Ectopic Pregnancy

TABLE OF CONTENTS
TABLE OF CONTENTS 1
INTRODUCTION 3
CHAPTER I: DEMOGRAPHIC PROFILE: 5
CHAPTER II: CLINICAL HISTORY 6
History of Present Illness 8
Past Medical History (previous illness and hospitalizations) 8
Genogram with Family History (narrative form) 8
Social Data 8
Lifestyle 8
Psychological Data 8
Patterns of Health Care / Health Screening 8
Developmental History 9
Erickson's Stages of Psychosocial Development 9
The Formal Operational Stage 9
Havighurst's Developmental Task Theory 9
Obstetric and Gynecologic History (for female clients only) 9
CHAPTER III: PHYSICAL ASSESSMENT 10
CHAPTER IV: NORMAL ANATOMY AND PHYSIOLOGY 13
The Female Reproductive System 14
Ovaries 15
Uterus 16
Fallopian Tubes 17
Vagina 18
Vulva 18
Mammary Glands 18
CHAPTER V: PATHOPHYSIOLOGY 21
CHAPTER VI: LABORATORY/DIAGNOSTIC EXAMINATIONS 24
ULTRASOUND 24

1
 HEMATOLOGY 25
COMPLETE BLOOD COUNT 25
DIFFERENTIAL COUNT 26
RED CELL INDICES 27
CHEMISTRY 27
URINALYSIS 28
CHAPTER VII: MEDICAL AND SURGICAL MANAGEMENT 31
CHAPTER VIII: DRUG STUDY 34
Dextrose 5% in Lactated Ringer‘s (D5LR) 35
Mifepristone 36
Methotrexate 37
CHAPTER IX: NURSING CARE PLAN/PROCESS 38
CHAPTER X: CURRENT TRENDS/INNOVATIONS/CLINICAL MANAGEMENT 54
CHAPTER XI: REFERENCES 56

2
 INTRODUCTION

In an ectopic pregnancy which is the term ectopic is derived from the Greek word ektopos,
meaning out of place, the gestation grows and draws its blood supply from the site of
abnormal implantation. Ectopic pregnancy is a known complication of pregnancy that can
carry a high rate of morbidity and mortality when not recognized and treated promptly.
Providers must maintain a high index of suspicion for an ectopic in their pregnant patients
as they may present with pain, vaginal bleeding, or more vague complaints such as
nausea and vomiting. Fertilization and embryo implantation involve an interplay of
chemical, hormonal, and anatomical interactions, and conditions to allow for a viable
intrauterine pregnancy. Much of this system is outside the scope of this article but the
most relevant anatomical components to our discussion on the ovaries, fallopian tubes,
uterus, egg, and sperm. Ovaries are the female reproductive organs located in both lateral
aspects of the uterus in the lower pelvic region. Ovaries serve multiple functions, one of
which is to release an egg each month for potential fertilization. The fallopian tubes are
tubular structures that serve as a conduit to allow the transport of the female egg from the
ovaries to the uterus. When sperm is introduced, it will fertilize the egg forming an embryo.
The embryo will then implant into endometrial tissue within the uterus. An ectopic
pregnancy occurs when this fetal tissue implants somewhere outside of the uterus or
attaches to an abnormal or scarred portion of the uterus. (see the images below).

3
 Ectopic pregnancy refers to the implantation of a fertilized egg in a location outside
of the uterine cavity, including the fallopian tubes (approximately 97.7%), cervix, ovary,
cornual region of the uterus, and abdominal cavity. Of tubal pregnancies, the ampulla is
the most common site of implantation (80%), followed by the isthmus (12%), fimbria (5%),
cornua (2%), and interstitia (2-3%). (See the image below.)

Patients with risk factors for ectopic pregnancy should be educated regarding their
risk of having an ectopic pregnancy. Women who are being discharged with a pregnancy
of an unknown location should be educated regarding the possibility of ectopic pregnancy
and their need for urgent follow-up.

4
CHAPTER I: DEMOGRAPHIC PROFILE:
a. Name: Melissa Danna Salazar (MDS)

b. Address: N/A

c. Age: 35

d. Status: Married

e. Occupation: Cosmetic saleswoman (Online Seller)

f. Educational Attainment: N/A

g. Chief Complaint: Heavy Prolonged Menstruation

h. Admitting Diagnosis: Abnormal Prolonged Uterine Bleeding

i. Present Diagnosis: Ectopic Pregnancy

j. Date and Time of Admission: March 1, 2022 3PM

k. Attending Doctor: Dra. Santos

5
CHAPTER II: CLINICAL HISTORY
History of Present Illness

Five days prior to admission, the patient experience unusual heavy prolonged
menstruation. Her last normal menstruation period was on the 7th of January 2022. The
current menstrual flow started on the 20th of February 2022 and was prolonged until the
date of the first consultation at the clinic. The patient had initially taken treatment from
another clinic to “increase” the flow of her menstruation when she experienced scanty
flow during the first three days of this cycle. Upon treatment, her menstruation became
heavy and prolonged. Hence, she sought a second opinion.

Past Medical History (previous illness and hospitalizations)

The patient had her first menstrual period at 15 years old. She has an Asthma
since she was 3 years old and completed her Flu vaccine last January 2022. In 2016, she
occurred a kidney infection treated with ampicillin and developed a generalized rash. The
patient had no known food allergies yet was allergic to dust mites.

6
Genogram with Family History (narrative form)

Mrs. MDS is the only daughter of the Family S. Her father died at the age of 43 in
a car accident while her mother had varicose veins, headache, and hypertension and died
at the age of 67 due to stroke. On the other hand, her elder brother has a high blood
pressure otherwise well at the age of 56 while her other brother is also well except for
mild arthritis at the age of 51.

Social Data

The patient Mrs. MDS never tried illegal drugs or alternative therapies. At the age
of 18, she consumes one pack of cigarettes per day. Also, she rarely drinks wine with no
history of abuse.

Lifestyle

The patient's diet is low in calcium with little milk or cheese while following a low
salt diet. She frequently eats mid-morning and evening snacks that are high in fat.
Generally, her sleep is good and on an average of 7 hours a day. In terms of exercise,
she stated that she has no time.

7
Psychological Data

Mrs. MDS, a Cosmetic saleswoman lives with her husband which recently moved
to a small apartment with a small store on it for 15 years of being an online seller. She
likes her job but feels stressed and sometimes experiences leg pain.

Patterns of Health Care / Health Screening

In 2012, the patient had her last pap smear which appeared normal. Also normal
in her mammogram last 2013. She does breast self-exams every month.

Developmental History

Erickson's Stages of Psychosocial Development

Intimacy vs. Isolation is the 6th stage of Erik Erikson’s psychosocial development.
This stage is about giving importance to building an intimate and loving relationship with
other people. Achieving success at this stage could lead to fulfilling relationships.
However, failure at this stage could lead to a person’s feeling of loneliness and isolation.
People who are between the ages of 19 to 40 are usually the ones who take the stage.

In the case study, the patient is a 35-year-old female married yet has a history of
smoking which is evidence of this theory that depicts her loneliness and isolation. In
connection to her social history, the patient has a history of smoking 1 pack of cigarettes
per day at the age of 18. The reason why the patient has been smoking a lot could be
assumed due to the loneliness and isolation brought by some uncertainties. In addition,
one of the precipitating factors of Heavy Prolonged Menstruation is smoking which may
lead to fatigue and nausea as symptoms that leads her life at risk.

8
The Formal Operational Stage

Piaget's theory involves a drastic increase in a person's logic. This includes his/her
ability to use deductive reasoning as well as comprehension of abstract ideas. Because
of this, people become more analytical, which applies to their daily lives as they see things
in the eyes of logic and science. For this reason, people can plan for the future and reason
about hypothetical situations. Since the client is already married, she is also the sole
carrier of her family together with his husband. This means that she is responsible for
looking after her family through her dedication to being a store online seller for 15 years
already. Planning about the future with or without a companion is one of the instances
that she encounters in her daily life considering Piaget's theory. This might be strenuous
to the client as she strives to provide for her family and plan for their future.

Havighurst's Developmental Task Theory

Robert Havighurst stated that learning is a basic yet very important task for all
people and that it continues through a life span. For Havighurst, growth, and development
occurs in six stages. The case of Patient MDS falls under the fourth developmental task
which is the Developmental Task of Early Adulthood. The tasks in this stage are mainly
about living with a married partner, building a complete family, and raising children
together with the partner. Nonetheless, Patient MDS and her husband faced health-
related challenges yet continued to strive for their family growth and future.

Obstetric and Gynecologic History (for female clients only)

Mrs. MDS is on her G3 T0 P2 A0 L0 or three pregnancies with two live births and no
abortus.

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 CHAPTER III: PHYSICAL ASSESSMENT

Body Part Method Use Findings Interpretation

General
Inspection of BMI Has gained about 10 lb in the Normal
(Anthropometric) past 4 years, no fatigue.

Skin
Inspection and Palpation No rashes or other changes. Normal

Head
Inspection and Palpation No abnormalities. Normal

Eyes
Inspection/Assessment Reading glasses for 5 years, Normal
(Snellen Chart)
Last checked 1 year ago. No

double or blurry vision.

Ears
Inspection/Assessment Hearing is good. No tinnitus, Normal
(Otoscope) vertigo, infections.

Nose
Inspection and Palpation Sinuses: Occasional mild cold. Normal
No hay fever, sinus trouble.

Mouth and Throat

Inspection and Palpation Last to dentist 2 years ago. Normal
Occasional canker sore.

Neck
Inspection and Palpation No lumps, goiter, pain. Normal

Breasts
Inspection and Palpation No lumps, pain, discharge. Normal

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Respiratory
Inspection, Palpation, No cough, wheezing, shortness Normal
Percussion and Auscultation of breath, pneumonia,
tuberculosis.

Cardiac
Inspection, Palpation, No known heart disease. Normal
Percussion and Auscultation
No orthopnea, chest pain,
palpitations.

Gastrointestinal
Inspection, Palpation, Appetite good; no reflux. Bowel Normal
Percussion and Auscultation movement about once daily
though sometimes has hard
stools for 2-3 days when
especially tense; no diarrhea or
bleeding. No pain, jaundice,
gallbladder or liver trouble.

Urinary
Inspection and Palpation No frequency, dysuria, Normal
hematuria or flank pain.

Musculoskeletal
Inspection , Palpation and Mild aching low back pain Normal
Manipulation often after a long day’s work;
no radiation down legs; used
to do back exercises, but not
now. No other joint pain.

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Peripheral Vascular
Inspection/Assessment (Ankle- Varicose veins appeared in both Normal
brachial pressure index) legs during first pregnancy. Has
had swollen ankles after
prolonged standing for 10 years;
no history of phlebitis.

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 CHAPTER IV: NORMAL ANATOMY AND
PHYSIOLOGY
The process by which organisms produce more organisms that are similar to
themselves is known as reproduction. The male and female gonads, namely the testes
and ovaries, produce sperm and ova as well as the hormones required for the proper
development, maintenance, and functioning of the reproductive organs as well as other
organs and tissues. Each sex has a different reproductive system than the other. They
have different shapes and structures, but they are both designed to produce, nourish, and
transport the egg or sperm (Vipula & Atula, 2018, p. 522). The following are the functions
of the reproductive system regarding the production of offspring (SEER Training Modules,
n.d):

- To produce egg and sperm cells. The organs of the reproductive system
produce sex cells: the former being produced by females and the latter produced
by males.
- To transport and sustain these cells. After ejaculation or artificial insemination
in the female reproductive tract, the sperm is delivered to the fertilization site of the
females.
- To nurture developing offspring. In the uterus, the fetus is nourished, and after
birth, it is given milk.
- To produce hormones. The reproductive system produces hormones that control
the development of gender-specific body structures.

The reproductive system in both sexes consists of primary sex organs, the gonads
(ovaries in females and testes in males), which produce gametes (ovum in females and
sperms in males), as well as several glands that produce secretions to carry and nourish
the gametes, and a system of tubes, the genital ducts, which transport gametes to the
outside of the body. Internal genitalia is made up of all of the reproductive or genital

13
system's components. External genitalia is the parts of the genital system that allow
sperm to be deposited inside the female genital system during copulation (Vipula & Atula,
2018, p. 523). It is important to note that this paper will focus on the female reproductive
system as it pertains to the health concern of the client.

The Female Reproductive System

The reproductive system of females is more complicated than that of males. It

produces ova (egg cells), nourishes, carries, and protects the developing embryo, and
after birth, it nurses the newborn. The female reproductive system is comprised of
structures such as the ovary, uterine tubes, uterus, vagina, vulva, and mammary glands
(Vipula & Atula, 2018, p. 528).

Figure 1. Female Reproductive System

Note. Sourced from Vipula & Atula (2018, p. 530)

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Ovaries

The ovaries, female gonads, reside in the pelvic part of the abdomen on either side
of the uterus. The ovaries are responsible for the following functions: producing ova,
estrogen and progesterone (female sex hormones), the menstrual cycle (a series of cyclic
changes to the endometrium or uterine lining begins), and the ovarian cycle (fluctuating
levels of ovarian hormones in the blood that causes the menstrual cycle). The ovaries
have ovarian follicles in all stages of development, the end product of which is the ovum
(Vipula & Atula, 2018, p. 523).

The ovarian cycle is the series of changes that occur in the ovary during the
menstrual cycle that cause the maturation of a follicle, ovulation, and development of
the corpus luteum. It starts with the follicular phase, the phase of the menstrual cycle
during which the follicles mature, which ends with ovulation. Ovulation is the phase in
which a mature ovarian follicle ruptures and discharges an ovum (unfertilized female
gamete). Following ovulation, the luteal phase begins with the formation of the corpus
luteum and ends in either pregnancy or luteolysis, the structural demise of the corpus
luteum (Ovarian Cycle, 2018).

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 Figure 2. Transverse Section of Ovary

Note. Sourced from Vipula & Atula (2018, p. 529)

Uterus

Located in the pelvic cavity in front of the rectum and behind the urinary bladder,
the uterus is a hollow, pear-shaped organ that functions to nourish and house a fertilized
egg until the fetus, or offspring, is ready to be delivered (Britannica, 2022). It has thick
muscular walls and a small central uterine cavity. The fallopian tubes connect to it on both
sides, and below it opens into the vagina through the cervix. The endometrium is the inner
lining of the uterus, and it contains a large number of tubular glands that proliferate
cyclically (Vipula & Atula, 2018, p. 532).

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 The uterus has four major regions, namely, the fundus, the body, the isthmus, and
the cervix (Britannica, 2022). The fundus is the upper wider portion, followed by the
tapered middle part called the body which ends at the cervix, the isthmus is the constricted
region between the body and cervix. The lower narrow part of the uterus that leads into
the vaginal canal is known as the cervix. It is crossed by a canal that opens above into
the uterine cavity through an orifice called internal os and below into the vagina through
an orifice called external os (Vipula & Atula, 2018, p. 532).

During menstruation, the endometrium layer is shed and then reconstructed.

During the menstrual cycle, the uterus undergoes cyclic changes called the uterine cycle.
The uterine cycle starts with the building up of the endometrial lining in preparation for the
implantation of the fertilized egg, without fertilization the endometrium breaks down and
menstruation occurs (Vipula & Atula, 2018, p. 532).

Fallopian Tubes

The fallopian tubes, otherwise called the oviducts or uterine tubes, are two tubes
that are located on each side of the uterus, hollow from the inside and open on their
respective sides, and their function is to transport the ova from the ovary to the uterus.
The tube's outer end widens into an infundibulum before ending in multiple fimbriae. The
fimbrial and tubular epithelia are ciliated in nature to transport the ovum from the ovary to
the uterus via ciliary movement. The tubes receive the developing ovum from the ovary
and are divided into three parts: infundibulum, ampulla, and isthmus. The infundibulum
end is located beside the ovary and has fimbria that sweep the developing ovum into the
tube. The ampulla is the middle part of the fallopian tube, it contains smooth muscle and
cilia that move the egg (fertilized state of the ovum) along the tube. The unfertilized ovum
degenerates in the ampulla while the egg resumes its journey to the uterus. Finally, the
isthmus is the end of the fallopian tube which opens into the uterus (Vipula & Atula, 2018,
p. 531).

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Vagina

The vagina is a canal that opens externally to the vulva. It is a muscular tube from
the uterus to the outside of the body, it secretes a lubricant fluid, and is normally collapsed
but can enlarge to accommodate an erect penis or birth. Its functions are to receive sperm
from sexual intercourse, channel menstrual flow out of the body, and as a birth canal to
deliver babies during childbirth (Vipula & Atula, 2018, p. 532).

Vulva

The vulva is the external genitalia which includes the mons pubis, labia majora,
labia minora, and clitoris. The mons pubis is a mound of fatty tissue at the junction of
thighs and torso and is covered with pubic hair during puberty. The labia majora are skin
folds that form the vulva outer border and also is covered by pubic hair during puberty.
The labia minora are the inner, smaller skin folds that surround the urethral and vaginal
orifice. The labia minora merge anteriorly to form the prepuce of the clitoris, a small
erectile structure that becomes engorged with blood during sexual excitement (Vipula &
Atula, 2018, p. 533). Its main functions are to protect the internal parts of the female
reproductive system (labia majora and minora), play a role in sexual arousal and
stimulation (clitoris), facilitate sex by providing lubrication (Bartholin’s glands), and
cushioning (mons pubis) (Seladi-Schulman, 2020).

Mammary Glands

The mammary glands are compound saccular glands modified from sweat glands.
These glands are usually inactive and are stimulated by pregnancy to secrete milk to
nourish a newborn. These glands have 15 to 20 lobes of glandular tissue that contain
lactiferous ducts that converge toward the nipple. The mammary glands are in the

18
breasts, overlie pectoral muscles, are attached to them via fascia, and connected to the
skin by suspensory ligaments of the breast. These glands are modified sweat glands that
produce and secrete milk during the lactation process to feed newborns, which are
stimulated by high oestrogen and progesterone levels during pregnancy. The
enlargement of the breasts during pregnancy is due to the hormones stimulating the ducts
and glands in the breasts (Vipula & Atula, 2018, p. 533).

Figure 3. Mammary Glands

Note. Sourced from Vipula & Atula (2018, p. 533)

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20
 CHAPTER V: PATHOPHYSIOLOGY
The pathophysiology illustrates the unique process by which the client acquired
the obstetric complication in question. Therefore, this chapter includes the predisposing
factors, the risk factors that make a person susceptible to developing a disease. Also
including precipitating factors, which are factors that create the onset of the disease or
initiating the disease (Biology Online, 2019). Shown below is the pathophysiology of the
obstetric complication experienced by the client in this case study.

21
22
**References of the pathophysiology diagram includes: (Sivalingam et al., 2012) (Dulay,
2020) (DeCherney et al., 2022)

23
 CHAPTER VI:
LABORATORY/DIAGNOSTIC
EXAMINATIONS
ULTRASOUND

Ultrasound also called sonography is a medical diagnostic imaging technology

that uses sound waves to create an image of organs, tissues, the fetus inside of a
mother’s womb and other structures in the body . It is used for observing the baby’s
growth, development and overall health. It is examined and interpreted to identify clinical
indications of a high-risk pregnancy through assessing images of the mother’s uterus,
ovaries and of the fetus inside the womb.

Vaginal examination excluded local causes of vaginal bleeding. On digital

examination there was tenderness at the posterior fornix. Urine pregnancy test was

24
positive. This was complemented by an empty uterine cavity with the presence of fluid in
the pouch of Douglas. Blood noted on TVS in the Pouch of Douglas.

HEMATOLOGY

Hematology includes the study of blood wherein different laboratory blood tests
are done to determine a client’s blood condition. Complete blood count is a major factor
being analyzed in laboratory examinations since it is an effective tool utilized in detecting
any blood-related complications such as anemia.

TEST RESULT REFERENCE INTERPRETATION

VALUE

Prothrombin 12.5 12 - 14.5 secs Normal

Time

PT Patient 12.5 12 - 14.5 secs Normal

PT Control 1.00 0.8 - 1.3 Normal

PT INR 100 70 - 100% Normal

% Activity

COMPLETE BLOOD COUNT

Complete blood count is a group of tests that evaluate the cells that circulate in
blood, including the red blood cells, white blood cells, and platelets. It is done to check
for any symptoms the patient may be experiencing, such as fatigue, exhaustion, or
bruising. This test is important for pregnant women to make the pregnancy safer and
check the baby’s health. Also help with the diagnosis of health problems such as anemia,
clotting disorders and infections.

TEST RESULT REFERENCE INTERPRETATION

VALUE

Hemoglobin 119 120 - 160g/L Abnormal. Can

indicate anemia

25
 due to a variety of
conditions such
as blood loss and
iron-deficiency
that causes
fatigue.

Hematocrit 1.35 0.37 - 0.43L/L Abnormal. Can

indicate fluid
deficiency.

WBC Count 11 4.0 - 10 x 109/L Abnormal. Can

indicate infection
or inflammation.

RBC Count 4.4 4.0 - 5.4 x 1012/L Normal

DIFFERENTIAL COUNT

Differential count measures the number of different types of white blood cells in
the blood and checks for irregular cells. This helps with indication of infection,
inflammation and other problems.

TEST RESULT REFERENCE INTERPRETATION

VALUE

Segmenters 0.70 0.55 - 0.65 Abnormal. Can

indicate bacterial
infection.

Lymphocytes 0.21 0.25 - 0.35 Abnormal. Can

indicate possible
infection.
Lymphocytes
decrease during
pregnancy.

Eosinophils 0.02 0.02 - 0.04 Normal

Basophils 0.00 0.00 - 0.01 Normal

Monocytes 0.06 0.03 - 0.06 Normal

26
RED CELL INDICES

Red cell Indices are calculations that provide information on the physical
characteristics of the red blood cells. This test is done to diagnose the cause of anemia
which indicates that there are too few red blood cells in the blood.

TEST RESULT REFERENCE INTERPRETATION

VALUE

MCV 83.5 80 - 96 Normal

MCH 27.8 27 - 31 Normal

MCHC 333 320 - 360 Normal

RDW 13.3 11 - 17 Normal

APTT 31.2 24 - 36 secs Normal

APTT Control 31.1 24 - 36 secs Normal

APTT Ratio 1.01

Blood Type O+ The blood type is

O+

CHEMISTRY

This test is done to a sample of blood to measure the amount of certain substances
in the body and it gives important information about how well a person’s organs are
working.

TEST RESULT REFERENCE INTERPRETATION

VALUE

Potassium, 3.4 3.5 - 5.1 mm ol/L Abnormal. The

Serum result is slightly
low.

Sodium, Serum 135 136 - 145 mm Abnormal. The

ol/L result is slightly
low.

27
 Creatinine, 57.5 53 - 97 mm ol/L Normal
Serum

Blood Urea 2.3 3.0 - 9.22 mm Abnormal. Can

Nitrogen ol/L be caused by low
protein in the diet
and it can occur
normally in
pregnancy. Low
BUN can indicate
kidney disease.

URINALYSIS

Urinalysis is an examination of a patient’s urine that involves checking the

appearance, content and concentration to detect abnormal metabolism, bacteria, or
infection. It examines the bladder or kidney infections, diabetes, dehydration, and
Preeclampsia as it assesses the levels of sugar, proteins, ketones, and bacteria. This
examination of pregnancy is important to observe bladder infections and to assess the
screening of levels of sugars and dehydration.

TEST RESULT REFERENCE INTERPRETATION

VALUE

Color Yellow Normal. The

result indicates
that the patient is
hydrated and
healthy.

Character Hazy Abnormal. Can

indicate medical
conditions such
as infection,
kidney stones
and other health
problems.

Specific Gravity 1.008 Normal. The

result indicates

28
 that there is no
problem in
kidneys nor
diabetic.

pH 7.0 The pH level is

neutral.

Albumin Negative Normal. The

result indicates
that there is no
kidney
complication.

Sugar Negative Normal. The

glucose levels are
normal.

WBC 0-5 Normal. The

result indicates
it is free from
infection,
inflammation
and
contamination.

RBC 6 4 Abnormal. Can

indicate infection
or kidney stones.

Bacteria 1+ Abnormal. Can

indicate urinary
tract infection.

Epithelial Cells 1+ Normal. It is

normal to have
one to five
epithelial cells.
Can indicate it is
free from infection
or kidney
disease.

Mucus Threads Trace casts Abnormal.

Excess amount
of mucus

29
 indicates urinary
tract infection.

Amorphous Few Normal. The

Urates result indicates
that there is no
kidney
complication.

Calcium Excess amount

Oxalates in the urine
cause kidney
stones and
crystals to form
can lead to
kidney failure

Pregnancy Test POSITIVE The results

indicate that the
patient is
pregnant.

Crystals

30
 CHAPTER VII: MEDICAL AND
SURGICAL MANAGEMENT

03/01/22

1500H

Medical Regimen Rationale

Please admit to room to ward under the service To promptly provide the patient with essential
of Dra. Santos healthcare actions.

Secure consent for admission and management To obtain informed consent

Monitor I&O q shift and record; To prevent dehydration, fluid retention, and other
problems related to fluid imbalance

Instruct NPO To prevent nausea or vomiting to keep any food or

liquid from getting into the lungs as anesthesia
increases the chances of regurgitating

To hook D5LR 1L to run for 8 hours To replace water and electrolyte loss in patients
after significant blood loss.

Medications:

Give mifepristone 200 mg single dose To block the hormone progesterone

Monitor for severe pain and signs of shock To determine if there are changes in a patient's
health and if the given treatment is working.

Diagnostics:
To determine a patient's blood condition and to
CBC monitor or diagnose conditions such as anemia,
infection and clotting disorders.

BUN and Creatinine To assess for the kidney or renal function.

Lipid profile To determine the patient’s cholesterol level.

Urinalysis To detect and manage a wide range of disorders

found in the urine like urinary tract infections.

31
ABO blood typing To determine a patient's blood type and to prepare
for possible blood transfusion.

Transvaginal pelvic ultrasound To provide visualization of the female reproductive

system to diagnose ectopic pregnancy.

HCG blood test To determine if the patient is pregnant.

03/02/22

0800H

Surgical Preparation (Pre and Post) Rationale

Seen and examined To monitor the condition of the patient and promptly
provide the patient with essential healthcare
actions.

Medication:

May give single dose of Methotrexate 50 mg/m2 To treat ectopic pregnancy that blocks folic acid to
stop the embryo from growing.

Monitor HCG titer To determine the ability of the fetus to survive

outside the uterus.

Continue IVF To replace water and electrolyte loss in patients

after significant blood loss.

Monitor I and O and record To prevent dehydration, fluid retention, and other
problems related to fluid imbalance

Monitor VS q4H To assess and record vital signs deviated from

normal.

For possible surgery and laparoscopy To ready patient in surgical intervention to treat life
threatening complications

Follow up lab results To check for changes in lab results to determine if the
treatment is successful or failed.

Refer patient to Dr. Monis ( Surgery Department) To collaborate with a surgeon to improve provision
for co management of healthcare for patients.

Refer to any untoward signs and symptoms To immediately take an action for presence of
untoward signs and symptoms

32
03/03/22

0700H

Seen and examined by Dr. Monis To ensure that the patient is eligible to undergo the
● Maintain client in NPO surgery

Secure consent for laparoscopy and To obtain informed consent

salpingectomy

For blood typing and crossmatching To determine a patient's blood type and
compatibility to the donor’s blood to prepare for
possible blood transfusion.

Vital signs q4 and record To assess and record vital signs deviated from
normal.

For Cardio Pulmonary clearance To avoid complications during surgery as a result of

an underlying cardiac condition.

Repeat for CBC with platelet, BUN To determine a patient's blood condition and to
monitor kidney function.

For laparoscopy and salpingectomy at 7pm To treat life threatening complications by removing
damage or ruptured fallopian tubes.

Place client on Bed rest To let the patient rest

For 02 therapy at 2 LPM To prevent complications and treat hypoxemia

Monitor urine output at 30ml/hr To prevent dehydration, fluid retention, and other
problems related to fluid imbalance

Refer accordingly To notify and advise attending health practitioners

regarding the patient’s condition

33
 CHAPTER VIII: DRUG STUDY
Name of Drug Classification and Indication and Adverse Nursing
Mechanism of Action Contraindication effects/Side Responsibilities
effects

34
Dextrose 5% in Classification: Indication: The most - Do not administer
Lactated Ringer‘s -Hypertonic - This solution is common adverse unless the solution
(D5LR) -Electrolyte indicated for effects are is clear and
-Nonpyrogenic parental infection at the undamaged.
Dosage: 1L -Parental fluid replacement of injection site, - Monitor the
-Nutrient replenisher extracellular losses thrombophlebitis, patient's intake and
Frequency: Run of fluids and extravasation, and output and observe
for 8 hours Mechanism of Action: electrolytes, with or hypervolemia are if there is any sign
-Hypertonic solutions have without minimal all reactions that of hypervolemia or
Route of an effective osmolarity that carbohydrate might occur signs of fluid
Administration: is higher than that of body calories. because of the overload.
Intravenous (IV) fluids. By osmosis, the - Treatment for administration - Hypertonic
fluid is drawn into the shock technique. solutions should
vascular, resulting in an not be stopped
increase in vascular Contraindication: The common suddenly.
volume. It increases - Dextrose 5% in side effects of -Monitor vital signs
intravascular osmotic Lactated Ringer’s is D5LR include and report for any
pressure and provides contraindicated in itching, nausea or adverse reaction to
energy by providing fluid, patients with a vomiting. the solution.
electrolytes, and calories. known
hypersensitivity to
any of the
components.

35
Mifepristone Classification: Indication: The adverse - Confirm the
-Antiprogestins - To block a effects include doctor's order.
Dosage: 200mg -Cortisol receptor blockers hormone called fetal death, - Administer the
progesterone anaphylactic right drug at the
Frequency: Mechanism of Action: needed for reactions, and right time and
Single-dose - Stimulate uterine pregnancy to syncope. dosage. Explain
contractility: antiprogestin; continue. the significance
Route of also increases The side effects and purpose of the
Administration: prostaglandins by Contraindication: of Mifepristone medication to the
Per orem inhibiting prostaglandin - Contraindicated in include vaginal patient.
dehydrogenase patients with a bleeding, - If a
known abdominal and hypersensitivity
Absorption hypersensitivity to pelvic pain, response occurs,
Peak Plasma Time: 1-2 hr mifepristone in the weakness, stop using the
(single dose) past and dizziness, nausea, medication.
prostaglandins. vomiting, and - Record any
Distribution diarrhea. adverse effects
Protein Bound: >99% to and report to the
alpha-1-acid glycoprotein; physician.
96-99% (active
metabolites)

Metabolized to 3 active
metabolites, of which 2 are
the product of
demethylation, while a
third active metabolite
results from hydroxylation

Elimination
Half-life: 20 hr (single
dose)

Excretion: 90% feces

36
Methotrexate Classification: Indication: The adverse - Confirm the
- Antimetabolite or folic - This is indicated to effects include doctor's order.
Dosage: acid antagonist diagnose ectopic confusion and - Check for the lab
50mg/m2 pregnancy- that seizures. exams to
Mechanism of Action: blocks the folic acid determine if the
Frequency: to stop the embryo The side effects patient is eligible to
Single-dose - Inhibits dihydrofolic acid from growing, which include dizziness, take the
reductase; inhibits purine ends the pregnancy. headache, medication.
Route of and thymidylic acid nausea, and - Administer the
Administration: synthesis, which in turn Contraindication: vomiting. right drug at the
Intramuscular interferes with DNA - Contraindicated in right time and
Injection synthesis, repair, and patients with dosage. Explain
cellular replication; cell ruptured ectopic the significance
cycle-specific for S phase pregnancy and and purpose of the
of cycle hemodynamically medication to the
unstable. patient.
Distribution - Record any
Protein bound: 50% - Contraindicated in adverse effects
patients with a and report any
Metabolism known significant
Metabolized by liver and hypersensitivity to changes.
intracellularly methotrexate such
as allergic reaction.
Excretion: Urine and feces.

37
 CHAPTER IX: NURSING CARE
PLAN/PROCESS

Assessment Nursing Case Plan of Interventions Rationale Evaluation

Diagnosis Background Care

Objective Cues Fatigue The patient was Goal: INDEPENDENT After 24 hours of
related to admitted to nursing
(+) Fatigue dizziness and hospital on To be free of interventions, goal
weakness, March 1, 2022, signs of Secure consent To ensure trust partially met as
(+) Dizziness abdominal with heavy fatigue as for admission between the evidence by
and weakness pain and prolonged evidenced by and nurse and the patient not
vaginal menstruation as an improved management patient with exhibiting signs of
(+) Abdominal bleeding a chief sense of good fatigue.
Cramping secondary to complaint and energy. understanding
ectopic had signs of of the risks and However, more
(+) Vaginal pregnancy as fatigue, Objectives: options to be information is
bleeding evidenced by abdominal taken needed in order to
fatigue, cramping, and After 24 fully determine
HGB: 119 g/L hours client whether the goal
dizziness and vaginal bleeding
will report Assess client’s To identify the
weakness, which are signs and each objective
HCT: 1.35 L/L improved belief about what cause of fatigue
abdominal of an ectopic are fully attained.
sense of is causing the on the patient’s
cramping, pregnancy With this,
energy fatigue perspective
vaginal evaluation will be
bleeding, updated once data
hemoglobin After 24 is complete.
Monitor vital To assess and
level of 119 hours client
signs record vital
will no longer
g/L, and signs deviated
have signs of
hematocrit from normal.
fatigue
level of 1.35
L/L.
After 24
Identify presence Obtain
hours client
of important
will exhibit
physical/psychol information if
normalization
ogical conditions fatigue is a
of laboratory
result of an
and
underlying
diagnostic
condition or
results.
disease
process.

38
Determine the To determin if
presence/degree fatigue can be a
of sleep consequence,
disturbances and/or
exacerbated by,
sleep
deprivation

Monitor input and Ensure that the

output patient has
proper intake of
fluid and other
nutrients.

DEPENDENT

Admit patient to To promptly

room to ward provide the
under Dr. Santos patient with
essential
healthcare
actions.

COLLABORATIVE

Carry out To determine a

complete blood patient's blood
count condition and to
monitor or
diagnose
conditions that
cause too much
bleeding or too
much clotting

Carry out urinary To determine if

pregnancy test client is
pregnant

39
 Treat underlying To reduce
conditions where fatigue caused
possible by treatable
conditions

Assessment Nursing Case Plan of Interventions Rationale Evaluation

Diagnosis Background Care

Objective Deficient fluid The patient was Goal: INDEPENDENT After 40 hours of
Cues: volume admitted to nursing
related to hospital on Patient will Secure consent To ensure interventions, goal
Chief active blood March 1, 2022, re-establish a for admission and trust between partially met as
Complaint: loss with heavy functional management the nurse and evidence by loss
Heavy secondary to prolonged body fluid the patient of vaginal
prolonged ectopic menstruation as volume and a with good bleeding.
menstruation pregnancy, a chief balanced understanding
as evidenced complaint and input and of the risks However, more
(+) vaginal by chief had signs of output status, and options to information is
bleeding complaint of fatigue, and be free be taken needed in order to
heavy abdominal of vaginal fully determine
(+) abdominal prolonged cramping, and bleeding. Monitor vital signs To assess and whether the goal
cramping menstruation vaginal bleeding record vital and each objective
, vaginal which are signs Objectives: signs deviated are fully attained.
(+) fatigue bleeding, of ectopic from normal. With this,
abdominal pregnancy. After 40 evaluation will be
HCT: 1.35 L/L hours, patient Monitor input and Ensure that
cramping, updated once data
fatigue, and will no longer output the patient has is complete.
hematocrit be proper intake
level of 1.35 experiencing of fluid and
L/L. vaginal other
bleeding nutrients.

After 24
Monitor for severe To assess if
hours, patient
pain and signs of patient is at
will have
shock risk of shock

40
normalization
of laboratory DEPENDENT
and
diagnostic To hook D5LR 1L For fluid and
results. to run for 8 hours electrolyte
replenishment
and caloric
supply

Prepare the To ready

patient for the patient for
surgical salpingectomy
intervention of and through
ectopic pregnancy laparoscopy

Place patient on To prepare

NPO patient for
delivery of
surgery

Provide For fluid and

supplemental IV electrolyte
fluids as indicated replenishment
and caloric
supply

COLLABORATIVE

Carry out To determine

complete blood a patient's
count blood
condition and
to monitor or
diagnose
conditions that
cause too
much bleeding
or too much
clotting

Carry out blood- To prepare

typing and patient for
crossmatching blood
transfusion as
required

41
 Review laboratory To review fluid
data and electrolyte
status

Discuss individual To reduce risk

risk factors, of injury and
potential dehydration
problems, and
specific
interventions

Assessment Nursing Case Plan of Interventions Rationale Evaluation

Diagnosis Background Care

Objective Cues Nausea as a The patient was Goal: INDEPENDENT

symptom admitted to After 24 hours of
Chief To decrease nursing
related to hospital on
interventions, goal
Complaint: the severity or Educate and assist Oral hygiene
ectopic March 1, 2022, partially met as
Heavy elimination of client about oral helps alleviate
pregnancy, as with heavy evidence by
hygiene. the condition patient not
prolonged nausea.
evidenced by prolonged and facilitates
menstruation comfort.
the chief menstruation as
Objectives:

42
 complaint of a chief complaint exhibiting signs of
(+) Nausea After 24 hours, Introduce cold These aid nausea.
heavy and had signs of
the client will water, ice chips, hydration.
prolonged fatigue, ginger products, Ginger helps However, more
(+) abdominal
no longer
menstruation, abdominal and room relieve nausea information is
cramping
have signs of temperature whether in needed in order to
abdominal cramping, and
nausea. appropriate to the ginger ale, fully determine
(+) vaginal cramping, and vaginal bleeding client’s diet. ginger tea, or whether the goal
bleeding vaginal which are signs chewed as and each
bleeding. of an ectopic crystallized objective are fully
(March 2, 2022, ginger. Fluids attained. With
pregnancy. After 24 hours, that are too cold this, evaluation
8AM)
the client will or hot may be will be updated
be able to eat difficult to once data is
tolerate. complete.
and drink
Vital Signs enough for
appropriate
BP: 110/90 fetal growth. Tell client to avoid Strong and
foods and smells noxious odors
Temp: 35.6 that trigger nausea. can contribute
to nausea.
CPR: 84BPM After 24 hours,
the client’s
RR: 22 Position the client This can be
health will upright while eating helpful in
improve. and for 1 to 2 hours reducing the
post-meal risk.

After 24 hours, DEPENDENT

the client will
have a
reasonable
quality of life. Admit client to room To promptly
to ward under Dr. provide the
Santos. client with
essential
healthcare
actions.

COLLABORATIVE

43
 Educate the Caregivers can
caregiver about promote
appropriate fluid adequate
and dietary options hydration and
for nausea. nutritional
status by
acknowledging
dietary points to
consider when
nauseated.

Educate the Teaching the

caregiver the use of caregiver
nonpharmacological methods to
nausea control control nausea
techniques such as increases the
relaxation, guided sense of
imagery, music personal
therapy, distraction, efficacy in
or deep breathing managing
exercises. nausea.

Assessment Nursing Case Plan of Interventions Rationale Evaluation

Diagnosis Background Care

Goal: INDEPENDENT

44
 To prevent
Objective Infection as a The patient was Obtain information Multiple sexual After 24 hours of
the risk of
Cues risk related to admitted to regarding client’s partners or nursing
infection.
ectopic hospital on past and present intercourse interventions,

Chief pregnancy, March 1, 2022, sexual partners with bisexual goal partially met

Complaint: as evidenced with heavy and exposure to men increases as evidence by

Heavy by the chief prolonged any STDs. risk of patient not

prolonged complaint of menstruation Objectives: exposure to exhibiting risk of

menstruation heavy as a chief STDs and infection.

prolonged complaint and After 24 HIV/AIDS.
menstruation, had signs of hours, the However, more
Risk of Infection
abdominal fatigue, client will information is
cramping, abdominal verbalize Review lifestyle Weak immune needed in order
and vaginal cramping, and understandin and profession for system, drug to fully determine
bleeding. vaginal g of individual the presence of abusers and whether the goal
bleeding which causative/risk associated risk healthcare and each
are signs of an factors. factors. professionals objective are
ectopic are at risk for fully attained.
pregnancy. exposure to With this,
After 24
hours, the HIV/AIDS and evaluation will be
client will HBV through updated once
review contact with data is complete.
techniques contaminated
and lifestyle needles, body
changes to fluids, and
reduce risk of blood
infection. products;
tuberculosis
through
After 24
airborne
hours, the
client will droplets.

45
 initiate
behaviors to Determine if the Although
limit the viral infection is recurrent HSV-
spread of either primary or II is associated
infection, as recurrent. with reduced
appropriate, viral shedding
and reduce time, the
the risk of newborn, if
complications exposed to the
. virus at
delivery, can
After 24 be affected
hours, the with either
client will visible lesions
achieve or a
timely disseminated
healing, free type of the
of disease.
complications
.
DEPENDENT

Admit client to To promptly

room to ward provide the
under Dr. Santos. client with
essential
healthcare
actions.

COLLABORATIVE

46
 Assess for any Identifiable
specific signs and signs of
symptom, if infection assist
present, notify in determining
healthcare the mode of
provider. treatment.

Availability of
staff and
Prepare for/assist equipment
in transfer to ensures
tertiary care center optimal care of
as indicated. high-risk client
and
fetus/newborn.

Assessment Nursing Case Plan of Interventions Rationale Evaluation

Diagnosis Background Care

Subjective Goal
Cues: To reduce INDEPENDENT
bleeding and

47
 Objective exhibit stable
Cues: Risk for Shock Patient was blood flow Establish rapport To gain After nursing
BP: 110/80 patient’s trust interventions and
related to admitted on
mmhg Objectives monitoring, the
HR: 85 bpm excessive March 01, 2022.
patient was able
RR: 22 cpm -After
blood loss The admitting to exhibit
T: 36.5 C performing
diagnosis is nursing hemodynamic
Height - 149cm secondary to interventions, stability as
Abnormal
Weight - 78kgs the client will evidenced by vital
ectopic report Secure consent for To ensure trust
Prolonged signs within
(+)fatigue pregnancy as reduced admission and between the normal range.
Uterine Bleeding
(+) vaginal bleeding. management nurse and the
bleeding evidenced by
and had a sign of patient with
(+) nausea -The patient However, more
vaginal
fatigue, nausea, good information is
(+) dizziness will exhibit
(+) bleeding, stable blood understanding needed in order to
and vaginal
lightheadednes fatigue and flow. of the risks and fully determine
bleeding which
s options to be whether the goal
nausea.
are signs of an taken and each
ectopic objective are fully
pregnancy. attained. With
this, evaluation
Embryo grows will be updated
outside the once data is
uterus commonly complete.

on the fallopian
tube and if the Monitor vital signs To assess vital
tube ruptures, signs deviated
from normal
excessive blood
loss happens and
can lead to
shock. Monitor I and O To prevent
dehydration,
fluid retention,
and other
problems
related to fluid
imbalance

DEPENDENT

48
 Admit patient to To promptly
room provide the
client with
essential
healthcare
actions.

Administer IV fluid To replace

(D5LR) as water and
prescribed. electrolyte loss
in patients after
significant blood
loss.

COLLABORATIVE

Carry out blood To determine a

typing and patient’s blood
crossmatching condition and to
prepare for
possible blood
transfusion.

49
 Provide oxygen, if To support cell
indicated. metabolism and
promote
stabilized
breathing

Teach the client and To heal and

family the support the
importance of immune system
consuming healthy
diet and exercising

50
Assessment Nursing Case Plan of Interventions Rationale Evaluation
Diagnosis Background Care

Subjective Goal
Cues: Acute pain Patient was To be INDEPENDENT After nursing
relieved from interventions and
secondary to admitted on
Objective pain and monitoring, the
Cues: ectopic March 01, 2022. have a pain
patient was able
BP: 110/80 scale of less Establish rapport To gain
pregnancy as The final to verbalize
mmhg than 4. patient’s trust
HR: 85 bpm evidenced by diagnosis is decrease or relief
RR: 22 cpm of pain and was
abdominal Ectopic
T: 36.5 C Objectives able to
pain. Pregnancy where demonstrate
Height - 149cm -After Secure consent for To ensure trust relaxation
fertilized egg
Weight - 78kgs performing admission and between the techniques to
implants outside nursing
management nurse and the control pain.
(+) +) fatigue interventions,
the main cavity of patient with
(+) mild the patient
abdominal the uterus and should report good However, more
cramping and relief from understanding information is
the patient had a
pelvic pain pain with a of the risks and needed in order to
(+) nausea sign of fatigue, pain scale of options to be fully determine
less than 4. taken
nausea, mild whether the goal
abdominal and each
objective are fully
cramping and attained. With
Monitor vital signs To assess vital
pelvic pain which this, evaluation
signs deviated
are signs of an will be updated
from normal
once data is
ectopic
complete.
pregnancy that
can cause further
complication for Assess pain level To help indicate
and location treatment to
the patient.
relieve pain

51
Position patient on To promote
bed rest. comfort and
enhance a
sense of well-
being

DEPENDENT

Admit patient to To promptly

room provide the
client with
essential
healthcare
actions.

May administer To provide pain

analgesics as relief to the
prescribed patient.

COLLABORATIVE

Encourage the To help the

patient to do patient explore
relaxation methods for the
techniques control of pain.

52
53
 CHAPTER X: CURRENT
TRENDS/INNOVATIONS/CLINICAL
MANAGEMENT
An increasing trend in the incidence of ectopic pregnancy is expected due to the
development and availability of minute diagnostic approaches and some baseline
amendable such as contraceptive methods and surgical interventions and unchangeable
such as the age of pregnancy and residency parameters.

54
 Reviewing the trend of the changes in the prevalence of ectopic pregnancy showed
a rate of 2.6 per 1000 recorded pregnancies with an increasing trend during ten years of
study. As previously pointed out, the main reason for this upward trend can be due to the
development of diagnostic tools and making more direct attention to identifying minute
statistics of this phenomenon and its main determinants in health centers in the entire
country. This might be influenced by some social and epidemiological factors such as the
age of the pregnancy, urban residency, women's occupational status, previous surgical
operations, and misuse of contraceptive methods. In this regard, the number of parities,
previous history of abortion or infertility, and history of pelvic inflammatory disorders were
less effective. The overall incidence of ectopic pregnancy increased during the mid-
twentieth century, plateauing at approximately almost 20 per 1000 pregnancies in the
early 1990s, the last time national data were reported by the Centers for Disease Control.
Another study by Kamwendo and colleagues emphasized the role of pelvic inflammatory
disorders in the increased prevalence of ectopic pregnancy so that the two to three times
higher ectopic pregnancy incidence in women older than 25 years of age was most
probably due to a cohort effect as the peak of pelvic inflammatory disease occurred a
decade earlier in younger women. Therefore, they concluded that the prevention of pelvic
inflammatory disease might not only reduce ectopic pregnancy but also reduce adverse
effects on tubal patency. In total, the current incidence of ectopic pregnancy is difficult to
estimate from available data (hospitalizations, insurance billing records) because
inpatient hospital treatment of ectopic pregnancy has decreased and multiple health care
visits for a single ectopic pregnancy have increased. In this line, time trends in the age
and regional distribution of ectopic pregnancy in some developing countries have
suggested that the increasing use of intrauterine contraceptive devices may be a major
factor contributing to this recent increase in extrauterine gestations, while recent age and
regional trends in tubal infection appear to be unrelated to the trends in ectopic
pregnancy.

55
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