ L 140.0- 440.0

MANUAL PLATELET COUNT: 50,000/ cumm

Exam date: March 02, 2010

HEMATOLOGY

Test Name Result Units Reference Range

Clotting Time –LW 13’30’’ min sec 7.0-15
Bleeding Time –
4’30’’ min sec 2.0-8.0
IVY

Exam date: March 02, 2010

CHEMISTRY
Test Referenc Referenc
Results Units Results Units
Name e Range e Range
Creatinin 53.4-
0.86 mg/dL 0.60-1.50 76.02 mg/dL
e 132.6
Sodium 134 mmol/L 133-146 134 mmol/L 133-146
Potassiu
3.46 mmol/L 2.4-5.2 3.46 mmol/L 3.4-5.2
m

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, Bartholin’s gland, Skene’s 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
 Labia Majora - Two longitudinal folds of adipose and connective
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
 Labia Minora - Consists of two thin folds of skin that extend to
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
 Clitoris - Erectile body about 2.5 cm in length and 0.5 cm in
diameter
- Contains erectile tissue and has significant supply
of nerve endings
- Serves as primary organ for sexual stimulation
 Vestibule - Area between two folds of labia minora
- Boat-shaped area containing the urethral meatus,
openings of the Skene’s glands, hymen,
openings of the Batholin’s glands and
vaginal introitus
 Skene’s Gland - Surround urethral meatus
- Provide lubrication to protect skin
 Vaginal Introitus - Entrance to vagina; size and shape may vary
 Hymen - Avascular thin fold of connective tissue
surrounding vaginal introitus in women who have not had
sexual experiences
 Bartholin’s Glands - 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 - Space between fourchette and anus
- Composed of muscle, elastic fibers, fascia, and
connective tissue
 Vagina - Muscular tube from cervix to vulva
- Located posteriorly to bladder and anteriorly to
rectum
- serves a female organ of copulation, birth canal,
and channel through which menstrual flow exists
 Cervix - End of uterus that projects into vagina
 Uterus - 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 fetus
 Uterine Tubes - 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 Unknown -rides on
motor-
-unaware of pregnancy cycle with
hus-
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 diagnosed early

If undiagnosed
- no Tx - oral meds
- (-) pregnacy (methotrexate, leucovorin,
Conceptus grows
Mifepristone)
Recovery UT
ruptures
Destruction of conceptus
- (-) pregnancy

Recovery
Uterine deciduas sloughs off scant vaginal spotting Pain (RLQ)
Bleeding

Additional bleeding
Hemoperitoneum
(1500 cc)
- shoulder
pain

Hypovolemia
- tachycardia, thready pulse
- tachypnea
- hyptotension

Total circulatory collapse

Coma

Death
 NURSING
NEED/NUR SCIEN
OBJECTIVES/
SING TIFIC OBJECTIV EVALUA EVALUA
NURSING RATIONALE
DIAGNOSI ANALY ES TION TION
INTERVENTIO
S/CUES SIS
NS

Acute pain Unplea After 3 1. Perform a -to assess After 3

related to sant days of comprehensiv etiology days of
post sensor nursing e assessment nursing
operative y and interventio of pain to interven
surgery as emotio n the include tion/
manifested nal patient location, -to rule out teaching
by characteristics
experie will be worsening of the goal
verbalized ,
reports. nce able to: onset/duration underlying will be
arising -report , frequency, condition/devel met,
from pain quality, opment of actions
Subjective: actual -follow severity, and complications. perform
Sakit jud aggreviating
or prescribed ed and
kayo akong factors.
tinahi dong potenti pharmacol -to have attain
as al ogical 2. Perform baseline data
verbalized tissue regimen pain of the client.
by the assessment
damag -
patient. each time pain
e or verbalized occurs. -to be
Objective: describ methods successful in
facial 3. Monitor vital
ed in that alleviating pain
grimacing, signs
terms provide
difficulty in of such relief
moving 4.Provide quiet
damag - -to promote
e demonstra environment wellness and to
te use of prevent
relaxation 5. Encourage fatigue.
skills adequate rest
periods

VI. NURSING CARE PLANS

NAME OF CLIENT: F.B.M ATTENDING
PHYSICIAN: Dr. Lyn Alana Busa
AGE: 25 years old
SEX: Female
STATUS: Married
RELIGION: Kristohanon CHIEF
COMPLAINT: RLQ abdominal pain
ADDRESS: Holy Name, Mabolo, Cebu City DIAGNOSIS: Ruptured Ectopic
Pregnancy, Right Uterine Tube
DATE AND TIME OF ADMISSION: March 02, 2010 08:58 A.M CLIENT
PROFILE: Received client on bed,
. asleep,
with husband, afebrile, without IVF
 NEED/ SCIENTIFI OBJECTIVES NURSING RATIO EVALUATION VALUE
NURSING C OBJECTIVES NALE INTEGR
DIAGNOSI ANALYSIS / NURSING ATION
S/ CUES INTERVENTI
ONS

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c needs: skin and of nursing risk s the of nursing learned
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Source: to 4. Provi ty at changes
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8th edition ment. care. environ
page 673 5. Monit To ment.
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NEED/ SCIENTIF OBJECTIVES NURSING RATIONA EVALUATION VALUE

NURSIN IC OBJECTIVES/ LE INTEGRA
G ANALYSI NURSING TION
DIAGNO S INTERVENTI
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ssness n is an interventions patien e the interventions an
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to early be able to: psych s fear of be able to: nding
loss of
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cy feelings suppo alone feelings heart to
feel sad of rt. and to of the
seconda
ry to and physical Visit encoura physical patient,
ectopic safety. freque ge a safety. to be
hopeless
pregnan b) Use ntly. trusting b) Use able to
much of effective 2. Be relation effective understa
cy.
the time. It coping availa ship. coping nd her
mechani ble to mechani feelings
is different sms to listen. sm to and to
S: Client To
states from reduce 3. Accept express reduce help her
she normal depressi the empath depressi get
feels on. patien y with on. through
sad at feelings of c) Mobilize t’s the c) Mobilize her
pregnan sadness, support feeling patient’ support problems
cy loss grief, systems s and s systems .
or
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deal nal 4. Instru To nal
energy.
with resource ct the reassur resource
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Anyone patient
n; has necessar t in at necessar
returne can have y. least that y.
d to depression d) Reestabli one they’re d) Reestabli
work sh and fear- appropri sh and
and has
. It often maintain reduci ate and maintain
forward- runs in adaptive ng valid. adaptive
thinking families. interpers behavi To help interpers
plans. onal or, the onal
But it can relations such patient relations
also hips. as gain a hips.
O: seekin sense of
Receive happen to g mastery
d pt. on someone suppo over the
bed with who rt current
grimace from situatio
face, doesn't others n.
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has the history of 5. Help
followin depression her
g vital under These
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one time crisis
R:
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If you think reacti
you may ons to
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tell your ers.

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

NAME OF CLIENT: F.B.M.

WARD & BED NO: 3B-SE7
AGE: 25 years old SEX: Female STATUS: Married RELIGION: Kristohanon
CHIEF
COMPLAINT: RLQ abdominal pain
ADDRESS: Holy Name, Mabolo, Cebu City OCCUPATION: Stocks In-charge,
Ever Care

DIAGNOSIS: 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 - explain why the drug is prescribed

- take his prescribed drugs unfailingly. 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
Treatment
- recognize the necessity to comply with
his treatment.
Health Teaching
- learn about ectopic pregnancy
Observable Signs & Symptoms
- recognize the signs and
symptoms of ectopic pregnancy
- site ways on how to provide a well
environment
- advise to follow scheduled checkups (if
there are any)
- advise to give maintenance drugs such as
vitamin supplements (if there are any)
- health teaching session

Diet - advise for admission when these occur

- identify due diet for faster -encourage prenatal care
recovery
- encourage to drink fluids as tolerated
Spirituality (water, fruit juices)
- improve spiritual wellness - encourage to eat fruits and vegetables,
and other nutrient-dense foods

- 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 OCCUPATION: Stocks In-charge,
Ever Care GOAL:
To lower down fever from 37.8°C to at least 37.5°C
DATE AND TIME OF ADMISSION: March 2, 2010 08:58 A.M. CLIENT
PROFILE: Received
client on bed, asleep, with husband, afebrile, without IVF

CLASSIFIC
ATION
INDICATION NURSING
AND CONTRAINDIC SIDE
DRUG S AND RESPONSIB
MECHANI ATIONS EFFECTS
DOSAGE ILITIES
SM OF
ACTIONS
mefenamic Mefenamic 500mg/tab GI ulceration of Gi Instruct
acid acid is a inflammation. disturbances patient to
(Dolfenal) Q6 RTC/ prn Kidney or liver and
nonsteroid for pain avoid
al anti- impairment. hemorrhage, alcohol
inflammato Relief of mild blood (includes
ry drug to dyscrasias. wine, beer,
(NSAID) moderately Drowsiness, and liquor)
which is an severe dizziness, when taking
anthranilic somatic and headache, this
acid neuritic pain; visual medicine
derivative. headache, disturbances. since it can
It exhibits migraine,trau Skin cause
anti- matic pain, reactions and increases in
inflammato post-partum nephropathy. stomach
Tramadol ry, pain, postop Resp irritation.
(TDL) analgesic pain, dental depression,
and pain and in especially in
antipyretic pain and presence of Avoid
activity by fever cyanosis and aspirin,
inhibiting following excessive
aspirin-
prostaglan various bronchial
containing
din inflammatory secretion, and
conditions; after op on products,
synthesis Nausea,
dysmenorrhe biliary tract. other pain
in body vomiting,
parecoxib al, Acute medicines,
tissues. fatigue,
(Dynastat) menorrhagia alcoholism, other blood
Unlike accompanied head injuries, headache,
most other constipation, thinners
by spasm of conditions in
nonsteroid drowsiness, (warfarin,
hypogastric which
al anti- intracranial confusion, ticlopidine,
pain
inflammato pressure is skin clopidogrel),
ry drugs, raised. Attack reactions, garlic,
mefenamic of dry mouth, ginseng,
acid 50mg Q6 prn bronchospasm. facial
ginkgo, and
appears to for Heart failure flushing,
compete sweating, vitamin E
painModerat secondary to
with vertigo, while taking.
e to severe chronic lung
prostaglan disease. bradychardia Talk with
acute and
dins for chronic pain, , palpitation, healthcare
binding at painful orthostatic provider
the diagnostic Hypersensitivit hypotension,
prostaglan procedures y to parecoxib hypothermia,
din and surgery or to any other restleness,
receptor ingredient of changes in
site and Dynastat. modod,
thus, Patients who miosis.
potentially have Rarely,
affect demonstrated muscle
prostaglan allergic-type weakness,ap
dins that reactions to petite
Short term
have changes,
treatment of sulfonamides,
already difficulty in
acute pain & acetylsalicylic
been passing
cefazolin post-op pain. acid (aspirin) or ®assess type,
formed. urine, biliary
(Stancef) May be used nonsteroidal location and
anti- spasm. intensity of pain
pre-op to
Binds to prevent or inflammatory before 2-3 hr
mu-opoid drugs (NSAIDS) Body as a after
reduce post- administration.
receptors. op pain; can including other Whole: Back
Inhibits reduce cyclooxygenas pain. ®assess BP
reuptake of e-2 (COX-2) Central and and RR. Respi
opioid depression has
serotonin requirements specific Peripheral
not occurred
and when used inhibitors; Nervous with
norepineph concomitantl asthma and System: recommended
rine in the y. urticaria Dizziness. doses.
ranitidine(E
ntac) CNS. GI System: ®advise patient
Therapeuti Alveolar to change
osteitis (dry position slowly
c effect: socket), to minimize
decreased constipation orthostatic
pain and hypotension.
flatulence. ®do not
Platelet, confuse
Bleeding and tramadol from
Clotting: toradol.
Ecchymosis.
Parecoxib Psychiatric:
is a Agitation and
prodrug of insomnia.
valdecoxib. History of Skin and
The shock by Appendages:
mechanism cefazolin. Increased
of action of sweating and
valdecoxib pruritus.
is by Events
inhibition Occurring
of ≥0.5% and
cyclooxyge <1%:
nase-2 Application
(COX-2)- Hypersensitivit Site: Injection
mediated 500mg y; some site pain.
prostaglan IVTT products that Autonomic
din Q8H contain alcohol Nervous
synthesis. and should be System: Dry
Cyclooxyge Infections of avoided in mouth.
nase is the resp, GIT patient with Body as a
responsible & GUT, otic & known Whole:
for bone; skin, intolerance; Asthenia and
generation soft tissue & some products peripheral
of post-op that contain edema.
prostaglan infections; aspartame and Hearing and
dins. Two bacteremia, patient with Vestibular:
isoforms, septicemia, phenylketonuri Earache.
COX-1 and endocarditis a. Heart Rate
COX-2, & other and Rhythm:
have been infections Bradycardia.
identified. due to Metabolic
COX-2 is susceptible and
the isoform organisms; Nutritional:
of the surgical Hyperglycem
enzyme prophylaxis ia.
that has Musculoskele
been tal System:
shown to Arthralgia.
be induced Treatment of Respiratory
by pro- peptic ulcer System:
inflammato disease, Pharyngitis.
ry stimuli GERD, Skin and
and has selected Appendages:
been cases of Rash and
postulated persistent skin Give the
to be dyspepsia, postoperativ medication
primarily pathological e around the
responsible hypersecreto complication clock at
for the ry states eg s. evenly
synthesis Zollinger- Urinary spaced
of Ellison System: times and to
prostanoid syndrome, Oliguria. finish the
mediators stress medication
of pain, ulceration & completely
inflammati in patient at at directed,
on and risk of acid Shock; even if
fever. At aspiration hypersensitiv feeling
therapeutic during ity reactions; better.
doses, general hematologic Check for
valdecoxib anesthesia. eg signs of
is a COX-2 granulocytop super
selective enia, infection
inhibitor of eosinophilia
(vaginal
both or
peripheral thrombocyto itching/
and central penia; discharges)
prostaglan hepatic, and allergy.
dins and renal
does not impairment;
inhibit GIT disease
COX-1, eg colitis;
thereby CNS signs
sparing including
COX-1- convulsions;
dependent alteration in
physiologic bacterial
al flora; vit Assess
processes deficiencies patient for
in tissues, & others eg epigastric or
particularly headache, abdominal
the dizziness or pain and
stomach, malaise frank or
intestine occult blood
and in the stool,
platelets. emesis, of
COX-2 is Confusion, gastric
also dizziness, aspirate.
thought to drowsiness, Administer
be involved hallucination, with meals
in headache. or
ovulation, Arrythmiasis, immediately
implantatio constipation
afterward
n and and nausea.
closure of and at
the ductus bedtime to
arteriosus prolong
and CNS effect.
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
at the h2-
receptor
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