Professional Documents
Culture Documents
College of Nursing
Tapuac District, Dagupan City
A
Case Study
On
Ruptured Ectopic Pregnancy
I. Introduction
II. Objectives
V. Patient’s History
a. History of Present Illness
b. History of Past Illness
c. Family History
VI. Assessment
The advocates of this case study would like to extend their warmest appreciation to all the
people who made the success for the making of this work.
First of all, to the Almighty God, for His everlasting love and blessings; for giving us enough
power and determination to face all the hardships in the making of this work. Praise and honor to You,
our God!
To Mrs. Maria Moppet Q. Araña, RN, our clinical instructor for her priceless time, knowledge and
effort rendered to us.
To the staff of Pangasinan Provincial Hospital, especially in the Obstetric Ward, for giving us the
opportunity to complete this work.
To our dear families and friends, for their endless support and understanding; for always being
there to guide us and care for us after the long days of duties; for being our inspiration to finish this
seemingly impossible task.
To the patients and their families for challenging us to do more and for giving us strength to give
our best in rendering care to maintain their normal vital signs and giving them enough knowledge in our
health teachings.
To the group, we would like to recognize each other for our own radical efforts in order to
complete this case study; for sticking together through hardships and for simply being there.
Lastly, to each and every one who helped realize this job into completion, may it be direct or
indirect, no matter how minimal, the gratitude and pleasure for the achievement of this task is ours to
share.
I. Introduction:
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.
Although a woman may experience typical signs and symptoms of pregnancy, the
following symptoms are used to help recognize a potential ectopic pregnancy: Sharp or
stabbing pain that may come and go and vary in intensity. The pain may be in the pelvis,
abdomen or even the shoulder and neck (due to blood from a ruptured ectopic pregnancy
gathering up under the diaphragm); Vaginal bleeding, heavier or lighter than the normal period;
Gastrointestinal symptoms; Weakness, dizziness, or fainting.
Specific Objectives:
In order to meet the general objective, the group aims to:
Establish rapport to the patient and the patient’s significant others,
Explain the related data gathered from the patient and her significant others,
state past, present and family health history of the patient,
Present the cephalocaudal assessment obtained from the patient,
Interpret the laboratory test results of the patient,
Define the complete diagnosis of the patient,
Discuss the anatomy and physiology of the organ involved in the patient’s disease,
Trace the pathophysiology of the patient’s disease,
Discuss the nature of the drugs given to the patient,
Discuss the surgical procedure performed to the patient,
Present a specific, measurable, attainable, realistic and time-bounded nursing care plans
for the client,
Provide the patient and family with proper discharge planning (M.E.T.H.O.D), and
outline recommendations based on the case study’s findings.
III. Significance of the Study
Nursing Education
There is a need for us to study Ectopic Pregnancy because this presents a major
health problem for women of childbearing age especially now that is one of the major
causes of bleeding in pregnancy during the first trimester. 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.
Nursing Practice
Studying this case is necessary to be able to develop and improve nursing practice
by determining interventions that are effective and important compared to those that
are not important and not helpful for the client. Interventions may include: Providing a
quiet and relaxing environment; Monitoring vital signs to check for changes of
respirations, pulse rate, temperature and blood pressure--increased or decreased of vital
signs may indicate an abnormality; Assessing for pain is also important knowing what
pain scale she feels wherein 10 is the painful; Assessing the vaginal bleeding including the
amount and characteristics to know if she’s suffering from hemorrhage. If so, there is a
need of emergency surgery; blood transfusion and analgesics should be administer as
prescribed by the doctor. Providing emotional support may help the patient express
feelings of grief and fear.
Nursing Research
Women with ectopic pregnancy may experience several complications that requires
not only medical attention but also nursing guidance. In this light, this study may be helpful
in determining interventions that will also help nursing research.
IV. Patient’s Profile
Patients Name: “Luningning”
Age: 24
Gender: Female
Birth date: March 22, 1987
Birth Place: Bayambang, Pangasinan
Civil Status: Married
Nationality: Filipino
Religion [Denomination]: Christianity [Roman Catholic]
Husband: “Lunongnong”
City Address: Bayambang, Pangasinan
Nationality: Filipino
Religion [Denomination]: Christianity [Roman Catholic]
V. Patient’s History
a. History of Past Illness
G4P1
First Pregnancy
o Abortion @ 2months (8weeks)
o Missed miscarriage/ Early Pregnancy failure
Second Pregnancy
o Post Mature—still birth @ 43weeks.
Third Pregnancy
o NSD
o Child 11 months old @ present
Fourth Pregnancy (Present pregnancy)
o Ectopic Pregnancy (to be discussed) 3WEEKS.
b. History of Present Illness
Chief Complaint: Prolonged vaginal bleeding
Started on January on & off vaginal bleeding
No consultation done.
1 day, consulted at BDH, UTZ done.
Result: Ruptured Ectopic Pregnancy Right fallopian tube.
Referred to PPH.
Abdominal assessment: globular, (+) tenderness all over
Admission diagnosis: Ruptured Ectopic Pregnancy
Principal Diagnosis: Ruptured Ectopic Pregnancy
Principal Operaton: (March 14, 2011) Explore Laparatomy
Operation Performed: Emergency Pelvic Laparotmy, Right Salpingectomy
Received plasma expander (Voluven) 500cc fast drip
Received 2u properly typed: O+ fresh whole blood
Received another 2u RBC
c. Family History
Cardiac Problem
Diabetes Mellitus
Meningitis
Asthma
Tuberculosis
Otitis Media
Hypertension
Cancer
VI. Assessment
Methods of
Body System assessment FINDINGS SIGNIFICANCE/REMARKS
I Pa Pe A
General Appearance
Expected weakness
Inspect physical
Appears weak related to the post-op
appearance.
status
Conscious and
Assess behaviour. Normal
coherent
Cooperative ;
Assess interactions with
interacts well with Normal
parents and nurse.
others
Moderate speech,
Assess overall
clear voice with Normal
development and speech.
moderate pace
Vital Signs
Measure blood pressure. 110/70 mmHg Normal
Measure pulse rate 66 beats/ min Normal
Measure respiratory rate. 22 breaths/min Normal
Measure temperature. 36.8:C Normal
Skin , Hair and Nails
No swelling/lesions
noted; skin warm to
Inspect and palpate skin. Normal
touch with good
turgor
Inspect and palpate hair(
Evenly distributed;
distribution and Normal
fine and silky
characteristics)
Inspect and palpate Smooth, convex in
nails(texture, shape, color, shape, light pink in Normal
condition) color
Head, neck and Cervical Lymph nodes
Inspect and palpate the
Normocephalic, no
head(symmetry, condition Normal
lesions are visible.
of fontanelles)
Symmetric with an
Inspect and palpate the oval appearance, no
Normal
face abnormal
movements noted.
Inspect head control, head Full range of motion-
posture and range of up and down and Normal
motion. sideways
Inspect and palpate the
neck ( suppleness, lymph No nodules or
nodes for swelling, swelling noted, (+) Abnormal
mobility, temperature and pain in the nape.
tenderness)
Mouth, throat, nose and sinuses
Inspect mouth and throat(
tooth eruption, condition
(+) Mouth lesion
of gums, lips, teeth, Improper oral hygiene
(gingivitis)
palpates, tonsils. Tongue
and buccal mucosa)
Smooth and
Inspect nose and sinuses
symmetrical; client
(discharge, tenderness. Normal
reports no
Turbinates[color,swelling])
tenderness
Eyes
Bilaterally equal in
Inspect external eye. Normal
size
Observe for redness, Skin on both eyelids
swelling or discharge or is without redness, Normal
lesions swelling or lesion.
Ears
Equal in size
bilaterally; skin is
smooth with no
Inspect external ears lesions, lumps or Normal
nodules. Color is
consistent with facial
color
Thorax and lungs
Scapulae are
symmetric and non-
protruding.
Shoulders and
Inspect shape of thorax scapulae are at equal
Normal
and respiratory effort horizontal position.
Respirations are
within normal range,
relaxed, effortless,
and quiet
Resonance, elicits flat
Percuss the lungs Normal
tone over the scapula
Auscultate for breath Breath sounds clear;
sounds and adventitious No adventitious Normal
sounds. sounds auscultated.
Breasts
Inspect and palpate Symmetrical, no Normal
breasts(shape, discharge, discharge or lesions
lesions) are noted
Heart
S1 and S2. No S3 and
Auscultate heart sounds Normal
S4 noted.
Abdomen
Inspect shape Symmetry Normal
Abdominal skin is
Observe the coloration of
paler than the Normal
the skin
general skin tone.
Muskuloskeletal
The edematous area
when held for a few
Assess feet and legs (+) edema
seconds, the depression
rapidly refills.
Clients appear to be
Assess spine and posture relaxed with Normal
shoulders
Gait is steady:
Assess gait Normal
opposite arm swings
Client reports no pain
Assess joints Normal
in her joints
No muscle weakness
Assess muscles
noted Normal
Normal
*often requested to monitor
Urea 2.5 – 6.1 3.7 mmol/L kidney function before starting to
take certain drugs and while taking
them.
Slightly Low
Creatinine 62. – 106. 61. umol/L *Creatinine levels are generally
lower in pregnancy
Diagnostics:
Ultrasound:
Significance: Abnormal
Findings: No Gestational Sac Noted
VIII. Disease Identity
a. Anatomy and Physiology
The female reproductive system is designed to carry out several functions. It produces the female egg
cells necessary for reproduction, called the ova or oocytes.
Labia majora: The labia majora enclose and protect the other external reproductive organs. Literally
translated as "large lips," the labia majora are relatively large and fleshy, and are comparable to the
scrotum in males.
Labia minora: Literally translated as "small lips," the labia minora can be very small or up to 2 inches
wide.
Bartholin’s glands: These glands are located next to the vaginal opening and produce a fluid (mucus)
secretion
Clitoris: The two labia minora meet at the clitoris, a small, sensitive protrusion that is comparable to the
penis in males. Like the penis, the clitoris is very sensitive to stimulation and can become erect
Perineum — A stretch of hairless, sensitive skin that extends from the bottom of the vaginal opening
back to the anus
Internal Organs
Vagina: The vagina is a canal that joins the cervix (the lower part of uterus) to the outside of the body. It
also is known as the birth canal.
Ovaries — A woman normally has a pair of ovaries that resemble almonds in size and shape. They are
home to the female sex cells, called eggs, and they also produce estrogen, the female sex hormone.
Women’s ovaries already contain several hundred thousand undeveloped eggs at birth, but the eggs are
not called into action until puberty. Roughly once a month, starting at puberty and lasting until
menopause, the ovaries release an egg into the fallopian tubes; this is called ovulation. When
fertilization does not occur, the egg leaves the body as part of the menstrual cycle.
Uterus — The uterus is located in the pelvis of a woman’s body and is made up of smooth muscle tissue.
Commonly referred to as the womb, the uterus is hollow and holds the fetus during pregnancy.
Cervix — The lower part of the uterus, which connects to the vagina, is known as the cervix.
Often called the neck or entrance to the womb, the cervix lets menstrual blood out and semen
into the uterus. The cervix remains closed during pregnancy but can expand dramatically
during childbirth.
Ovulation
The ovulation process is important if subsequent fertilization is to take place. This is an
exquisitely timed phenomenon dependent on a host of hormonal interactions involving a variety
of endocrine glands. Tubal function must also be adequate or the ovum will not be picked up by
the fallopian tube to be fertilized within the ampulla.
Fertilization
Following ovulation, the ovum with its cumulus oophorus cells are picked up by the fimbria of
the fallopian tube. The ovum has now formed the first polar body. It remains in the ampulla
portion of the tube and is viable for about 18 to 24 hours. If fertilization does not occur, the
ovum disintegrates and is destroyed by the tube. Sperm will remain viable in the female
reproductive tract for about 48 hours, although this can be quite variable. Sperm present in the
ampulla meet the cumulus oophorus mass and penetrate by chemical and mechanical means to
reach the zona pellucida. One sperm penetrates the zona pellucida, the second polar body is
formed, and the nuclear material of the sperm enters the vitelline membrane. The diploid
chromosome number is re-established, and mitotic cell division can now occur.
Implantation
After fertilization occurs, the ovum remains in the fallopian tube for about 72 hours. During this
time there are several cellular division, but the size of the fertilized ovum does not increase.
Around 72 hours the zona pellucida fragments and falls away. The ovum enters the uterine
cavity for 60 to 72 more hours, and the central cavity begins to form. A definite cell mass is
formed on one side of the blastocyst by the time implantation occurs. The trophoblast cells
burrow into the endometrial stroma to form syncytiotrophoblast. Primitive amniotic and
chorionic cavities begin to form, and a germ disk is recognizable soon after implantation.
b. Pathophysiology
a. Drug Study
Generic Name: Category: Side Effects: Take each dose with a full glass of
Clindamycin Anti-bacterial GI: nausea, vomiting water (decreases esophageal
irritation)
Mechanism of action: Adverse Reactions:
Brand Names: It inhibits protein synthesis in CNS: convulsions (over dosage) May be taken without regard for
Dalacin C susceptible bacteria, causing cell GI: Severe colitis, including pseudomembranous meals
death colitis, diarrhea, abdominal pain, Report S&S of severe diarrhea and
Dosage: esophagitis, anorexia, jaundice, hepatic colitis
300mg TID function changes
Hema: Neutropenia, Leukopenia, Monitor BP and pulse after
Route: agranulocytosis, eosinophilia administration.
Per orem (P.O.) Hypersensitivity: Rashes, utricarial to Be alert for signs of superinfection
anaphylactoid reaction and anaphylactoid reactions that
require immediate attention.
Contraindications: Patient and Family Education:
Hypersensitivity to the drug or lincomycin, Complete full course of therapy
tartrazine dye; ulcerative colitis/ enteritis Report loose stool or diarrhea (more
than 5 loose stools daily) promptly
and do not self-medicate with anti-
diarrheal preparations.
Generic Name: Category: Side Effects: Assessment:
Mefenamic Acid Non-Steroidal Anti-inflammatory Upset stomach, nausea, heartburn,
Drug (NSAID), antipyretic dizziness, drowsiness, diarrhea, and Renal, hepatic, blood studies: BUN,
Brand Names: creatinine, Hgb, before treatment,
headache may occur. periodically thereafter
Ponstel
• Pain: note type, duration, location, and
Dosage and Route: intensity with ROM 1 hr after
Mechanism of action:
5oomg 1cap TID administration
It inhibits prostaglandin synthesis by Adverse Reactions:
decreasing enzyme needed for GU: nephrotoxicity, renal failure • Audiometric, ophthalmic exam before,
biosynthesis; analgesic, anti- Hema: Leukopenia, thrombocytopenia, during, after treatment; for eye, ear
inflammatory, antipyretic agranulocytosis, anemia, neutropenia, problems: blurred vision, tinnitus; may
lymphocytosis, eosinophilia, indicate toxicity
pancytopenia, hemolytic
anemia • Fever: temp before and 1 hr after
Misc: Anaphylaxis, serum sickness administration
Implementation:
Contraindications:
Contraindicated with allergies to sulfonamides,
celecoxib, NSAID’s, or aspirin, significant renal
impairment; perioperative pain post CABG
surgery; pregnancy (3rd trimester), lactation.
Use cautiously with impaired hearing, hepatic
and CV conditions.
Brand name: Action of the Drug: Side Effects: • Assess patient for epigastric or abdominal
Zantac Inhibits the action of histamine at the CNS: h/a, pain and frank or occult blood in the stool,
H2 receptor site located primarily in CV: tachycardia, bradycardia, PVCs (rapid IV emesis, or gastric aspirate.
Generic name: gastric parietal cells, resulting in administration) • Nurse should know that it may cause false-
ranitidine inhibition of gastric acid secretion. Dermatologic: alopecia positive results for urine protein; test with
GI: Constipation, diarrhea, Nausea & vomiting, sulfosalicylic acid.
Dosage: Classification: abdominal pain • Inform patient that it may cause
50mg q8h Anti-ulcer agents GU: gynecomastia, impotence or decreased drowsiness or dizziness.
H2 antagonist libido • Inform patient that increased fluid and
Route: Local: pain at IM site, local burning or itching at fiber intake may minimize constipation.
Intravenous (IV) IV site • Advise patient to report onset of black,
tarry stools; fever, sore throat; diarrhea;
Adverse reaction dizziness; rash; confusion; or hallucinations
CNS: malaise, dizziness, drowsiness, to health care professional promptly.
somnolence, insomnia, vertigo • Inform patient that medication may
Dermatologic: Rash temporarily cause stools and tongue to
GI: hepatitis, increased ALT levels. appear gray black.
Hematologic: leukopenia, granulocytopenia,
thrombocytopenia,pancytopenia
Other: arthralgias
Contraindications:
Contraindicated with allergy to
Ranitidine, lactation
Use cautiously with impaired renal or
hepatic function, pregnancy
GENERIC NAME: CLASSIFICATIONS: SIDE EFFECTS/ADVERSE EFFECT: •Do not drink alcohol (beverages or
metronidazole Amoebicides & Antiprotozoals CNS: fever, vertigo, headache, ataxia, dizziness, preparations containing alcohol,cough
syncope, incoordination, confusion, irritability, syrups) for 24-72◦ of drug use;severe
BRAND NAMES: ACTION OF DRUG: depression, weakness, insomnia, seizures, reactions may occur.
Flagyl Bactericidal; Inhibits DNA synthesis peripheral neuropathy
CV: flattened T wave, edema, flushing, •Your urine may be a darker color than
DOSAGES & ROUTE: thrombophlebitis after I.V. infusion usual; this is expected.
500mg GI: unpleasant metallic taste, anorexia, nausea &
I.V. q 8◦ vomiting, diarrhea, GI upset cramps •Refrain from sexual intercourse during
GU: dysuria, incontinence, darkening of urine treatment for trichomoniasis, unless partner
LOCAL: thrombophlebitis (I.V.), redness, burning, wears condom.
dryness, and skin irritation
HEMATOLOGIC: transient leukopenia, •You may experience these side effects:dry
neutropenia mouth w/ strange metallic taste (frequent
MUSKULOSKELETAL: fleeting joint pains mouth care, sucking sugarless candies may
RESPIRATORY: upper respiratory tract infection help); nausea, vomiting, diarrhea(eat
SKIN: rashes frequent small meals)
•Report severe GI upset, dizziness, unusual
CONTRAINDICATIONS: fatigue, or weakness, fever, chills.
•Contraindicated w/ hypersensitivity to
metronidazole, pregnancy, (do not use for
Trichomoniasis in first trimester)
•Use cautiously w/ CNS diseases, hepatic
diseases, candidiasis (moniliasis), blood
dyschasias, lactation
Generic Name: Classification: Side effects: Assess usual bowel patterns.
BISACODYL Laxatives Upset stomach, diarrhea, intestinal irritation
Don’t give if client has abdominal
pain.
Brand Name: Action of the Drug: Adverse effects:
BUSCOPAN It works by stimulating enteric nerves Abdominal pain, cramping, perineal irritation, Use other methods to relieve
to cause colonic mass movements. It excessive bowel activity constipation where possible.
is also a contact laxative; it increases
Dosage: fluid and NaCl secretion. Action of Provide comfort measures.
10mg ( 1 suppository daily Bisacodyl on small intestine is Contraindications:
rectally) negligible; stimulant laxatives mainly Hypersensitivity rectal fissures, abdominal pain, Carefully monitor the I&O when
promote evacuation of the colon. nausea, vomiting, appendicitis, acute surgical patient is receiving tube feedings.
abdomen, ulcerated haemorrhoids, acute
Route: hepatitis, fecal impaction, intestinal, bilary tract
Rectal (suppository) obstruction
b. Surgical Management
i. Exploratory Laparotomy
ii. Salphingectomy
Exploratory Laparotomy
-this was done to the patient because she suffered from ectopic pregnancy
-since the patient had an ectopic pregnancy in her abdomen they used laparotomy to explore the
cause of preoperative symptoms
-using this surgical treatment there are normal results in reasons why exploratory laparotomy is
performed. The procedure may indicate further treatment if necessary.
Salphingectomy
-performed Salphingectomy as an emergency procedure because the patients fallopian tube has
ruptured.
Dependent:
- administer analgesics as - alleviate pain
ordered
Nursing Diagnosis:
Acute pain related to
surgical incision as
manifested by pain
scale of 5/10.
Problem: Environmental STO: Independent: STO:
Inadequate sleep factors (government Within the shift, - assess sleep pattern - sleep disturbances can Goal met. Patient
hospital setting: patient will have an disturbances that are affect the recovery of verbalized
2patients per bed) improvement in sleep associated with patient enhancement of sleep
Subjective: ↓ pattern as evidence by environment pattern and appeared
“hindi ako makatulog External factors verbalization of - observe and obtain -to determined usual rested within the shift.
masyado sa iyak ng (crying babies and enhancement in sleep feedback regarding sleeping sleeping patterns and if
mga baby at mayat- nurses’ frequent pattern and rested pattern, bedtime routine there are any
maya minomonitor monitoring of vital appearance and hours of sleep changes/improvements
ako” as verbalized by signs) -do as much care as possible
the patient. ↓ without waking the patient -to avoid disturbances and
Inability to sleep and do as much care as to maximize sleep and rest
↓ possible when patient is of the patient
Objective: Inadequate sleep awake
- weak in appearance -explain the importance of
- yawning monitoring v/s and care
-presence of eye bags when hospitalized -to minimize complaints and
-restless for patient to understand
the care being done to her
Nursing Diagnosis:
Disturbed sleeping
patterns related to
therapeutic purposes
and other generated
awakening as
manifested by
restlessness and
presence of eye bags
Problem: Ruptured ectopic Short term objective: Independent: STO:
pregnancy
Anemia After 1 hour of -Monitor vitalsigns, heart -to evaluate degree of Goal met.
↓ nursing Interventions, sounds, and cardiac rhythm inadequacy of tissue
the client will After 1 hour of nursing
perfusion
Emergency verbalize -measure capillary refill then interventions, the
Objective: laparotomy and palpate for presence or -to note degree of client verbalized
understanding of
- (+) pale & weak in salpingectomy conditions, therapy absence and quality of impairment understanding of
appearance regimens, and when pulses conditions, therapy
↓ regimens, and when to
to contact health care -Perform assistive or active
- Hgb Count of 103 Profuse blood loss contact health care
provider. ROM exercises provider.
- edema present on
the legs and feet
↓ -encourage early -to maximize tissue
ambulation when possible perfusion
Anemia Long term Objective:
LTO:
-discourage sitting or -enhances venous return
After 8 hours of
Nursing Diagnosis:
nursing intervention, standing for long Goal not met.
“ Inadequate Tissue the client will periods,wearing constrictive After 8 hours of nursing
clothing or crossing legs -to maximize tissue
Perfusion related to demonstrate intervention, the client
perfusion
decreased increased perfusion as -elevate the legs when still exhibits decreased
hemoglobin evidenced by absence sitting but avoid sharp tissue perfusion as
concentration in the of edema angulation of the hips or evidenced by presence
blood as manifested knees of edema.
by paleness and
weakness
-to maximize tissue
perfusion
Bibliography
Pillitteri, Adele. 2007. Maternal and Child Health Nursing: Care for the Childbearing
and Childbearing Family, ed. 5. Philippines: Lippincott Williams and Wilkins.
Abarquez, et. al. (2006) A Case Study on Ectopic Pregnancy. Ateneo de Davao University College of
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