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A CASE A CASE PRESENTATION ON PRESENTATION ON ECTOPIC ECTOPIC PREGNANCY PREGNANCY (S/P BTL 1 YEAR) (S/P BTL 1 YEAR) BY: Mr. Bucare Manarondong RN BY: Mr. Bucare Manarondong RN
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Page 1: Ectopic Pregnancy

A CASE A CASE PRESENTATION ONPRESENTATION ON

ECTOPICECTOPIC

PREGNANCYPREGNANCY (S/P BTL 1 YEAR)(S/P BTL 1 YEAR)

BY: Mr. Bucare Manarondong RNBY: Mr. Bucare Manarondong RN

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I. INTRODUCTION

Ectopic pregnancy presents a major health problem for women of childbearing age. 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.

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Ectopic pregnancy currently is the leading cause of pregnancy-related death during the first trimester in the country, accounting for 9% of all pregnancy-related deaths. In addition to the immediate morbidity caused by ectopic pregnancy, the woman's future ability to reproduce may be adversely affectedas well.

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Ectopic pregnancy is derived from the Greek word ektopos, meaning out of place, and it refers to the implantation of a fertilized egg in a location outside of the uterine cavity, including the fallopian tubes, cervix, ovary, cornual region of the uterus, and the abdominal cavity. This abnormally implanted gestation grows and draws its blood supply from the site of abnormal implantation. As the gestation enlarges, it creates the potential for organ rupture because only the uterine cavity is designed to expand and accommodate fetal development. Ectopic pregnancy can lead to massive hemorrhage, infertility, or death.

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Multiple factors contribute to the relative risk of ectopic pregnancy. In theory, anything that hampers the migration of the embryo to the endometrial cavity could predispose women to ectopic gestation. The most logical explanation for the increasing frequency of ectopic pregnancy is previous pelvic infection; however, most patients presenting with an ectopic pregnancy have no identifiable risk factor. It has been observed that women diagnosed with pelvic inflammatory disease, those with history of prior ectopic pregnancy, of tubal surgery and conception after tubal ligation are at risk of ectopic pregnancy. It has also reported that smoking, the use of fertility drugs or reproductive technology, intrauterine device and increasing age, T-shaped uterus and ruptured appendix may predispose a woman to such conditions.

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Sites and frequencies of ectopic pregnancy. By Donna M. Peretin, RN.(A) Ampullary, 80%; (B) Isthmic, 12%; (C) Fimbrial, 5%; (D) Cornual/Interstitial, 2%; (E) Abdominal, 1.4%; (F) Ovarian, 0.2%; (G) Cervical, 0.2%.

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The classic clinical triad of ectopic pregnancy is pain, amenorrhea, and vaginal bleeding. Unfortunately, only 50% of patients present typically. Patients may present with other symptoms common to early pregnancy, including nausea, breast fullness, fatigue, low abdominal pain, heavy cramping, shoulder pain, and recent dyspareunia. Astute clinicians should have a high index of suspicion for ectopic pregnancy in any woman who presents with these symptoms and who presents with physical findings of pelvic tenderness, enlarged uterus, adnexal mass, or tenderness. The result of the ultrasound is tge most reliable indicator that a woman is suffering from ectopic pregnancy. Early detection means saving the woman from blood loss and death.

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• Marie Stopes InternationalMarie Stopes International (MSI)(MSI) is an is an International International Non-Governmental Non-Governmental OrganisationOrganisation working on Sexual and working on Sexual and Reproductive HealthReproductive Health with headquarters in with headquarters in LondonLondon, , UKUK. It is named after . It is named after Marie StopesMarie Stopes a Scottish author, campaigner for women's a Scottish author, campaigner for women's rights, and a pioneer in the field of family rights, and a pioneer in the field of family planning. planning.

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• Marie Stopes is a Marie Stopes is a pro-choicepro-choice organisation, organisation, and provides a variety of sexual and and provides a variety of sexual and reproductive healthcare services including reproductive healthcare services including advice, advice, vasectomiesvasectomies, and , and abortionsabortions in the in the UK.UK.

• Even here in the Philippines, the foundation Even here in the Philippines, the foundation is recognized and they provide free surgical is recognized and they provide free surgical missions for those individuals on missions for those individuals on reproductive age who opted to have family reproductive age who opted to have family planning like the mentioned methodsplanning like the mentioned methods

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• As for this case, the patient’s health history As for this case, the patient’s health history revealed upon interview that she had bilateral revealed upon interview that she had bilateral tubal ligation last March 09, 2010 which was tubal ligation last March 09, 2010 which was sponsored by Marie-Stopes Foundation as one sponsored by Marie-Stopes Foundation as one of their yearly goals to provide free surgeries of their yearly goals to provide free surgeries for those women who desire to have BTL, in for those women who desire to have BTL, in specified areas in the country. The said specified areas in the country. The said foundation was about to sponsor another foundation was about to sponsor another surgical mission for this year but it was surgical mission for this year but it was postponed since the incident of this patient postponed since the incident of this patient

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A.) OBJECTIVES OF THE STUDY

The main reason and purpose is to conduct care study to identify problems encountered by the clients; this is one of our tools of learning knowledgeably and skillfully.

We, as health care providers; it is indeed our vocation to adjoined hands w/ the health team for the promotion of wellness of our clients. Our main objectives for this study are the following:

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In general, this study aims to enhance the skills and knowledge of the nurses in providing holistic care to the patient. Nurses logically search further knowledge in order to attain the desired goal and intervention for the wellness of the patient.

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CLIENT’S PROFILE

Name of Patient:Name of Patient: Nacaytuna, Marissa Geronima Nacaytuna, Marissa Geronima Sex: Sex: femalefemaleAge: Age: 32 32 years old years oldReligion: Religion: Roman CatholicRoman CatholicAddress:Address: Poblacion, Barangay 9 Poblacion, Barangay 9

Malaybalay City Malaybalay CityCivil Status: Civil Status: Married Married Occupation: Occupation: W WaitressaitressIncome: Income: P 5,000/ monthP 5,000/ monthNationality: Nationality: FilipinoFilipinoDate Admission: Date Admission: August August 19,2010 19,2010Time: Time: 10: 00 am10: 00 am

Place of Admission: Bukidnon Provincial MedicalPlace of Admission: Bukidnon Provincial Medical CenterCenter

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• Age married: 20 years oldAge married: 20 years old

• Gravida: 5, Gravida: 5, Menarche: 14 Menarche: 14 years oldyears old

• Para: 3 (1 hospital, 2 lying-inPara: 3 (1 hospital, 2 lying-in ))

• Term: 3Term: 3

• Preterm: 0Preterm: 0

• Abortion: 2 (1Abortion: 2 (1stst - June 2001, 3 - June 2001, 3rdrd- September- September

2005)2005)

• Livebirths: 3 Livebirths: 3

• Last Delivery: August 13, 2008 lying in clinicLast Delivery: August 13, 2008 lying in clinic

OBSTETRIC HISTORY

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• Known familial disease: HypertensionKnown familial disease: Hypertension

• Attended last pregnancy by: Barangay MidwifeAttended last pregnancy by: Barangay Midwife

• Previous Illness/Surgery: Bilateral Tubal Ligation Previous Illness/Surgery: Bilateral Tubal Ligation (Free Surgical Mission by Marie Stopes (Free Surgical Mission by Marie Stopes Foundation)Foundation)

• Date: March 09, 2010Date: March 09, 2010

• Place: City Health Office, MalaybalayPlace: City Health Office, Malaybalay

• Last menstrual period: jUNE 28, 2010 (2-3 Last menstrual period: jUNE 28, 2010 (2-3 days)days)

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BASELINE VITAL SIGNS( August 16, 2010)BASELINE VITAL SIGNS( August 16, 2010)Temperature: Temperature: 37.6 C37.6 CPulse Rate: Pulse Rate: 101101 bpm bpmRespiratory rate: Respiratory rate: 2222 cpm cpm Blood PressureBlood Pressure: : 130/90 mmHg130/90 mmHgHeight: Height: 5’0’’5’0’’Weight: Weight: 4949.5 kgs.5 kgs

Chief complaints:Chief complaints: on and off vaginal on and off vaginal bleeding for three days withbleeding for three days with

hypogastric painhypogastric pain

Admitting Diagnosis: Admitting Diagnosis: T/C Ectopic PregnancyT/C Ectopic Pregnancy Final DiagnosisFinal Diagnosis Ruptured Ectopic PregnancyRuptured Ectopic Pregnancy

(L) Ampullary G5P3203 S/P (L) Ampullary G5P3203 S/P BTL 1yrBTL 1yr Operation PerformedOperation Performed (L) Salphingectomy(L) Salphingectomy

Attending Physician:Attending Physician: Dr. GalangDr. Galang

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NURSING THEORY NURSING THEORY RELATED TO NURSING RELATED TO NURSING MANAGEMENT OF THE MANAGEMENT OF THE DISEASEDISEASE• Self –care Model developed by Self –care Model developed by

Dorothea OremDorothea Orem• The goal of this theory is for the achievement of optimal The goal of this theory is for the achievement of optimal

client self-care so that clients can achieve an optimal health client self-care so that clients can achieve an optimal health state. When a person is sick, any interference with self-state. When a person is sick, any interference with self-care, object or condition, event and circumstance is care, object or condition, event and circumstance is considered a deficit. In order to achieve that optimal client considered a deficit. In order to achieve that optimal client self-care, one must be viewed as functioning biologically, self-care, one must be viewed as functioning biologically, symbolically and socially who initiates and performs self-symbolically and socially who initiates and performs self-care activities on his/her own behalf in maintaining life, care activities on his/her own behalf in maintaining life, health and well-being.health and well-being.

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• These self-care activities deal with air, These self-care activities deal with air, water, food, elimination, activity and rest, solitude and water, food, elimination, activity and rest, solitude and social interaction, hazards to life and well-being and social interaction, hazards to life and well-being and being normal. The role of a nurse in this model is to being normal. The role of a nurse in this model is to provide assistance to influence client’s development in provide assistance to influence client’s development in achieving an optimal level of self-care. Orem also achieving an optimal level of self-care. Orem also developed five general ways of assisting clients to developed five general ways of assisting clients to overcome their self-care deficit such as: acting for or overcome their self-care deficit such as: acting for or doing for, guiding, supporting, providing a doing for, guiding, supporting, providing a developmental environment and imparting health developmental environment and imparting health teachings to patients and significant others.teachings to patients and significant others.

•   ..

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• The nursing management of this The nursing management of this client is anchored to the theory client is anchored to the theory popularized by Dorothea orem.popularized by Dorothea orem.

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C.) CHIEF COMPLAINT AND HISTORY OF PRESENT C.) CHIEF COMPLAINT AND HISTORY OF PRESENT ILLNESSILLNESS

Three days prior to admission, the patient experienced Three days prior to admission, the patient experienced on and off vaginal bleeding accompanied by on and off vaginal bleeding accompanied by hypogastric pain. Symptoms experienced prompted hypogastric pain. Symptoms experienced prompted her to seek consultation last August 18, 2010 at her to seek consultation last August 18, 2010 at BPMC-OPDepartment and was advised for ultrasound BPMC-OPDepartment and was advised for ultrasound which revealed a suggestive ruptured ectopic which revealed a suggestive ruptured ectopic pregnancy. Upon assessment made by the doctor the pregnancy. Upon assessment made by the doctor the patient was conscious, anicteric sclera, clear breath patient was conscious, anicteric sclera, clear breath sounds wherein no rales, wheezes and murmurs was sounds wherein no rales, wheezes and murmurs was heard. Aside from the mentioned signs the patient also heard. Aside from the mentioned signs the patient also complained of body weakness, and nausea . The complained of body weakness, and nausea . The doctor came out to have a diagnosis of T/C Ectopic doctor came out to have a diagnosis of T/C Ectopic Pregnancy at BPMC Malaybalay and was ordered for Pregnancy at BPMC Malaybalay and was ordered for Emergency Pelvic LaparotomyEmergency Pelvic Laparotomy

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is the condition in which the ovum implants in area is the condition in which the ovum implants in area other than the endometrial lining of the uterus other than the endometrial lining of the uterus and occurs WHEN there is a tubal blockage that and occurs WHEN there is a tubal blockage that prevents the fertilized ovum from passing through prevents the fertilized ovum from passing through the fallopian tubes.the fallopian tubes.

RISK FACTORSRISK FACTORS

PATHOPHYSIOLOGY OF PATHOPHYSIOLOGY OF ECTOPIC PREGNANCYECTOPIC PREGNANCY

PRECIPITATING•Pelvic Inflammatory Disease•Endometriosis•Congenital anomalies of the

fallopian tubes•T-shaped uterus

PREDISPOSING

•Use of fertility drugs or assisted reproductive technology

•Use of an intrauterine device

•Increasing age

•Smoking

•Ruptured appendix•Previous tubal surgery or tubal pregnancy

RISK FACTORS

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TYPESTYPES

AMPULLARYISTHMIC

TYPES

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OVARIANOVARIAN

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• CORNEALCORNEAL • FIMBRIAFIMBRIA

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• CERVICALCERVICAL • ABDOMINALABDOMINAL

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Dysfunction of the cilia which usually propel The fertilized ovum through the tube into theuterine cavity

Disruption or scarring of the fallopian tube

Blocks or slows the movement of a fertilized Egg through the fallopian tube to the uterus

Fertilized egg attaches to an area outside ofThe uterus(ampullary area of the fallopianTube) wher it implants and

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AmenorrheaAbnormal bleedingFrom the vagina Usually scanty Amounts or spotting

Sudden severe Abdominal/Hypogastric pain Usually unilateralIn nature

Transvaginal/Abdominal ultrasoundFindings:(+) positive embrio sacNo intauterine sac Identified; suggestiveOf rupturedEctopic pregnancy

SIGNS & SYMPYOMS

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OUTCOME

Internal hemorrhage On the tube as theAffected area starts to rupture

Profound drop on cardiac output

Hypovelemic Shock

DEATH(may occur)

S/sx: <BP >HR,RR,sweating DOB Restlessness and other signs

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VII.VII. MEDICAL MANAGEMENTMEDICAL MANAGEMENT

DOCTOR’S ORDERDOCTOR’S ORDER

Please admit to ward

Secure consent to care

NPO

TPR q 4 hrs

Start IVFluid of D6LR 1 LAnd regulate at 36gtts/min

RATIONALERATIONALE•For medical/surgical management

•To obtain patient permission to conduct treatment• To prevent aspiration and other complications during/after the operation

•Baseline purposes in determining any deviation from normal reading

•Hypertonic solution provides accessible means for emergency drug therapy

DATE/TIMEDATE/TIME

August 19,201010:00 amB/P – 130/90HR – 101RR – 22T – 37.6

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DOCTOR’S ORDERDOCTOR’S ORDER

LABS:

CBC stat

BT stat

HBSAG det stat

Urinalysis stat

Start D5LR 1L at 40gtts/min

RATIONALERATIONALE

•Determining hemoglobin hematocrit count

•To identify the patient’s blood type for possible blood transfusion intra and post operatively

•To determine if reactive to hepatitis B and if so to execute strict isolation techniques/procedures

•To detect any abnormalities

•Hypertonic solution that provide accessible means for emergency drug therapy

DATE/TIMEDATE/TIME

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DOCTOR’S ORDERDOCTOR’S ORDER

MEDS:Cefazolin 1g IVTT q 8 hrs ANST ( )

For “E” Pelvic Laparotomy Re: Ectopic Pregnancy

Please secure consent for sugery

RATIONALERATIONALE

• Act as prophylaxis

• Desired procedure to prevent hypovemic shock and other complications

•To obtain permission for surgery and attest understanding about the procedure

DATE/TIMEDATE/TIME

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DOCTOR’S ORDERDOCTOR’S ORDER

Please inform OR/Anesthesiologist on call

For pre op order please

To secure 2 “U” of WB with proper typing and cross- matching- standby for OR use

Start bloodline of PNSS1L

RATIONALERATIONALE

•For the staff to prepare materials/instruments for the specified operation

•for cases of massive blood loss during the operation and possible blood transfusion•Hypotonic solution for possible BT

DATE/TIMEDATE/TIME

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DOCTOR’S ORDERDOCTOR’S ORDER

Please inform Dr. Buenaventura of this admission

Please insert FBC F16 and attach to UB

Refer for BP < 90/60 mmHg pressure,SOB and any signs of shock

Please facilitate meds

Dr. Galang

RATIONALERATIONALE

• Consultant on on call. For further management and evaluation

•To monitor fluid balance or state of hydration and renal function

•Signs of shockSigns of shock

• for availability of meds for availability of meds for successful operationfor successful operation

DATE/TIMEDATE/TIME

11:30 am

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DOCTOR’S ORDERDOCTOR’S ORDER

PRE-OP ORDERS

NPO 6-8 hours

Secure consent

On call meds:

Ranitidine 0 mg IVTT

RATIONALERATIONALE

•To prepare the patient for surgery and prevent complication suring the operation

•To obtain permission for surgery and attest understanding about the procedure

• Inhibits action of histamine on the H2 receptor sites of parietal cells and decrease gastric secretions.

DATE/TIMEDATE/TIME

11:00am11:00am

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DOCTOR’S ORDERDOCTOR’S ORDER

Metoclopromide 1o mg IVTT

Refer accordingly

Dr. Estopia

RATIONALERATIONALE

• to prevent vomiting during the operation

•To measure accurate intake and output and determine untoward effects brought by anesthesia

•To evaluate patient and provide appropriate measure

DATE/TIMEDATE/TIME

1 :18pm

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DOCTOR’S ORDERDOCTOR’S ORDER

POST OP ORDERS

To PACU

NPO

Monitor V/S q 14 minsFor 2 hours then hourly until stable

Monitor I and O q hour until stable

O2 at 2-3 liters via N.C.

Transfuse 1 u of WB with PTXM and regulate at KVO rate for the 1st hour and 30gtts/min thereafterMonitor for signs of reaction

RATIONALERATIONALE

•For close monitoring of patient’s vital signs

•To prevent aspiration

•To evaluate status and detect abnormal vital signs

•To measure accurate intake and output and assess renal perfusion functioning

• to provide adequate tissue perfusion

•To replace the blood loss brought by surgery and prevent complication

DATE/TIMEDATE/TIME

1:40pm

EST: 900cc

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DOCTOR’S ORDERDOCTOR’S ORDER

Flat on bed due 6 hours Flat on bed due 6 hours post oppost op IVF: D5LRiL at 30gtts/ min(L) PNSSiL at KVO

Medications:

1. Cefazolin 1gm IVTT q 8h ANST ( ) 2. Ketorolac 30 mg IVTT q 8h x 3 doses

RATIONALERATIONALE

•To prevent spinal headache

•Hypertonic solution that provide accesible means for emergency drug therapy

•To prevent infection

•For relief of pain

DATE/TIMEDATE/TIME

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DOCTOR’S ORDERDOCTOR’S ORDER

4. Famotidine 20 mg IVTT q 12h x 2 doses

RATIONALERATIONALE

•To prevent gastric acid secretion.

DATE/TIMEDATE/TIME

ho

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DOCTOR’S ORDERDOCTOR’S ORDER

6. Paracetamol 300 mg IVTT q 4h for T>37.8C

Repeat HGb and Hct 6h post op

Refer accordingly

Dr. Estopia

RATIONALERATIONALE

• analgesic for signs of hyperthemia

•To monitor the normality of blood count and determine the need for another transfusion• to evaluate patient’s condition

DATE/TIMEDATE/TIME

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DOCTOR’S ORDERDOCTOR’S ORDER

Please remove FBC

May have clear liquids then soft diet

Place abdominal binder

RATIONALERATIONALE

• to prevent infection

• facilitate normal intake of foods gradually

•To prevent dehiscence or evisceration while patient is ambulating

DATE/TIMEDATE/TIME

August 20, 2010

6:00 AM

(+) flatus

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DOCTOR’S ORDERDOCTOR’S ORDER

Encourage ambulation

Continue Cefazolin 1 gm IVTT x 2 more days then shift to Cefuroxime 600 mg BID x 7 days

RATIONALERATIONALE

• For effective recovery For effective recovery and prevent and prevent complicationcomplication

•To prevent infection To prevent infection and prepare patient for and prepare patient for per orem medsper orem meds

DATE/TIMEDATE/TIME

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DOCTOR’s Order

Mefenamic Acid 600mg q 8h for pain

FESO4 OD x 1 mo

Dr.Galang

RATIONALERATIONALE

• relief of post op pain

•For prevention of anemia and to provide dietary supplements

DATE/TIMEDATE/TIME

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IVTFF: D6LR 1L at 30gtts/ min

Cont meds

Refer

Dr.Chavez

RATIONALERATIONALE

•Provide accessible means for emergency drug therapy

• for continued care and determine any complications

DATE/TIMEDATE/TIME

August August 21,201021,2010

8:00am8:00am

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Terminate IVF

MGH anytime

Continue p.o meds at home

Dr.Chavez

RATIONALERATIONALE

•For compliance of drug therapy and prevent infection/complications

DATE/TIMEDATE/TIME

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LABORATORY AND DIAGNOSTIC EXAMINATIONSLABORATORY AND DIAGNOSTIC EXAMINATIONS

Diagnostic Diagnostic Exams Exams

Result Result Normal Normal ValueValue

InterpretatioInterpretationsns

ImplicationsImplications

White Cell Count

11.1 5.0 – 10 Elevated

Inflammatory process results in leukocytosis

Hemoglobin 11.2M 13.7-16.7 decreased Reduced RBC production

Hematocrit 38.2M 40.5-49.7 Decreased Reduced RBC productions

Platelet count

Adequate 144,000 to 372,000

Within normal range

Normal

DifferentiaL count: SegmentersLymphocytes Monocyte

67 %28%05%

43.4-76.2% 17.4 – 46.2 4.5% - 10.5

NormalNormal

decreased

NormalNormaldecreased

Bleeding Time

3 mins &10 1-3 mins Normal Normal

Clotting time

Blood type

HBSAG Det

4 mins

“O”

NR

3 – 5 mins Normal Normal

Date: August 19,2010

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Diagnostic Diagnostic Exams Exams

Result Result Normal Normal ValueValue

InterpretatioInterpretationsns

ImplicationsImplications

White Cell Count

5.0 – 10 Elevated

Hemoglobin 12.9 13.7-16.7 normal Below normal

Hematocrit 39.4M 40.5-49.7 Normal below normal

Platelet count

144,000 to 372,000

normal range Normal

DifferentiaL count: SegmentersLymphocytes Monocyte

80 %16%04%

43.4-76.2% 17.4 – 46.2 4.5 - 10.5

increaseddecreaseddecreased

Bleeding Time

1 min 1-3 mins Normal Normal

Clotting time

3 – 5 mins

Date: August 19, 2010 11:00pm REPEAT HGB and HCT Result

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UrinalysisUrinalysis

Color: Color: yellowyellow pus cells: pus cells: 5 – 10 hpf5 – 10 hpf Transparency: Transparency: clearclear

RBC RBC 0-2/hpf0-2/hpf Specific gravity: Specific gravity: 1.0251.025

epithelium:epithelium: occasional occasional Reaction: Reaction: 6.06.0 Sugar Sugar (-)(-) AlbuminAlbumin (+)(+) PROTIME:PROTIME: Control: Control: 15.1 secs15.1 secs Patient:Patient: 20.5 secs 20.5 secs % activity % activity 48%48% INR INR 1.481.48

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ULTRASOUND ULTRASOUND RESULT(TransvaginAL)RESULT(TransvaginAL)

Findings: in line of positive pregnancyFindings: in line of positive pregnancy suggestive of ruptured ectopic pregnancysuggestive of ruptured ectopic pregnancy

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Blood Transfusion RecordBlood Transfusion Record

VS before BT: T:36.0CVS before BT: T:36.0C HR: 68bpmHR: 68bpm RR: 20cpm RR: 20cpm Time transfuseD: 12:30pm ended: 4:49pmTime transfuseD: 12:30pm ended: 4:49pm Blood Type: “O”Blood Type: “O” Unit: 1 or 500ccUnit: 1 or 500cc Component: Whole bloodComponent: Whole blood Serial number: BPH2690Serial number: BPH2690 Adverse Reaction: noneAdverse Reaction: none VS After BT: T:36.0C RR:19cpmVS After BT: T:36.0C RR:19cpm

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DRUG STUDYDRUG STUDY

Name of Drug: CEFAZOLIN (ZOLICEF)/ CEFUROXIME 500mg icap BIDName of Drug: CEFAZOLIN (ZOLICEF)/ CEFUROXIME 500mg icap BID(Aug 20,2010)(Aug 20,2010)

Date Ordered: August 19, 2010Date Ordered: August 19, 2010

Classification: CEPHALOSPORINClassification: CEPHALOSPORIN

Dose/Fequency/Route: 1 gram IVTT (intravenously) every 8hours Dose/Fequency/Route: 1 gram IVTT (intravenously) every 8hours ANST ( ) ANST ( )

Mechanism of Action: both bactericidal and bacteriostatic which Mechanism of Action: both bactericidal and bacteriostatic which interferes with the cell-wall-binding ability ofinterferes with the cell-wall-binding ability of bacteria when they divide thereby preventingbacteria when they divide thereby preventing the bacteria from biosynthesizing the the bacteria from biosynthesizing the framework of their cell walls swell and burst framework of their cell walls swell and burst

asas a result of osmotic pressure within the cell.a result of osmotic pressure within the cell.

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Specific Indication( why drug is ordered): for the treatment ofSpecific Indication( why drug is ordered): for the treatment of infections caused by susceptible bacteria in theinfections caused by susceptible bacteria in the respiratory tract, skin, genitourinary, biliary tract,respiratory tract, skin, genitourinary, biliary tract, bone, joint, myocardial infections as well as sepsisbone, joint, myocardial infections as well as sepsis

Contraindication: should not be used with patients with knownContraindication: should not be used with patients with known

allergies to cepahalosporins or penicillins because aallergies to cepahalosporins or penicillins because a cross-sensitivity often occurs. Must also be used withcross-sensitivity often occurs. Must also be used with caution in patients with renal failure, pregnant andcaution in patients with renal failure, pregnant and lactating women.lactating women.

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Side Effects/Toxic Effects: Side Effects/Toxic Effects:

Most common: GI Tract such as nausea, vomiting, Most common: GI Tract such as nausea, vomiting, diarrhea,diarrhea,

abdominal pain, anorexia and flatulenceabdominal pain, anorexia and flatulence

Less common: Peudomembranous colitisLess common: Peudomembranous colitis CNS symptoms include headache, CNS symptoms include headache,

dizziness,dizziness, lethargy and paresthesiaslethargy and paresthesias PhlebitisPhlebitis

Nursing Precaution: Nursing Precaution: >Check culture and sensitivity reports >Check culture and sensitivity reports to ensure this is the drug of choice for this to ensure this is the drug of choice for this

patientpatient

> Monitor renal function tests prior to and > Monitor renal function tests prior to and periodicallyperiodically

during therapy during therapy to arrange for appropriate to arrange for appropriate dosagedosage

reduction as neededreduction as needed

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> Ensure that the patient receives the full course of > Ensure that the patient receives the full course of thethe

cephalosporin as prescribed, divided around the cephalosporin as prescribed, divided around the clock clock to increase effectiveness and to decrease the risk to increase effectiveness and to decrease the risk of of

resistant strainsresistant strains

> Monitor the site of infection and presenting signs > Monitor the site of infection and presenting signs andand

symptoms throughout the course of therapy. symptoms throughout the course of therapy. Failure toFailure to

resolve these signs indicate a need to reculture resolve these signs indicate a need to reculture the the

sitessites> provide small frequent meals as tolerated, > provide small frequent meals as tolerated,

frequentfrequent mouth care, and ice chips or sugarless candy to mouth care, and ice chips or sugarless candy to

suck ifsuck if stomatitis and sore mouth are problems to relieve stomatitis and sore mouth are problems to relieve

discomfort and provide nutrition and adequate fluidsdiscomfort and provide nutrition and adequate fluids

> Provide safety measures> Provide safety measures

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Name of Drug: RANITIDINE/ FAMOTIDINEName of Drug: RANITIDINE/ FAMOTIDINE

Date Ordered: August 19, 2010 Date Ordered: August 19, 2010

Classification: Histamine H2 AntagonistClassification: Histamine H2 Antagonist

Dose/Fequency/Route: 1ampule IVTT on call,20mg IVTT q Dose/Fequency/Route: 1ampule IVTT on call,20mg IVTT q 12hrs x 2 12hrs x 2 dosesdoses

Mechanism of Action: block H2 antagonists block H2 Mechanism of Action: block H2 antagonists block H2 receptor sites receptor sites and leads to a reduction in gastric acid and leads to a reduction in gastric acid secretion and reduction secretion and reduction in overall pepsin production.in overall pepsin production.

Specific Indication( why drug is ordered): Prophylaxis of Specific Indication( why drug is ordered): Prophylaxis of stress-stress- induced ulcer and acute upper GI bleeding, relief of induced ulcer and acute upper GI bleeding, relief of symptoms symptoms of heartburn, acid indigestion and sour of heartburn, acid indigestion and sour stomach.stomach.

Contraindication: Not advised to patients with known Contraindication: Not advised to patients with known allergy of this allergy of this class. Caution should be used in pregnancy, class. Caution should be used in pregnancy, lactation, and in lactation, and in patients with renal and hepatic patients with renal and hepatic dysfunction.dysfunction.

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• Side Effects/Toxic Effects: Side Effects/Toxic Effects: *diarrhea or constipation*diarrhea or constipation*dizziness*dizziness*headache *headache *confusion.*confusion.

• Nursing Precaution: Nursing Precaution:

*Monitor paient response to the drug (relief of GI *Monitor paient response to the drug (relief of GI symptoms, ulcer healing, prevention of progression of symptoms, ulcer healing, prevention of progression of ulcer).ulcer).*Monitor for adverse effects (dizziness, confusion, *Monitor for adverse effects (dizziness, confusion, hallucinations, GI alterations, cardiac arrythmias, hallucinations, GI alterations, cardiac arrythmias, hypotension, gynecomastia). hypotension, gynecomastia). *Evaluate effectiveness of teaching plan (can the patient *Evaluate effectiveness of teaching plan (can the patient name drug, dosage, adverse effects to watch for, and name drug, dosage, adverse effects to watch for, and specific measures to avoid advers effects?).specific measures to avoid advers effects?).*Monitor effectiveness of comfort measures and compliance *Monitor effectiveness of comfort measures and compliance with regimen.with regimen.

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Name of Drug: KETOROLAC (Ketomed)/MEFENAMIC ACID 500mg

Date Ordered: August 19 , 2010

Classification: NSAID

Dose/Fequency/Route:30 mg IVTT (intravenously) every 8hours

Mechanism of Action: The anti-inflammatory, analgesic, and antipyretic effects of the NSAIDs are largely related to inhibition of

prostaglandin synthesis.

Specific indication (why drug is ordered): Short-term management of pain; topically to relieve ocular itching.

Adverse effects: Adverse effects associated with acetaminophen use include headache, hemolytic anemia, renal dysfunction, skin rash, and fever. Hepatotoxicity is a potentially fatal adverse effect that is usually associated with chronic use and overdose and is related to direct toxic effects on the liver.

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Nursing Precaution:

*Administer with food if GI occurs.

*Monitor for adverse effects: CNS changes, rash, GI upset, CHF, liver dysfunction, asthma.

*Evaluate drug effects

*Evaluate effectiveness of patient teaching program.

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Name of Drug: FERROUS SULFATE

Date Ordered: August 20 , 2010

Classification: IRON PREPARATION

Dose/Fequency/Route:1 tab OD

Mechanism of Action: Iron preparation elevate the serum iron concentration. They are then either converted to hemoglobin or trapped in reticuloendothelial cells for storage and eventual release for conversion into a useable form of iron for RBC production.

Specific indication (why drug is ordered): Treatment of iron deficiency anemia

Adverse effects:*GI irritation*anorexia*nausea*vomiting*diarrhea*dark stools*constipation

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Nursing Precaution:

*Confirm iron defiency anemia before administering drugs to ensure proper use of the drug.

*Consult with the physician to arrange for treatment of the underlying cause of anemiaif possible, as iron replacement will not correct the cause of the iron loss.

*Caution the patient that stool may be dark or green to prevent undue alarm if this occurs.

*Arrange for hematocrit and hemoglobin levels before administration and periodically during therapy to monitor drug effectiveness.

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Nursing Diagnosis:Nursing Diagnosis:

Acute pain may be related to related to distention or upture Acute pain may be related to related to distention or upture of falllopian tubeof falllopian tube

Possibly evidenced byPossibly evidenced by

– Reports of pain with our without radiationReports of pain with our without radiation– Facial grimacingFacial grimacing– Restlessness, changes in level of consciousnessRestlessness, changes in level of consciousness– Changes in pulse, BPChanges in pulse, BP

Desired outcomesDesired outcomes Patient will verbalize relief control of painPatient will verbalize relief control of pain Demonstrate use of relaxation techniquesDemonstrate use of relaxation techniques Display reduced tension, relaxed manner, ease of Display reduced tension, relaxed manner, ease of

movementmovement

IDEAL NURSING CARE PLANIDEAL NURSING CARE PLAN

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Independent Independent 1.1. Obtain full description of pain from Obtain full description of pain from

patien including location, intensity (0-patien including location, intensity (0-10), duration; quality (dull/crushing); 10), duration; quality (dull/crushing); and radiationand radiation

2.2. Instruct patient to report pain Instruct patient to report pain immediatelyimmediately

3.3. Provide quiet environment, calm Provide quiet environment, calm activities, and comfort measures (e.g., activities, and comfort measures (e.g., dry/ wrinkle—free linens, backrub). dry/ wrinkle—free linens, backrub). Approach the patient calmly and Approach the patient calmly and confidentlyconfidently

• Pain is a subjective experience and Pain is a subjective experience and must be described by the patient. must be described by the patient. Assist patient to quantify pain by Assist patient to quantify pain by comparing it to other experiences.comparing it to other experiences.

• Delay in reporting pain hinders pain Delay in reporting pain hinders pain relief/ may require increased dosage relief/ may require increased dosage of medication to achieve relief. In of medication to achieve relief. In addition, severe pain may induce addition, severe pain may induce shock by stimulating the shock by stimulating the sympathetic nervous system, sympathetic nervous system, thereby creating further damage and thereby creating further damage and interfering with diagnosis and relief interfering with diagnosis and relief of pain.of pain.

• Decreases external stimuli, which Decreases external stimuli, which may aggravate anxiety and cardiac may aggravate anxiety and cardiac strain and limit coping abilities and strain and limit coping abilities and adjustment to current situation.adjustment to current situation.

INTERVENTIONS RATIONALE

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4.4. Assist/ instruct in relaxation techniques, Assist/ instruct in relaxation techniques, e.g, deep/ slow breathing, distraction e.g, deep/ slow breathing, distraction behaviors, visualization, guided imagerybehaviors, visualization, guided imagery

DEPENDENT:DEPENDENT:

1. Administer pain reliever as ordered1. Administer pain reliever as ordered

• Helpful in decreasing perception of/ response Helpful in decreasing perception of/ response to pain. Provides a sense of having some to pain. Provides a sense of having some control over the situation, increase in control over the situation, increase in positive attitude.positive attitude.

• For the relief of painFor the relief of pain

INTERVENTIONS RATIONALE

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Nursing Diagnosis:

Fluid volume Deficit, High Risk may be related to hemorrhagic losses, active blood loss and decreased/ restricted intake

POSSIBLT EVIDENCED BY: hypotensionThirstIncrease pulse rateDecreased skin turgorChange in mental stateIncreased body temperatureLow CBC result

Desired outcomes patient have attain normal vital signs and negative of symptoms of hypotension CBC result reveal a normal result

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INTERVENTIONSINTERVENTIONS RATIONALERATIONALE

• INDEPENDENTINDEPENDENT

1. Assess/monitor vital signs >to determine progress of condition 1. Assess/monitor vital signs >to determine progress of condition

2. Note presence of physical signs > to identify signs of shock2. Note presence of physical signs > to identify signs of shock

3. Review laboratory data ex. HGB and HCT count3. Review laboratory data ex. HGB and HCT count > to determine signs of > to determine signs of

anemia and need fro BTanemia and need fro BT

• DEPENDENTDEPENDENT

1. Administer IV fluids as approriate >prevent shock and for fluid 1. Administer IV fluids as approriate >prevent shock and for fluid replacementreplacement

1Perform Blood Transfusion PRn and as ordered> to prevent hypovolemia 1Perform Blood Transfusion PRn and as ordered> to prevent hypovolemia andand

other complicationother complication

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(SOAPIE FORM)

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S “sakit kaau akong pus-on, musamot kun magtakilid ko”

O facial grimaces

changes in vital signs, baseline: HR=101, BP=130/900

A Acute pain related to distention/rupture of fallopian tube

P At the end of 30 minutes, patient will be able to verbalize relief of

pain, display reduced tension, relaxed manner and ease of movement

Desired “Outcome: patient will verbalize deminished hypogastric pain

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Independent

1. Obtained full description of pain from patient including location, intensity (0-10), duration, quality and radiation.

2. Positioned patient comfortably, in moderate high back rest

3. Instructed patient in relaxation techniques, i.e., deep/slow breathing

• Pain is a subjective experience and must be described by the pt. Assist pt. to quantify pain by comparing it to other experiences.

• This allows for lung expansion by lowering the diaphragm

• Helpful in decreasing perception of/ response to pain. Provides a sense of having some control over the situation, increase in positive attitude.

INTERVENTIONS RATIONALE

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collaboration

5. Administered supplemental oxygen by means of nasal cannula @ 3L/min.

• Increases amount of oxygen available for adequate tissue perfusion

INTERVENTIONS RATIONALE

At the end of 8 hours, patient verbalized relief of pain

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S “mura ko ug gakalumos and lipong NG AKONG

Paminaw”

O facial grimaces

changes in vital signs, baseline: HR=101,

BP=130/90

HGB nd HCT result

A High Risk for fluid Volume Deficit R/T

hemorrhage losses and restricted intake

P At the end of 3-8hours, patient will be able to maintain fluid volume at a functional level as evidenced by normal vital signs and relief of discomfort

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INTERVENTIONINDEPENDENT

1. Assessed and monitored vital signs

2. Observed for physical signs of anemia/ hypovolemic shock

3. Instructed to verbalize any discomforts

DEPENDENT

1. Transfused 1 whole blood as ordered1. At the end of 8 hours, the patient verbalized relie

2. ]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]

3. \]

4. ‘f of discomfort, Hgb/HCt status was taken and it revealed a below normal result which can be corrected with intake of iron supplements

RATIONALE

1.To monitor for any deviation in normal vital signs

2. To evaluate patient response and progress to regimen provided

1. To correct anemia and prevent shock

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REFERRALS AND FOLLOW – UP (Health teaching)Medication

Advised patient to take prescribed medication at regular basis;

ExerciseAt the hospital, patient is advised to initiate gradual exercise for ambulationsuch as;

a. Lying or sitting exercise( arms, legs, trunk)b. Exercise progress to standing and slow walking in the hall.c. Exercise must be done twice a day for about 20 minutesd. Exercises (Deep, pursed lip or deep breathing exercises)

TreatmentIn the hospital, patient is provided with the following treatment ;

a. Supplemental oxygen by nasal cannula @ 2-4 L/min.b. Frequent monitoring of vital signs including temperature , pulse rate ( apical/ radial) and blood

pressure and intake and outputc. Pharmacologic management to stabilize client condition.

Out patientWhen the patient will be discharged, out patient program will be imparted specifically on the patient’s scheduled follow up check up and daily dressing and removal of sutures on affected wound.

DietClient is advised to follow the prescribed recommended diet ;

a. Frequent intake of green leafy vegetablesb. Compliance to prescribed medicationc. Intake of vitamin C rich foods , taking Ferrous tab with orange juice for fast absorptiond. Avoidance of caffeine or milk while takin gferrous sulfate

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RecommendationsAdvised the patient for followed up check up from her assigned physician.

Advised patient peer for frequent monitoring of hemoglobin

Provided adequate information patient with queries about fertility and possible pregnancy as well as other risk factors of developing the same disorder.

Provide positive reinforcement for gains/ improvement and participation in self care/treatment program.

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B I B L I O G R A P H Y

Smeltzer.Bare. Textbook on Medical-Surgical Nursing (10th edition) Lippincott-Raven Publisher.Copyright 1996

Wilson, Billie Ann Nurse’s Drug Guide (vol. 1 & 2) Pearson Education Inc.,Copyright 2000

Mosby’s Pocket Dictionary of Medicine, Nursing and Allied Health (4th edition) Elsevier(Singapore) PTE LTD> Copyright 2002

Doenges, Marilynn Nursing Care Plans, Guidelines for Individualizing Patient Care(6th edition) F.A Davis Company. Copyright 2000

Kozier. Erb. Blais. Wilkinson. Fundamentals in Nursing (5th Edition). Addison esley Longman Inc. 1998.

MacMahon, S. Blood pressure and the risk of cardiovascular disease. N Engl J Med 2000; 342:50

HTML1Rollins Gina. "With smoking cessation drugs, dosing is key", ACP-ASIM Observer, 22(4); 1,16-17.

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W E B L I O G R A P H Y

http://biology.clc.uc.edu/courses/bio105/circulat.htm

wwwmedlib.med.utah.edu\webpath\TUTORIAL\ECTPREG.com

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