CASE STUDY :

ECTOPIC
PREGNANCY

SIR JESSE B. BANTALI

Submitted to:

ORLYN JOY TANAWE

Submitted by:
Section: BSN IV-C
Inclusive dates: 23-25, 2023
I. Introduction

Ectopic pregnancy occurs when fertilized egg implants itself outside of the womb. On a usual occurrence, ectopic
pregnancies happen in one of the fallopian tubes, to which (fallopian tubes) connects the ovaries to the womb. This
complication (ectopic pregnancy) deprives fertilized egg of its development into a baby and risks the pregnant mother of health
complications.

Ectopic pregnancy usually, is not detected on early stages of manifestations of fertility however, may be detected
during a routine pregnancy scan. Symptoms of manifestation develops between 4th and 12th week of pregnancy. Symptoms
include missed period and signs of pregnancy, abdominal pain on one side of the lower quadrant, vaginal bleeding as well as
brown watery discharge, pain on the tip of the shoulder, discomfort during defecation and urination. However, having few of
these symptoms such as discomfort during defecation are not, invariably, indicative of ectopic pregnancy, these could also be an
indication of other health problems.

Ectopic pregnancy are addressed with main treatments. Expectant management which are monitored carefully, and if
instances that fertilized egg are not dissolve by itself are treated. Treatment can be by medication via injections, patient is
injected with methotrexate stopping further development and growth of the fertilized egg. Another is by laparoscopy, to which
the patient undergoes anesthetics to remove the fertilized egg and usually along with the fallopian tube. These procedures
however, may affect and reduce the mother’s ability to be able to conceive.

Factors causing ectopic pregnancy includes, pelvic inflammatory disease inflammation of the female reproductive
system, usually caused by a sexually transmitted infection (STI). Previous case of ectopic pregnancy the risk of having another
ectopic pregnancy is around 10%, surgery on your fallopian tubes. In addition, women who had a previous case of ectopic
pregnancy has a 15% chance of experiencing it again. Furthermore, fertility treatment such as in vitro fertilization (IVF),
conception while using intrauterine device (IUD) or intrauterine system (IUS), and women who conceives at the age of 35 to 40
are at risk of experiencing ectopic pregnancy. For women who smokes the risk of acquiring ectopic pregnancy is 4 to 20 times
higher than those who doesn’t.

II. Patient’s Profile

Name : Patient X
Age/Sex : 33/F
Ward : OB ward
Occupation : Housewife
Marital status : Single
Religion : Roman Catholic
Date of admission : October 23, 2023
Admitting diagnosis : Threatened abortion, G1P0

Surgery operation : Exploratory Laparoscopy, Ectopic

Chief Complaint: Abdominal pain and vaginal bleeding

III. Present History of Illness

The patient has a sudden onset of severe pain on her left lower quadrant of abdomen with associated vaginal
spotting.
Past History of Illness
Patient has no history of hypertension and diabetes. No known allergies, and history of goiter and
cancer.

IV. 13 Areas of Assessment / Review of Systems

Psychosocial and Psychological Status
Patient X is 33 years old currently residing in La Trinidad, Benguet. She is a nonsmoker and nondrinker. She is a house
wife and practices Roman Catholic. She is easily distracted, not comfortable and accustomed with her current situation.
Mental and Emotional Status
Patient was conscious, coherent, alert, and correspondent. She also responds appropriately to questions. She can
express how she feels through complains. No developmental delay wherein her motor function, speech and language, cognitive,
play, and social skills corresponds to her age. The patient knows and understands her condition.
Environmental Status
 Patient is located in the OB ward and is familiar with the room set up. She is oriented that she is in the hospital. Bed
rails are available to the patient together with disinfectants, drinking water and food located in her bedside. There is a steady
pattern of activity like noise and color in her environment and it does not distract her. Patient is comfortable with the room
ventilation and lighting.
Sensor Status
a. Visual Status
Patient X has no difficulty in opening and closing her eyes, able to distinguish objects such as pen and
notebooks. Her eyes are symmetrical and round, the sclera is white in color. She has the ability to see, has no special
aids such as glasses, no blurred visions, no itching, no excessive tearing/discharge, no redness or trauma to the eye.
b. Auditory
Patient’s ears are symmetrical with enough earwax observed, no tenderness upon palpating. She was also
instructed to repeat the words that are whispered on both left and right ear, and she was able to repeat all the words
correctly. She has the ability to hear, has no special aids like hearing aids, no tinnitus, no pain, no discharges or trauma
to ears and can hear normal voice tone and level.
c. Olfactory Status
Her nose is symmetrical, no nasal flaring noted, there are no tenderness and lesion upon palpating the sinuses,
no pain, no post nasal drip, no sneezing or frequent nose bleed. Patient was able to distinguish different scents by letting
her smell 3 scents such as alcohol, strawberry scent, and lemon.
d. Gustatory Status
She was able to make a distinction between sweet, sour, salty and bitter foods by letting her taste these 4
different flavors with her eyes occlude.
e. Tactile Status
Patient was able to identify rough and smooth things and has the ability to feel like touch, pain, heat, and cold
by letting rough and smooth surface, sharp, hot and cold things touch her skin.
Motor Status
Patient’s movement is limited due to pain. There is no bone deformity that can affect motor function. No abnormal
movements like fasciculation and tics. Muscle mass are good but petite, noted symmetry between sides of the body and
distribution distally and proximally. Muscle tone are good in resistance. Muscle mass is appropriate to her age and gender.
Thermoregulatory Status
Date Time Temperature
October 23, 2023 7:00 AM 36.5 °C
10:00 AM 36.4 °C
2:00 PM 36.6 °C

Respiratory Status
Date Time RR SPO2
October 23, 2023 7:00 AM 19 95%
10:00 AM 18 96%
2:00 PM 18 96%

Circulatory Status

Date Time PR (bpm) BP (mmHg)

October 23 2023 7:00 AM 62 90/60
10:00 AM 65 110/70
2:00 PM 64 120/80
Nutritional Status
No allergies to food. She was able to consume 70 percent of food served.

Sleep, Rest and Comfort Status

Patient usually sleep 4 to 5 hours a day due to pain. Has abnormal sleeping pattern, has difficulty in falling
asleep/remaining asleep.
Fluids and Electrolytes Status
Patient IV fluids of PNSS 1L, 42 gtts per minute for 8 hours infusing well at the left arm. She drinks less than 5 glasses
of water.
Integumentary Status
The skin color is brown with freckles on her face, no lesions but pallor is present on her palms (yellowish because of
brown skin), dry and slow skin turgor. The hair color is black, greasy, untied and messy, the amount and distribution were
normal, scalp has no lesion or infestation. Long nails are observed. Patient do not have proper hygiene and grooming. Patient
has surgical wound on her left lower abdomen, no swelling, no redness and no exudates.
REVIEW OF SYSTEM

The female reproductive system consists of several key parts:

 Ovaries: Produce eggs (ova) and release hormones, including estrogen and progesterone.
 Fallopian Tubes: Tubes that transport eggs from the ovaries to the uterus. Fertilization
typically occurs in the fallopian tubes.
 Uterus: A muscular organ where a fertilized egg implants and develops into a fetus
during pregnancy.
 Cervix: The lower part of the uterus that connects to the vagina. It allows the passage of menstrual blood
and serves as the entrance for sperm during fertilization.
 Vagina: A muscular tube connecting the cervix to the external genitals. It also serves
as the birth canal during childbirth.
 Labia and Clitoris: External genital structures that play roles in sexual arousal and
pleasure.
V. Pathophysiology
VI. Drug Study

A. Drugs
DRUG NAME MECHANISM OF ACTION INDICATION / ADVERSE EFFECT NURSING RESPONSIBILITIES
CONTRAINDICATION

GENERIC: Tramadol and its active metabolite INDICATIONs: Respiratory: a. Observe 10 rights in drug administration to
(M1) binds to μ-opiate receptors in avoid medication errors.
TRAMADOL the CNS causing inhibition of Relief of moderate to Bronchitis, cough, nasal congestion, b. Check for allergies.
moderately severe pain. nasopharyngitis, pharyngitis, rhinitis, c. Monitor vital signs.
ascending pain pathways, altering
rhinorrhea, sinus congestion, sinusitis, d. Be aware that tramadol shouldn’t be given to
the perception of and response to patients with a history of anaphylactoid
pain; also inhibits the reuptake of sneezing, upper respiratory tract infection
BRAND: reactions to codeine or other opioids.
norepinephrine and serotonin, which CONTRAINDICATION: e. Know that chronic maternal use of tramadol
GI:
ULTRAM, are neurotransmitters involved in the during pregnancy can result in neonatal opioid
CONZIP descending inhibitory pain pathway Suicidal patients, acute GI pain, diarrhea, vomiting, nausea, withdrawal syndrome (NOWS), which may be
responsible for pain relief. alcoholism; head injuries; life-threatening if not recognized and treated
constipation
raised intracranial appropriately. NOWS occurs when a newborn
has been exposed to tramadol for a prolonged
pressure; severe renal CNS:
CLASS: period while in utero.
impairment; lactation. f. Use tramadol cautiously in patients who are
Anxiety, apathy, ataxia, chills,
THERAPEUTIC taking tranquilizers or antidepressant drugs and
confusion, depersonalization, depression, in patients who use alcohol in excess or who
ANALGESIC falling, feeling hot, hypoesthesia, suffer from emotional disturbance or
lethargy, nervousness, pain, paresthesia, depression.
restlessness, rigors, agitation, euphoria, g. Know that if patient has respiratory depression,
hypertonia, malaise, sleep disorder, respiratory status must be assessed often;
PHARMACOLOGI expect to give a non opioid analgesic—not
withdrawal syndrome, insomnia, seizures
C tramadol.
dizziness, headache, somnolence
OPIOID
Hematologic:
AGONISTS
neutropenia, leukopenia, decreased Hgb
or Hct, bone marrow depression

Dermatologic:
DOSAGE:
Diaphoresis, dermatitis, skin rash,
50mg. q 8hrs. pruritus
 Cardiovascular:

ROUTE: Flushing, chest pain, hypertension,

vasodilation, peripheral edema,
IV orthostatic hypotension

Gastrointestinal: Constipation, nausea,

vomiting, xerostomia, dyspepsia

Drug name Mechanism of action Indication/contraindication Adverse effect Nursing responsibilities

GENERIC: The mechanism of action of INDICATIONs: CNS: a. Check brand and label to know that appropriate
CELEBREX is believed to be due dose to be given.
Celecoxib to inhibition of prostaglandin Osteoarthritis (OA). Dizziness, headache, insomnia b. Assess range of motion, degree of swelling, and
Rheumatoid Arthritis (RA). pain in affected joints.
synthesis, primarily via inhibition
BRAND: Juvenile Rheumatoid Arthritis CV: c. Assess patient for allergy to sulfonamides,
of COX-2. aspirin, or NSAIDs.
(JRA). Ankylosing Spondylitis
Celebrex edema d. Check client history before administering drug.
Prostaglandins are mediators of (AS). Acute Pain. Primary e. Assess for hepatic impairment
CLASS: inflammation. Celecoxib is an Dysmenorrhea. GI: f. Check history of GI bleeding or peptic ulcer
inhibitor of prostaglandin disease
antirheumatics, synthesis, its mode of action may GI BLEEDING, abdominal pain,
nonsteroidal anti- be due to a decrease of diarrhea, dyspepsia, flatulence, nausea.
CONTRAINDICATIONS:
inflammatory agents prostaglandins in peripheral
DERM:
tissues. Known hypersensitivity (e.g.,
PHARMACOLOGIC:
anaphylactic reactions and Exfoliative Dermatitis, Stevens-
COX-2 inhibitors serious skin reactions) to Johnson Syndrome, Toxic Epidermal
celecoxib, any components of Necrolysis, rash.
DOSAGE: the drug product.
ENDO:
50mg, 100mg, 200mg, History of asthma, urticaria, or
400mg other allergic-type reactions hyperkalemia.
after taking aspirin or other
ROUTE:
NSAIDs.
Oral
In the setting of CABG
 surgery

In patients who have

demonstrated allergic-type
reactions to sulfonamides.

DRUG NAME MECHANISM OF ACTION INDICATION / ADVERSE EFFECT NURSING RESPONSIBILITIES

CONTRAINDICATION

GENERIC: Stimulates peristalsis. Alters fluid INDICATIONs: GI: abdominal cramps, BEFORE:
and electrolyte trans- port, nausea, diarrhea, rectal
Bisacodyl producing fluid accumulation in Treatment of constipation. burning. Dx:
the colon.
CONTRAINDICATION: MS: hypokalemia (with a. Assess the patient for hypersensitivity or any signs of abdominal
pain, nausea and vomiting that is contraindicated to drug therapy.
chronic use)
BRAND: Hypersensitivity; Tx:
SOURCE: Davis’s Drug Guide Abdominal pain; MISC: protein losing
Bisacolax Obstruction; Nausea or a. Perform an abdominal examination to check for abdominal
for Nurses: Sixteenth Edition enteropathy, tetany distensions, presence of bowel sounds and usual pattern of bowel
vomiting (especially with (with chronic use). function.
fever or other signs of an EDx:
CLASS: acute abdomen).
a. Explain the drug therapy to the patient to increase compliance.
THERAPEUTIC: DRUG TO DRUG
Laxatives INTERACTION:
DURING:
PHARMACOLOGIC: A. Antacids, histamine
Stimulant laxatives H2-receptor Dx:
antagonists, and
DOSAGE: 10mg gastric acid–pump a. Do not confuse the drug with similar brand names but different
inhibitors may generic name.
ROUTE: Rectal remove enteric b. Make sure that the site of administration is cleaned prior to placing
coating of tablets the drug.
 resulting in gastric c. Lubricate suppositories with water or water soluble lubricant before
irritation/dyspepsi insertion.
a. Tx:
B. May lower the
absorption of other a. Administer at bedtime for morning results.
orally b. Suppository or enema can be given at the time a bowel movement
administered drugs is desired.
because of high EDx:
motility and low
transit time. a. Encourage patient to retain the suppository or enema 15 – 30 min
before expelling.

AFTER:

Dx:

a. Assess the patient for abdominal pain, fever, nausea and vomiting
that comes with constipation and encourage client not to take the
drug.
Tx:

a. Increase the fluid intake of the client to prevent dehydration.

EDx:

a. Advise the client not to prolong drug therapy which may cause drug
dependence and electrolyte imbalance.
b. Encourage the patient to use other forms of bowel regulation.
(increasing bulk in the diet, increasing fluid intake, or increasing
mobility).

DRUG NAME MECHANISM OF ACTION INDICATION / ADVERSE EFFECT NURSING RESPONSIBILITIES

CONTRAINDICATION

GENERIC: Exerts a bacteriostatic effect INDICATIONs: CNS: BEFORE:

against a wide variety of gram-
DOXYCLYCLI positive and gram-negative cutaneous, GI, or Bulging fontanels (infants), Dx:
NE HYCLATE organisms. Doxycycline is more inhalation anthrax, headache, intracranial
BRAND: inflammatory lesions hypertension, paresthesia a. Monitor patient closely for hypersensitivity,
lipophilic which may occur as early as first dose.
ACTICLATE (papules
CLASS: CV: Tx:
than other tetracyclines, which a. Perform a thorough physical assessment to establish
and pustules) of rosacea,
THERAPEUTIC allows it to endocervical, rectal, and Pericarditis, phlebitis baseline data before drug therapy begins, to determine the
ANTIBIOTIC urethral infections caused effectiveness of therapy, and to evaluate for the
pass more easily through the by Chlamydia trachomatis, EENT: occurrence of any adverse effects associated with drug
PHARMACOLOGIC: bacterial lipid bilayer, where it epididymoorchitis caused therapy.
OPIOID AGONIST binds reversibly to 30S Black “hairy” tongue, glossitis, b. Periodically assess dose.
by C.
hoarseness, oral candidiasis, EDx
DOSAGE: ribosomal subunits. Bound pharyngitis, stomatitis, tooth a. Tell patient to complete full course of ofloxacin therapy
trachomatis or Neisseria
200 mg doxycycline discoloration, visual exactly as prescribed even if he feels better before it’s
gonorrhoeae complete.
disturbances
ROUTE: blocks the binding of aminoacyl b. Urge patient not to take antacids, iron or zinc
or nongonococcal
INTRAVENOUS transfer RNA to messenger RNA, GI: preparations, or other drugs (such as didanosine and
urethritis caused by sucralfate), within 2 hours of ofloxacin to prevent
thus inhibiting bacterial protein
Anorexia; bulky, loose stools; decreased or delayed drug interruption.
synthesis. C. trachomatis or
Ureaplasma Urealyticum, diarrhea; dysphagia;
DURING:
malaria, early syphilis in enterocolitis; epigastric distress;
penicillinallergic patients, esophageal ulceration; Dx:
SOURCE: Jones & Bartlett hepatotoxicity; inflammatory
As adjunct to amebicides
Learning., & Jones & Bartlett lesions in anogenital region; a. Monitor for these reactions which include angioedema,
in acute
Publishers. (2018). Nurse's drug nausea; pancreatitis; bronchospasm, dyspnea, itching, jaundice, rash, shortness
handbook (17th ed). intestinal amebiasis, as pseudomembranous colitis; of breath, and urticaria. If these signs or symptoms appear,
notify prescriber immediately and expect to discontinue
adjunct therapy to treat rectal candidiasis; vomiting
Sudbury, MA: Jones and Bartlett drug.
severe b. Monitor for the client’s breathing
Publishers. GU:
acne, syphilis of more than
1 Anogenital lesions, dark
Tx:
yellow or brown urine, elevated
year’s BUN level, vaginal candidiasis a. Proper dosage should be administered carefully for it is an
antibiotic.
duration in penicillin- HEME:
allergic patients, all other EDx:
infections caused by Eosinophilia, hemolytic
anemia, neutropenia a. Encourage patient to take each dose with a full glass of
susceptible organisms thrombocytopenia, water
thrombocytopenic purpura b. Tell patient to limit exposure to sun and ultraviolet light to
prevent phototoxicity.
SKIN: c. Advise patient to notify prescriber immediately about
CONTRAINDICATION: abnormal motor or sensory function, burning skin, hives,
Dermatitis, drug rash with itching, rapid heart rate, rash, and tendon pain. Also advise
Hypersensitivity to eosinophilia and systemic patient to stop taking ofloxacin immediately and notify
doxycycline prescriber if any other persistent, serious, or worsening
symptoms (DRESS), erythema
adverse effects occur.
multiforme, erythematous d. Urge patient to seek medical care immediately for trouble
 rashes, exfoliative dermatitis, breathing or swallowing, which may signal an allergic reaction.
photosensitivity, rash, Stevens– AFTER:
Johnson syndrome, toxic
Dx:
epidermal necrolysis, urticaria
a. Assess the patient for any reactions stated in the adverse
Other:
effects of the drug
Tx:
Anaphylaxis, angioedema,
exacerbation of systemic lupus a. Provide comfort measures (e.g. voiding before dosing,
erythematosus, injection-site taking food with drug, etc.) to help patient tolerate drug
phlebitis, serum sickness effects.

EDx:

a. Advise patient to avoid hazardous activities until CNS

effects of drug are known.

DRUG NAME MECHANISM OF ACTION INDICATION / ADVERSE EFFECT NURSING RESPONSIBILITIES

CONTRAINDICATION

GENERIC: Antagonizes the inhibitory INDICATIONs: CNS: a. Use metoclopramide cautiously in patients with hypertension
effect of dopamine on GI smooth because it may increase catecholamine levels.
METOCLOPRAMI muscle. This causes gastric Prevention of Drowsiness, extrapyramidal b. Monitor patient with NADH-cytochrome b5 reductase
DE chemotherapy-induced reactions, restlessness, deficiency because metoclopramide increases risk of
contraction, which promotes gastric
emesis. Treatment of NEUROLEPTIC MALIGNANT methemoglobinemia and sulfhemoglobinemia, and patient
emptying and peristalsis, thus can’t receive methylene blue.
reducing gastroesophageal reflux. postsurgical and diabetic SYNDROME, anxiety,
c. Assess patient for signs of intestinal obstruction, such as
Metoclopramide also blocks gastric stasis. Facilitation depression, irritability, tardive abnormal bowel sounds, diarrhea, nausea, and vomiting,
BRAND:
dopaminergic receptors in the of small bowel intubation dyskinesia. before administering metoclopramide. Notify prescriber if
METOZOLV, chemoreceptor trigger zone, in radiographic procedures. you detect them.
Management of esophageal CV: d. For I.V. use, you need not dilute doses of 10 mg or less.
REGLAN preventing nausea and vomiting.
reflux. Treatment and Give drug over 1 to 2 minutes. For doses larger than 10 mg,
arrhythmias (supraventricular dilute in 50 ml normal saline solution, half-normal (0.45)
prevention of postoperative
tachycardia, bradycardia), saline solution, D5W, or lactated Ringer’s solution and
SOURCE: nausea and vomiting when
CLASS: hypertension, hypotension. infuse over at least 15 minutes.
nasogastric suctioning is e. Assess for drug allergies
Jones & Bartlett, (2018). Nurse’s
f. Assess drug history that may cause interactions with
drug handbook, seventh edition, p.
THERAPEUTIC 705. ISBN: 978-1-284-12134-6 undesirable. Migraine. GI: metoclopramide
g. Assess bp and compare to normal values
ANTIENEMIC, constipation, diarrhea, dry
upper GI stimulant mouth, nausea.
CONTRAINDICATIONS
PHARMACOLOGIC : ENDO:
a.
DOPAMINE GI hemorrhage, Gynecomastia b. Store in a closed container in a cool place out of the reach of
RECEPTOR mechanical obstruction and children.
ANTAGONISTS perforation; HEMAT: a.
phaeochromocytoma;
DOSAGE: methemoglobinemia,
history of seizures
neutropenia, leukopenia,
10mg. q 6hrs agranulocytosis.

ROUTE: IV

B. IV Fluids
Name Classification Component/s Use & Effects Nursing Responsibilities
 Dextrose 5% in Hypertonic Electrolytes 1000ml Use:  Do not administer unless solution is clear and container is
Lactated Ringers Nonpyrogenic Sodium 130 mmol Lactated Ringers in 5% Dextrose is a prescription medicine undamaged.
Solution (D5LRS) Parenteral fluid Potassium 4 mmol used to treat the symptoms of [conditions]. Lactated Ringers in  Caution must be exercised in the administration of parenteral
Electrolyte Calcium 1.4 mmol 5% Dextrose may be used alone or with other medications. fluids, especially those containing sodium ions to patients
Nutrient Chloride 109 mmol receiving corticosteroids or corticotrophin.
replenisher Lactate 28 mmol Effects:  Solution containing acetate should be used with caution as
Osmolality 406 mOsm abdominal pain, swelling of the face, arms, hands, lower legs, excess administration may result in metabolic alkalosis.
or feet, blurry vision, body aches, chills, confusion, cough,  Solution containing dextrose should be used with caution in
little or no urination, dizziness, lightheadedness, dry mouth, patients with known subclinical or overt diabetes mellitus.
ear pain, fever, headache, increased thirst or urination,  Discard unused portion.
irregular or rapid heartbeats, loss of appetite, loss of voice,  In very low birth weight infants, excessive or rapid
muscle pain or cramps, nausea, vomiting, nervousness, tingling administration of dextrose injection may result in increased
and numbness in the hands, feet, or lips, pale skin, pounding in serum osmolality and possible intracerebral hemorrhage.
the ears, rapid weight gain, runny or stuffy nose, sneezing, sore  Properly label the IV Fluid
throat, sweating, difficulty breathing, unusual bleeding or
 Observe aseptic technique when changing IV fluid
bruising, tiredness, weakness, weight gain or loss, chest pain,
flushed or dry skin, fruity breath odor, increased hunger, and
unexplained weight loss.
Nursing Care Plans

NCP 1

ASSESSMENT EXPLANATION OBJECTIVES NURSING RATIONALE EVALUATION

OF THE INTERVENTIONS
PROBLEM

Subjective: The patient was STO: Dx: STO:

hospitalized
Patient verbalized, because she had Within 30 minutes of effective a) Assessed by  Assessing level, location, severity, (Goal Met)
“masakit po ung nursing interventions, the patient palliation, and characteristics of pain
undergone left
naoperahan sa bandang will be able to: location/radiation, determines the patient’s capability Within 45 minutes of effective
salpingectomy to comply with other interventions.
kanan ng aking tiyan severity, duration and nursing interventions, the patient:
because of ectopic
tapos hindi po ako pregnancy. characteristics of pain
a) report relief of pain from a) reported relief of pain from
masyadong nakakatulog experienced by the 6/10 to
6/10 to
dahil sa sakit,” and rates Salpingectomy is client and her ability
pain as 6/10 with 0 as the surgical b) demonstrate use of: to perform activities b) demonstrated use of:
the lowest and 10 as the removal of one  relaxation of daily living.  relaxation skills
highest level of pain. (unilateral) or both skills (breathing
(bilateral) fallopian (breathing b) Monitored and techniques)
techniques)  To establish baseline data serving  diversional
tubes to treat recorded vital signs. as comparison from previous
 diversional activities (listening
ectopic pregnancy. measurements thus determine any
Objective: activities to music, watching
Stitches on the improvements or further a movie, and
(listening to
 Grimacing incision site music, deterioration of the client’s playing games).
explains the watching a condition. c) able to sleep better than
 Guarding patient's movie, and before.
behavior abdominal pain. playing c) Reviewed patient’s
games).  To check if there are doctor’s order
chart related to managing pain and
 Limited LTO:
c. able to sleep better contraindications to certain
movements
than before. medications. (Goal Met)
SOURCE/S:
 Presence of Tx:
abdominal Pietrangelo, A., LTO: Within 72 hours of effective
rigidity (2018, September a) Provided comfort nursing interventions, the patient:
Within 72 hours of effective  Providing comfort to the patient
16). measures such as helps the recover quicker and have
nursing interventions, the patient a) understood the plan of care
Salpingectomy: room ventilation, better health outcomes.
What to Expect. will: privacy, and noise
Nursing Diagnosis: b) enumerated and stated the
Healthline. purpose of each
a) understand the plan of care
Physical discomfort Retrieved from through enumeration, minimization. management strategy.
related to left https://www.health explanation, and  To help with relieving pain.
salpingectomy line.com/health/sal demonstration b) Demonstrated deep c) reported pain reduction
from 6/10 to 3/10.
secondary to ectopic pingectomy breathing techniques.
b) enumerate and state the
pregnancy as evidenced purpose of each A good pace is 4-5
by acute left lower management strategy. seconds per inhale and
quadrant pain. 4-5 seconds per
c) report pain reduction from exhale. On the exhale,
6/10 to 3/10. empty your lungs
completely.

c) Provided proper
positioning (side
lying) with pillow to  To relieve pressure on the incision
support head. site and to relax the patient.

d) Tramadol, Celecoxib,
Ketorolac, and  To provide pharmacologic pain
Mefenamic given as management.
ordered.

Edx:

a) Educate the plan of

care to the patient
such as managing pain
 For patient compliance and
and complying in cooperation.
pharmaceutical
intervention

b) Advised to report
promptly any
untoward feelings and
concerns.  Verbalizing untoward feelings and
concerns helps to improve patient’s
condition as soon as possible.
c) Encouraged the use of
relaxation technique
(such as deep
 breathing and  Relaxation technique may decrease
imagery) and the pain perception by interrupting
diversional acts (such the conduction of nerve pain
as listening to music impulse.
and talking to a family
member)

d) Instructed to report if
pain persist.  To change pain intervention.

e) Educated the patient

that it is normal to feel
pain about the stitches.  To let the patient know what to
And it will take while expect regarding her condition.
to heal.

NCP 2

ASSESSMENT EXPLANATION OF OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

THE PROBLEM

Subjective: Water is a critical element STO: Dx: STO: (Goal Met)

of the body, and keeping
Patient verbalized “mas the body adequately Within 2-3 hours of effective a) Assess for possible  To determine or identify Within 2-3 hours of effective
less ang water intake ko hydrated is a must to nursing intervention, the patient conditions or processes reasoning or factors that nursing intervention, the patient:
ngayon than usual”. allow the body to will: that may lead to fluid affect the low fluid
deficit. intake. a) was able to identify that
function. The inability to
a) verbalize awareness of her less fluid intake can
drink adequately is a causative factors and
b) Assessed skin and oral  To assess other signs of cause her dehydration.
Objective: potential cause of behaviors’ essential to
dehydration, whether it is correct fluid deficit. mucous membranes and dehydration.
- poor skin turgor (2.5 the lack of availability of capillary refill.
seconds) water, intense nausea with b) explain measures that
can be taken to treat or c) Checked vital signs (BP b) explained measures that
- dry mouth and skin or without vomiting, or
prevent fluid volume can be taken to treat or
- Dark-yellow urine the lack of strength to and SPO2)
loss.  To determine if there are prevent fluid volume loss.
-Vaginal spotting drink. This coupled with changes in the level of
routine or extraordinary fluid volume
water losses can
VS: compound the degree of Tx:
BP=90/60 mmHg dehydration.
(minimum normal) a) Monitored patient’s vital
In sufficient SPO2=90% signs including her
 To monitor dehydration
weight daily.
since it’s a factor in
LTO: loosing weight.

Nursing Diagnosis: Within 24-72 hours of effective

nursing intervention, the patient b) Monitored for circulatory  To ensure adequate LTO: (Goal partially met)
Fluid Volume Deficit will: blood volume through hydration.
Within 24-72 hours of effective
related to active blood input and output.
a) re-establish a nursing intervention, the patient:
loss secondary to left
functional body fluid
salpingectomy as volume and a balance c) Provided high water a) slightly balanced input and
 To supplement fluid to
manifested by low blood input and output content foods (e.g., output.
prevent edema from
pressure, pallor, and statues flavored gelatin, frozen excessive oral salts and
vaginal spotting. juice bars, sports drink, intravenous hydration
watermelon, coconut therapy.
b) patient must exhibit
juice), porridge, low
moist mucous
sodium diet. b) exhibited improved
membranes, good skin
turgor, and adequate mucous membranes; poor
d) Provided short-term skin turgor (2.5 seconds),
capillary refill
oxygen therapy (nasal mouth and skin, capillary
(maximum 2 secs).
cannula for 15 minutes) refill of 3 seconds.
as ordered.  To increase the amount of
c) demonstrate adequate oxygen in the lungs.
hydration as evidenced
e) Administered D5LRS as
by increased fluid c) maintained an increased
ordered.
intake. fluid intake (at least 7
 To aid in hydration.
glasses a day)
d) have a urine output Edx:
more than 250 mL/day;
specific gravity of a) Encouraged patient to
1.010 -1.025, light increase fluid intake and
yellow instruct significant other  To provide alternative d) had a urine output within
to provide appealing appealing liquids to the
normal range (315mL for
liquids to the patient. patient.
e) improved BP (average 3 times a day), urine
normal 120/80); SPO2 specific gravity; 1.030,
(95%-100%) b) Advised patient yellow urine.
significant others or care
 giver to assist with  To meet prescribed intake
f) show no pallor. feeding or in fluid intake, independently because e) had a vital sign of
as necessary. patient may be weak to BP=110/70 mmHg;
rehydrate independently. SPO2=98%.
c) Emphasized the
relevance of maintaining  To increase the patient’s f) had impoved pallor.
proper nutrition and knowledge level to assist
hydration. in preventing and
managing the problem.

 To promote interest in
d) Emphasized importance
drinking and reduce
of oral hygiene.
discomfort of dry mucous
membranes.

NCP 3
EXPLANATION
NURSING
ASSESSMENT OF THE OBJECTIVES RATIONALE EVALUATION
INTERVENTIONS
PROBLEM
Subjective: The patient had STO: Dx: STO:
undergone left
“Nanghihina ako tapos salpingectomy. The After 30 minutes to 1 a) Assessed site of impaired  Redness, swelling, pain, (Goal met)
ang sakit ng na- hour of effective nursing tissue integrity and its burning, and itching are
operahan sa akin” incision can result in an interventions, the patient condition. indications of After 30 minutes to 1 hour of
infection, since sutures will be able to understand inflammation and the effective nursing
introduce foreign the signs and symptoms body’s immune system interventions, the patient
materials into the body of infection. response to localized understood the signs and
Objective:
and create additional tissue trauma or symptoms of infection.
Neutrophils: 79%
wounds by puncturing the impaired tissue
skin repeatedly, by that integrity.
patient is susceptible to
Nursing Diagnosis: infection. Bacteria are the LTO:
cause of infected stitches LTO:
Risk for Infection  Systematic inspection
because broken skin After 8 hours of nursing
related to impaired b) Monitored site of impaired can identify impending
cannot protect the body interventions, the patient (Goal met)
skin & tissue integrity tissue integrity for color problems early.
from germs as well as will be able to
secondary to left changes, odor of secretions, After 8 hours of nursing
intact skin can. demonstrate
salpingectomy as redness, swelling, warmth, interventions, the patient was
understanding of plan to
manifested by an pain, or other signs of able to demonstrate
heal tissue and prevent
increased in infection. understanding of plan to heal
injury.
neutrophils - 79%  Fever is a systemic tissue and prevent injury.
(neutrophilia). c) Monitored temperature. manifestation of
inflammation and may
indicate the presence of
infection.

Tx:  Promotes wound

healing.
a) Promoted enough rest.
 Nutrition plays an
important role in
b) Encourage increase intake of maintaining an intact
protein, vitamin B, Vitamin skin and in promoting
C, and iron except grapefruit, wound healing.
Grapefruit interacts with
antibiotics and tramadol

 Reduces the risk of

c) Applied sterile dressing infection in impaired
 during wound care. tissue integrity. The
dressing replaces the
protective function of
the injured tissue during
the healing process.

 To avoid circulation of
microorganisms that can
d) Provided clean, well- access entry in the site
ventilated environment of surgery.
(turning off central air-
conditioning and opening
window for good ventilation;
room with negative air
pressure, etc.).
 Provide a positive
nitrogen balance, which
Edx: aids in healing and
contributes to general
a) Educated patient about good health.
proper nutrition (e.g., Malnutrition weakens
controlled glucose intake) the immune system;
and hydration. elevated serum glucose
levels provide growth
media for pathogens.

 Early assessment and

intervention help
prevent the development
of serious problems.

b) Educated patient about skin

 Accurate information
and wound assessment, and
increases the patient’s
ways to monitor for signs
 and symptoms of infection, ability to manage
complications, and healing. therapy independently
and reduce the risk for
c) Instructed patient, the proper infection as this site is a
care of the wound including first-line defense.
constant hand washing,
wound cleansing, and  Establishing
dressing changes. comparative baseline
will allow for early
intervention (e.g.,
antimicrobial therapy,
wound irrigation or
d) Instructed client/SO in packing).
routine inspection of incision
or wound and to report
changes in wound indicative
of failure to heal (e.g.,
deepening wound, local or  Premature
systemic fever, exudates) discontinuation of
and/or voicing out untoward treatment when client
feelings and concerns begins to feel well may
result in return of
infection and
potentiation of drug-
e) Emphasize the necessity of
resistant strains.
taking antivirals or
antibiotics, as directed (e.g.,
dosage and length of
therapy).