Ectopic Pregnancy_CS

8/9/2019 Ectopic Pregnancy_CS

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I. Introduction

An ectopic pregnancy is a pregnancy that develops outside a woman's uterus(womb). This happens when the fertilized egg from the ovary does not implant itself

normally in the uterus. Instead, the egg develops somewhere else in the abdomen. The

products of this conception are abnormal and cannot develop into fetuses.The most common place that ectopic pregnancy occurs is in one of the fallopian

tubes (a so-called tubal pregnancy). These are the tubes that transport the egg from the

ovary to the uterus. Ectopic pregnancies also can be found on the outside of the uterus, onthe ovaries, or attached to the bowel.

The most serious complication of an ectopic pregnancy is intra-abdominal

hemorrhage (severe bleeding). In the case of a tubal pregnancy, for example, as

the products of conception continue to grow in the fallopian tube, the tube expands andeventually ruptures. This can be very dangerous because a large artery runs on the outside

of each fallopian tube. If the artery ruptures, you can bleed severely.

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 containsit. This can cause severe bleeding and endanger the mother's life. A classical ectopic

pregnancy never develops into a live birth.Ectopic pregnancy is usually found in the first 5-10 weeks of pregnancy.


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II. Patients Profile

Name: ?

Age: 34 years old

Sex:Female

Civil Status: Married

Address: ?

Nationality:Filipino

Religion:Roman Catholic

Occupation:House Wife

Birth Place: ?

Birth Date: ?

Name of Father: ?

Name of Mother: ?

Name of Spouse: ?


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III. Developmental Task

Freud theorized that the libido developed in individuals by changing its object,

through the process ofsublimation. He argued that humans are born "polymorphous

perverse"[1], meaning that any number of objects could be a source of pleasure. Following

a biological logic, Freud established a rigid model for that "normal" sexual developmentof the human being, or the "libido development". Each child passes through five

psychosexual stages. During each stage, the id focuses on a distinct erogenous zone on

the body. . The term "psychosexual infantilism," refers to those who become fixated inthis way and fail to mature through the psychosexual stages into heterosexuality. Freud

related the resolutions of the stages with adultpersonalities andpersonality disorders.

Despite their popularity among psychoanalytical psychologists, Freud's

psychosexual theories are commonly criticized as being sexist. For example, Freud stated

that young females develop "penis envy" toward the males during their psychosexual

development. In response, Karen Horney, a German Freudian psychoanalyst, argued that

young females develop "power envy" instead of "penis envy" toward the male.

Genital phase

The genital stage starts at puberty, allowing the child to develop opposite sex

relationships with the libidinal energy again focused on the genital area. According toFreud, if any of the stages are fixated on, there is not enough libidinal energy for this

stage to develop untroubled. To have a fully functional adulthood, the previous stages

need to be fully resolved and there needs to be a balance between love and work.

Eriksons theory of psychosocial development is one of the best-known theories

of personality inpsychology. Similar to Freud, Erikson believed that personality develops

in a series of stages. Unlike Freuds theory of psychosexual stages, Eriksons theorydescribes the impact of social experience across the whole lifespan.

One of the main elements of Eriksons psychosocial stage theory is the develoment of

ego identity. Ego identity is the conscious sense of self that we develop through social

interaction. According to Erikson, our ego identity is constantly changing due to new

experience and information we acquire in our daily interactions with others. In addition to

ego identity, Erikson also believed that a sense of competence also motivates behaviorsand actions.

Each stage in Eriksons theory is concerned with becoming competent in an area

of life. If the stage is handled well, the person will feel a sense of mastery. If the stage is

managed poorly, the person will emerge with a sense of inadequacy.

In each stage, Erikson believed people experience a conflict that serves as a turning pointin development. In Eriksons view, these conflicts are centered on either developing a

psychological quality or failing to develop that quality. During these times, the potential

for personal growth is high, but so is the potential for failure.

Psychosocial Stage 6 - Intimacy vs. Isolation
http://en.wikipedia.org/wiki/Libidohttp://en.wikipedia.org/wiki/Sublimation_(psychology)http://en.wikipedia.org/wiki/Polymorphous_perversehttp://en.wikipedia.org/wiki/Polymorphous_perversehttp://en.wikipedia.org/wiki/#_note-myre396http://en.wikipedia.org/wiki/Sexual_developmenthttp://en.wikipedia.org/wiki/Human_beinghttp://en.wikipedia.org/wiki/Ego%2C_Superego_and_Idhttp://en.wikipedia.org/wiki/Psychosexual_stageshttp://en.wikipedia.org/wiki/Heterosexualityhttp://en.wikipedia.org/wiki/Freudhttp://en.wikipedia.org/wiki/Personalityhttp://en.wikipedia.org/wiki/Personality_disordershttp://en.wikipedia.org/wiki/Sexisthttp://en.wikipedia.org/wiki/Penis_envyhttp://en.wikipedia.org/wiki/Karen_Horneyhttp://en.wikipedia.org/w/index.php?title=Power_envy&action=edithttp://en.wikipedia.org/wiki/Penis_envyhttp://psychology.about.com/index.htmhttp://en.wikipedia.org/wiki/Libidohttp://en.wikipedia.org/wiki/Sublimation_(psychology)http://en.wikipedia.org/wiki/Polymorphous_perversehttp://en.wikipedia.org/wiki/Polymorphous_perversehttp://en.wikipedia.org/wiki/#_note-myre396http://en.wikipedia.org/wiki/Sexual_developmenthttp://en.wikipedia.org/wiki/Human_beinghttp://en.wikipedia.org/wiki/Ego%2C_Superego_and_Idhttp://en.wikipedia.org/wiki/Psychosexual_stageshttp://en.wikipedia.org/wiki/Heterosexualityhttp://en.wikipedia.org/wiki/Freudhttp://en.wikipedia.org/wiki/Personalityhttp://en.wikipedia.org/wiki/Personality_disordershttp://en.wikipedia.org/wiki/Sexisthttp://en.wikipedia.org/wiki/Penis_envyhttp://en.wikipedia.org/wiki/Karen_Horneyhttp://en.wikipedia.org/w/index.php?title=Power_envy&action=edithttp://en.wikipedia.org/wiki/Penis_envyhttp://psychology.about.com/index.htm


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This stage covers the period of early adulthood when people are exploring

personal relationships.

Erikson believed it was vital that people develop close, committed relationships

with other people. Those who are successful at this step will develop relationships

that are committed and secure.

Remember that each step builds on skills learned in previous steps. Erikson

believed that a strong sense of personal identity was important to developingintimate relationships. Studies have demonstrated that those with a poor sense of

self tend to have less committed relationships and are more likely to suffer

emotional isolation, loneliness, and depression.

Havighurst developmental Task

Developmental Tasks of Early Adulthood

1. 1. Selecting a mate

2. 2. Achieving a masculine or feminine social role

3. 3. Learning to live with a marriage partner

4. 4. Starting a family

5. 5. Rearing children

6. 6. Managing a home

7. 7. Getting started in an occupation

8. Taking on civic responsibility


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IV. Anatomy and Physiology

ANATOMY

The Fallopian tubes are paired, tubular, seromuscular organs whose course runs mediallyfrom the cornua of the uterus toward the ovary laterally. The tubes are situated in the

upper margins of the broad ligaments between the round and utero ovarian ligaments

(Fig. 2). Each tube is about 10 cm long with variations in length from 7 to 14 cm. Theabdominal ostium is situated at the base of a funnel-shaped expansion of the tube, the

infundibulum, the circumference of which is enhanced by irregular processes called

fimbriae. The ovarian fimbria is longer and more deeply grooved than the others and isclosely applied to the tubal pole of the ovary. Passing medially, the infundibulum opensinto the thin-walled ampulla forming more than half the length of the tube and 1 or 2 cm

in outer diameter; the isthmus, a round and cord-like structure constituting the medial

one-third of the tube and 0.5-1 cm in outer diameter, succeeds it. The interstitial or conualportion of the tube continues from the isthmus through the uterine wall to empty into the

uterine cavity. This segment of the tube is about 1 cm in length and 1 mm in inner

diameter.

PHYSIOLOGY

The tubes act as ducts for sperm, oocyte, and fertilized ovum transport, in addition to

being the normal site of fertilization. These functions depend mainly on three factors:

tubal motility, tubal cilia, and tubal fluid.


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V. Pathophysiology

Predisposing Factors:

Sex women of childbearing age are affected.

Age women of childbearing age are affected.

Precipitating Factors:

Prior pelvic inflammatory disease

Prior ectopic pregnancy

Pregnancy in a woman with an intrauterine device (IUD) in place

Pregnancy achieved by means of in vitro fertilization or fertility drugs

Prior tubal surgery (reconstruction or tubal coagulation)

Cigarette smoking

Increasing age

Schematic Diagram:

Fertilized egg inability to work

its way quickly enough down the fallopian

tube into the uterus

infection or inflammation of the tube may have

partially or entirely blocked it

endometriosis or scar tissue from previous

abdominal or fallopian surgeries

can also cause blockages

alter the shape of the tube and disrupt

the eggs progress


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VI. Medical Management

Doctors Order- refer to OR department for operation

o to prepare the patient for the operation

- insert D5LR 1liter at 120 gtts/min- follow PNSS 1liter at KVO rate

o for IVTT medication purpose

- administer Tramadol 50 mg IVTT every 6 hours

o use for management of moderate to moderately severe pain

- administer Ketorolac 30 mg IVTT every 8 hours

o use for short term management of pain

- administer Ranitidine 50 mg IVTT every 8 hours NPO

o use for short term treatment of active duodenal ulcer

- administer Metoclopramide 10 mg IVTT every 8 hours

o use for symptomatic treatment of gastroesophageal reflux

- administer Nubain 3 mg IVTT 8 hours for severe pain (reserve dose)- monitor I & O

o use to monitor if the intake and output of the patient is equal

- for blood transfusion

o to compensate blood loss

- refer accordingly

VII. Laboratory Results

Blood Typing

Type: A+

HematologyCBC - 60

Hemoglobin - 25 - severe hemorrhage

WBC - 60 - surgeryHematology - 25 - hemorrhage

Platelet - 60


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VIII. Drug Study

Generic Name: TramadolDate Ordered: May 7.2007

Classification: Opioid Analgesics

Dosage, Frequency, Route: 50 mg IVTT every 6 hoursMechanism of Action: Unknown. A centrally acting synthetic analgesic compound not

chemically related to opioids. Thought to bind to opioid receptor

and inhibit reuptake of norepinephrine and serotonin.Specific indication: Moderate to moderately severe pain

Contraindication: Contraindicated in patients hypersensitive to drug or other opioids Adverse Reaction: Vertigo, malaise, vasodilation, visual disturbances, constipation, and

menopausal symptomsNursing Precaution: Monitor CV and respiratory status. Withhold dose and notify

prescriber if respiration decrease or rate is below 12 breaths/minute

Generic Name: KetorolacDate Ordered: May 6, 2007

Classification: Nonsteriodal anti-inflammatory drugsDosage, Frequency, Route: 30 mg IVTT every 8 hoursMechanism of action: Unknown. May inhibit prostaglandin synthesis, to produce anti-

inflammatory, analgesics and antipyretic effects.Specific indication: Short term management of moderately severe, acute pain for single

dose treatmentContraindication: Contraindicated as prophylactic analgesic before major surgery or

intraoperatively when hemostasis is critical and in patients currently

receiving aspirinAdverse Reaction: Sedation, hypertension, and dyspepsia, prolonged bleeding time

Nursing Precaution: Correct hypovolemia before giving ketorolac

Generic name: RanitidineDate ordered: May 6, 2007Classification: Antiulcer drugDosage, Frequency, Route: 50 mg IVTT every 8 hours NPO

Mechanism of action: Competitively inhibits action of histamine on the H2 at receptor

sites of parietal cells, decreasing gastric acid secretionSpecific indication: Duodenal and gastric ulcer; pathologic hypersecretory condition such

as Zollinger-Ellison syndromeContraindication: Contraindicated in patients hypersensitive to drug and to those with

acute porphyria

Adverse reaction: Malaise, blurred vision, jaundice, burning and itching at injection siteNursing precaution: Assess patient for abdominal pain. Note for presence of blood in

emesis, stool or gastric aspirate.


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Generic name: MetoclopramideDate ordered: May 6, 2007Classification: antiemeticsDosage, Frequency, Route: 10 mg IVTT every 8 hours

Mechanism of action: Stimulates motility of upper GI tract, increases lower esophageal

sphincter tone and blocks dopamine, receptor at the chemoreceptor trigger zoneSpecific Indication: Emesis during pregnancy

Contraindication: Contraindicated in patients hypersensitivity to drug and in those with

pheochromotoma or seizure disorderAdverse reaction: Restlessness, hypotension, bowel disorder, urinary frequency, loss of

libidoNursing precaution: Safety and effectiveness of drug havent been established for therapy

lasting longer than 12 weeks

Generic name: NubainDate Ordered: May 7, 2007Classification: Opioid analgesicsDosage, Frequency, Route: 3 mg IVTT 8 hours for severe pain

Mechanism of action: Unknown. Binds with opiate receptors in the CNS, altering

perception of and emotional response to painSpecific indication: Moderate to severe painContraindication: Contraindicated to patients hypersensitive to drugAdverse reaction: Sedation, hypertension, blurred vision, dry mouth, cramps, urinary

urgency Nursing precaution: Monitor circulatory and respiratory status and bladder and bowel

function. Withhold dose and notify prescriber if respirations

shallow or rate is below 12 breaths/minute.


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IX. Ideal Nursing Management

Diagnosis: Knowledge deficient regarding condition, prognosis, and treatment related tolack of exposure.

Intervention Rationale1. Review specific pathology andanticipated surgical procedure. Verify that

appropriate consent has been signed

- provides knowledge base from whichpatient can make informed therapy choices

and consent for procedure and presents

opportunity to clarify misconceptions

2. Use resource teaching materials,

audiovisuals as available

- specially designed materials can facilitate

patients learning

3. Implement individualized preoperative

teaching program:

preoperative/postoperative procedures anddietary considerations.

- enhances patient understanding/control

and can receive stress related to the

unknown/ unexpected

4. Implement individualized preoperativeteaching program: preoperative instructions

and which medication to take

- helps reduce possibility of post operativecomplications and promotes a rapid return

to normal body function.

5. Provide opportunity to practicecoughing, deep breathing, and muscular

exercises.

- enhances learning and continuation ofactivity postoperatively

Diagnosis: Risk for infection related to broken skin or traumatized tissue

Intervention Rationale

1. Prepare operative site according tospecific procedure

Minimizes bacterial counts and operativesites

2. Examine skin for breaks or irritation,

signs of infection

Disruption of skin integrity at or near the

operative sites are sources of contamination

to the incision

3. Identify breaks in aseptic technique and

resolve immediately on occurrence

Contamination by environmental/personnel

contact renders the sterile field unsterile,thereby increasing the risk for infection

4. Apply sterile dressing Prevents environmental contamination of fresh wound

5. Administer antibiotics as indicated May be given prophylactically for

suspected infection or contamination


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Diagnosis: Acute pain related to disruption of the skin.

Intervention Rationale

1. Provide information about transitorynature of discomfort, as appropriate

Understanding the cause of the discomfortprovides emotional reassuarance

2. Reposition as indicated e.g.,semi-Fowlers position

May relieve pain and enhances circulation.

3. Provide additional comfort measures Improve circulation, reduces muscle

tension and anxiety associated with pain.

4. Encourage use of relaxation technique Relieves muscle and emotional tension;

enhances sense of control and may improvecoping abilities

5. Provide oral care, occasional icechips/sips of fluid as tolerated

Reduces discomfort associated with drymucous membranes due to anesthetic

agents, oral restrictions.

IX. Actual Nursing Management

S Natingala jud ko nganong nain-ani ko., as verbalized by the client.

O Looked confused

A Knowledge deficient regarding condition, prognosis, and treatment related

to lack of exposure.

P Long term: At the end of 2 days the patient will understand her condition.

Short term: at the end of 2 hours the the patient will be oriented with her

condition.

I 1. Reviewed specific pathology and anticipatedsurgical procedure. Verify that appropriate consent has been signed.

2. Used resource teaching materials,audiovisuals as available.

3. Implemented individualized preoperative

teaching program: preoperative/postoperative procedures and dietaryconsiderations.

4. Implemented individualized preoperative

teaching program: preoperative instructions and which medication totake.

5. Provided opportunity to practice coughing,

deep breathing, and muscular exercises.E At the end of 2 hours the clint was able to understand her condition.


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S Dili man ko kabalo mulimpyo sa akong inoperahan, mahadlok man gani

ko mutan-aw., as verbalized by the client.

O Facial expression (confused)A Risk for infection related to broken skin or traumatized tissue

P Long term: At the end of 4 days the patient will be able to learn how to

maintain the incision site clean.Short term: At the end of 2 hours the patient will be able to learn how to

clean the incision site.

I 6. Prepared operative site according to specific

procedure.

7. Examined skin for breaks or irritation, signsof infection.

8. Identified breaks in aseptic technique and

resolve immediately on occurrence.9. Applied sterile dressing.

10. Administered antibiotics as indicated.

E At the end of 2 hours the patient was able to learn how to clean and how tomaintain the incision site clean.

Diagnosis: Acute pain related to disruption of the skin.

S kung mutukar na gani ang kasakit grabe jud,murag dili jud nako

makaya., as verbalized by the client.O Facial grimace

Making a fistReports of pain

A Acute pain related to disruption of the skin.

P Long term: At the end of 2 days the pain felt by the client will be lessen.

Short term: At the end of 4 hours the pain felt by the client will bealleviated.

I 11. Provided information about transitory natureof discomfort, as appropriate.

12. Repositioned as indicated e.g.,semi-Fowlers

position.13. Provided additional comfort measures.14. Encouraged use of relaxation technique.

15. Provided oral care, occasional ice chips/sips

of fluid as tolerated.

E At the end of 2 hours the pain felt by the client was alleviated.


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XI. Health Teaching

Exercise

Prior to patient sent at OR, patient and the

significant others was encourage to do the

following simple exercises after one day:

Encourage the patient to change

position every 30 minutes

- this is to prevent pulmonarycomplication such as pneumonia

if patient can handle herself,

encourage the patient to ambulate- to promote proper blood circulation- to increase energy requirements to

perform activities of daily living

Diet

The patient was encouraged to have the

following diet:

increase protein intake such foodslike meat, fruits and egg

- this is to promote wound healing

increase intake of fruits and

vegetables such as papaya, monggo,

cabbage- this is to promote roughage in the

body in order to avoid constipation

Treatment

The significant others and the patient was

encouraged to do the following treatmentafter the operation:

If patient will have fever

- do the tepid sponge bath and

afterwards check the temp

heat losses will occur as skin and

mucous membranes are exposed to

cool environment temperature- give patient antipyretic medication

this is to lower the patients

temperature- encouraged the patient to increase

fluid intake

it aids and help to mobilize internalheat from the body through water


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- do wound dressing

this is to promote proper wound

healing and will decrease the

multiplication of the

microorganisms

Medications

The patient and the significant others of thepatient was encouraged to let the patienttake her medications religiously,

medications such as:

- Tramadol- Ketorolac

- Ranitidine

- Metoclopramide- Nubain

XII. Referral and Follow-up

Because of the risk of subsequent ectopic pregnancies, the patient is advised to

seek preconception counseling before considering future pregnancies and to seek early

prenatal care. Psychological support and counseling may be advisable for woman andthier partner to help them deal with the los of pregnancy. Follow-up contact enables the

nurse to answer questions and clarify information for woman and her partner. In addition,

it provides an opportunity to assess their ability to cope with the loss of the pregnancy.

The patient was advised to have an appointment with Dr. x 2 weeks after theoperation to check the patient for any complications and also to check the incision site for

any signs of infection.

XIII. Bibliography

1. Medical Surgical Nursing, Suzanne C. Smeltzer

Vol. 2, 10th EditionNursing 2006 Drug Handbook, Lippincott Williams and Wilkins

26th Edition

Documents

Ectopic Pregnancy_CS