UNIVERSITY OF THE CORDILLERAS ODC Form 1A

College of Nursing
Governor Pack Road, Baguio City, Philippines 2600 ACTUAL DELIVERY
(+6374) 442-3316, 442-2564, 442-8219, 442-8256 FORM
E-mail: [email protected]
Website: www.bcf.edu.ph

ECTOPIC PREGNANCY, PIH

A Case Presented to the

College of Nursing

In Partial Fulfillment of the requirements in the Course

NCM 112 CARE OF THE CLIENTS WITH PROBLEMS IN OXYGENATION, F&E, INFECTIOUS, I&I
RESPONSE, CELLULAR ABBERARION, ACUTE & CHRONIC

Submitted by:

BELLY, Audrey Rose T.

CARAGAN, Mac Cristian A.
IBAÑEZ, Alice Joy S.
MEDENILLA, Gemalyn B.
OGUNDEJI, Ayomide Florence
PRENDOL, Ryna Kryzzea B.
RAFAEL, Hajime Melchor W.
REBOLLEDO, Osdrei Marion S.
TABIOS, Shaira Annie A.
TIYAD, Emily B.
TOLERO, Kenji F.
VALLEDO, Denielle T.
VELORIA, Mikko DC.

(Date: 16-NOVEMBER-2020)

Noted and Approved for Presentation:

Name of Case Presentation Adviser or Panel/s

________________________
Signature of Adviser / Date

ABSTRACT

TITLE: Ectopic pregnancy (EP) and PIH is a condition presenting as a major health problem for women of
childbearing age. This study aimed to identify potential risk, to evaluate the contribution of the risk factors
associated to and the treatment and management used for these diseases.
BACKGROUND: Ectopic pregnancy 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 the death of the
fetus. Without timely diagnosis and treatment, ectopic pregnancy can become a life-threatening situation.
While pregnancy induced hypertension (PIH) is one of the most common causes of both maternal and neonatal
morbidity, affecting about 5 – 8 % of pregnant women. It is associated with adverse pregnancy outcomes as
well as maternal morbidity and mortality.

CASE DESCRIPTION: Patient A is 31 years old, married, a resident of Puguis, La Trinidad, Benguet. She is
on her 8 weeks of AOG, and went to Benguet General Hospital Emergency department with chief complaints
of irregular vaginal bleeding, abdominal discomfort, weakness, headache, and dizziness. Upon assessment, her
initial blood pressure is 140 / 100 mmHg and heart rate is 97 bpm. The abdomen is soft and non-distended.
There is tenderness on deep palpation in the suprapubic and right iliac fossa regions, but no rebound tenderness
or guarding. Bimanual examination is performed. The patient was conscious and responsive. Her skin feels
cool to touch with mild edema noted on her upper and lower extremities. Skin turgor revealed 3 seconds with
mild edema noted on her lower extremities. Her eyes were slightly sunken with pinkish conjunctiva. PERRLA
was noted. She was seen wearing corrective glasses and she reported that she has been utilizing it for four
years now due to her nearsightedness. She also relayed to have (+) family history of the following: Type 1
Diabetes from his father’s side; Chronic Hypertension from both her parents’ side; and CVA from her
grandfather. After several minutes of assessment, the patient reported to feel dizzy or weak; having headache;
flulike symptoms, and nausea. The patient was given PLRS 1L X 20 gtts / min, Aspirin, Ca, Methotrexate,
Hydralazine, Nifedepine, low Na diet and strict BR.

CONCLUSION: Poor knowledge of management of PIH and EP, and inadequate resources are a threat to the
proper management of these diseases. This study helps us to acquire knowledge and integrate our ideas and
competency and also application of nursing process to help the patient have a better health. Health education is
an important way to help the patient reduced the risk of having EP and PIH.

TABLE OF CONTENTS

I. Introduction.............................................................................................................................................３
II. Statement of Objectives..............................................................................Error! Bookmark not defined.
A. General Objectives.....................................................................................Error! Bookmark not defined.
B. Specific Objectives......................................................................................Error! Bookmark not defined.
III. Patient’s Profile..........................................................................................Error! Bookmark not defined.
IV. Chief Complaint..........................................................................................Error! Bookmark not defined.
V. Present History of Illness.......................................................................................................................４
VI. Past History of Illness.............................................................................................................................４
VII. Family Health History............................................................................................................................４
VIII. Developmental History...........................................................................................................................５
IX. Social and Environmental History........................................................................................................５
X. Lifestyle and Health Practices...............................................................................................................５

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XI. Health Assessment..................................................................................................................................６
A. General Survey........................................................................................................................................６
B. Head to Toe Assessment.........................................................................................................................６
C. 13 Areas of Assessment..........................................................................................................................７
XII. Diagnostics...............................................................................................................................................10
XIII. Comprehensive Pathophysiology..........................................................................................................13
XIV. Treatment/Management........................................................................................................................14
A. Drugs....................................................................................................................................................14
B. IV Fluids..............................................................................................................................................14
C. Surgery................................................................................................................................................14
XV. Nursing Care Plans.................................................................................................................................16
A. Prioritization of Problems....................................................................................................................16
a.1. List of Problems..............................................................................................................................16
a.2. Basis for Prioritization....................................................................................................................16
B. Nursing Care Plans...............................................................................................................................17
NCP 1...........................................................................................................................................................17
NCP 2...........................................................................................................................................................17
NCP 3...........................................................................................................................................................17
NCP 4...........................................................................................................................................................17
NCP 5...........................................................................................................................................................17
C. Discharged Plan......................................................................................................................................18
XVI. Learning Insights....................................................................................................................................18
XVII. List of References...................................................................................................................................19
XVIII. Appendices..................................................................................................Error! Bookmark not defined.
Appendix A: Approval/ Request Letter............................................................Error! Bookmark not defined.
Appendix B: Interview Guides..........................................................................Error! Bookmark not defined.
Appendix C: Others............................................................................................Error! Bookmark not defined.

I. Introduction
As the word ‘ectopic’ means ‘the wrong place’, the ectopic pregnancy depicts the abnormal
pregnancy, where the embryo develops outside of the uterus (Thomas, 2016). 95% of ectopic pregnancies
typically occur in the fallopian tube. Other sites are ovary, cervix, and abdomen. Between 6 to 16% of
pregnant women who go to an emergency department in the first trimester for bleeding, pain or both have an
ectopic pregnancy. The incidence of ectopic pregnancy is about 1%-2% of all pregnancies reported in the
developed world (Ali, et al, 2019). According to the March of Dimes, about 1 in every 50 pregnancies in the
U.S. is an ectopic pregnancy “tubal pregnancy” (Danielsson, 2020). There was approximately six-fold
multiplication in the incidence of ectopic pregnancy which is mainly due to three prominent factors: increased
use of Assisted Reproductive Technology (ART), Pelvic Inflammatory Diseases (PID) and increased smoking
consumption in the women of reproductive age (Ali et al, 2019). ART procedures involve surgically removing
eggs from a woman’s ovaries, combining them with sperm in the laboratory, and returning them to the
woman’s body or donating them to another woman (CDC, 2019). Pelvic inflammatory disease is an infection
of a woman’s reproductive organs. It is a complication often caused by some STDs, like chlamydia and
gonorrhea. Other infections that are not sexually transmitted can also cause PID (CDC, 2015).

Pre-eclampsia is a serious condition that can occur during pregnancy where there is high blood
pressure and abnormal kidney function. During pregnancy your blood pressure will be checked at every
antenatal appointment because a rise in blood pressure can be the first sign of pre-eclampsia, also called
pregnancy-induced hypertension (PIH), pre-eclamptic toxemia and hypertensive disease of pregnancy.
Although most cases of pre-eclampsia are mild and cause no trouble, the condition can get worse and be
serious for both mother and baby. It can cause fits (seizures) in the mother, which is called 'eclampsia', and can
affect the baby’s growth (N.A. 2018). Disorders of pregnancy induced hypertensive are a major health problem
in the obstetric population as they are one of the leading causes of maternal and perinatal morbidity and
mortality. The World Health Organization estimates that at least one woman dies every seven minutes from
complications of hypertensive disorders of pregnancy (Gudeta et al, 2019).

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 The Philippine’s maternal mortality continues at an unacceptably high level. While maternal mortality
figures vary widely by source and are highly controversial, the best estimates for the Philippines suggest that
approximately 4,100 to 4, 900 women and girls die each year due to pregnancy-related complications.
Additionally, another 82, 00o to 147, 000 Filipino women and girl will suffer from disabilities caused by
complications during pregnancy and childbirth each year (MNPI, N.A.).
II. Statement of Objectives
A. General Objectives
This case analysis aims to increase the understanding and knowledge of student
nurses on Ectopic pregnancy and PIH and how to care for patients with Ectopic pregnancy
effectively and efficiently.

B. Specific Objectives
Specifically, this case analysis aims to:
1. define Ectopic pregnancy and its effects to the body;
2. illustrate the pathophysiology of Ectopic pregnancy and in relation to the signs and
symptoms specifically observed in the patient;
3. describe and identify the common signs and symptoms, clinical manifestations, and
risk factors of Ectopic pregnancy;
4. discuss the medical interventions for the management of Ectopic pregnancy;
5. formulate appropriate nursing care plans suited for the patient based on the
assessment findings;
6. identify care measures to be given to the patient and family to promote continuity of
care and independence after discharge;
7. identify measures to prevent Ectopic pregnancy.

III. Patient’s Profile

Name : Patient X
Ethnic Background : Igorot
Civil Status : Married
Religion : Roman Catholic
Occupation : none
Admitting Diagnosis : Abdominal Pain & Vaginal Bleeding t/c Ectopic
Pregnancy
Final/Principal Diagnosis : Ectopic Pregnancy, PIH
Date and Time Admitted : November 5, 2020 at 11:00 pm
Date Handled :

IV. Chief Complaint

Irregular vaginal bleeding, abdominal discomfort, weakness, headache, and dizziness.

V. Present History of Illness

The patient’s condition started 2 days PTA, when the patient, while simply doing his homework, felt a
sudden sharp chest pain. Pain rate was with the severity of 8/10. It was not radiating to other parts of the body
but was accompanied by difficulty of breathing, weakness, shortness of breath, and sudden hacking cough. She
had experienced fever, change in appetite, nausea, or vomiting for four days already. She says that her bowel
and urinary habits are usually normal, defecating once to twice a day, except for the previous two days wherein
she did not yet have any bowel movement.
VI. Past History of Illness
The patient had no history of accidents and or trauma, only minor illnesses, such as cough, colds and
fever and was remedied with over the counter medications such as Bioflu and water therapy with rest. The
patient however, was admitted last May 2019 at Benguet General Hospital Emergency department prior to
conception due to hypertension. She received medical interventions such as medications for hypertension and
was discharged home after 5 days of hospitalization. The patient has unrecalled immunization status and with
no history of prolonged case of use of medications such as aspirin or NSAIDs. He also verbalized that she did
not have known allergies for foods or medications.

VII. Family Health History

The patient claims to have familial history of Type 1 Diabetes from his father’s side; Chronic
Hypertension from both her parents’ side; and CVA from her grandfather. No present illness is currently
experienced by any member of the family.

VIII. Developmental History

The patient is a female 31 years old married and already in her 3rd pregnancy , and according to Erik Erikson
psychological stage she is under intimacy vs. isolation which is appropriate to her age because patient is able

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to share herself more intimately with others and has a sense of commitments, safety, and care within
relationship.

IX. Social and Environmental History

Patient smoke for 10 years but already refrain to do so for 2 years ,She is a roman catholic and 8 years
married to his husband and currently pregnant pregnant they are currently residing at Puguis, La Trinidad
Benguet,
The patient belongs to a family with history of type 1 diabetes from his father’s side : Chronic Hypertension
from both her parents sides ; and Cerebrovascular accident or stroke from her grandfather thus making her
mindful on any changes with her physical health with her pregnancy,
X. Lifestyle and Health Practices
She is hypertensive and she is mindful on her current health condition because she is able to go to
hospital and consult with medical professionals with regards to her complaints of having irregular vaginal
bleeding ,abdominal discomfort, weakness, headache and dizziness , her current sleep is not enough due to
discomfort and even though she tried to do so she can’t , According to her she often drinks coffee , coke and
rarely drink water ,she also admitted that she smoke 7-10 sticks of cigarettes for 10 years and 2 years ago she
quit on doing it She reported that during intercourse with his husband they generally use condoms but there
were times that they don’t ,she is also mindful with her health because she submit herself to have sexual health
screen 6 months ago at genitourinary clinic in which fortunately all here swabs were negative.

XI. Health Assessment

A. General Survey

The patient was received awake, lying on bed, with ongoing IVF of PLRS I L x 20 gtts per minute
infusing well on the left arm. Patient appears weak, with limited movements and slow ambulation. She wears a
neat gown, hygiene is fair. Patient is conversant, conscious and responsive. Speech is well formulated, oriented
to the self and others around her, able to determine the time and date. Patient is easily irritable with poor pain
threshold. No signs of distress noted and thought process is stable.

B. Head to Toe Assessment

1. Head The head is normocephalic, no palpable masses and nodules. Hair is

well distributed, oiliness and flaking noted.

2. Eyes Eyes were slightly sunken with pinkish conjunctiva. The pupils are
equally round and reactive to light and accommodation (PERLA was
noted). Corrective glasses were noted for near sightedness. Able to
follow the penlight when assessing the six fields of gazes. Fine
distribution of hair on eyebrows and eyelashes. Presence of dark
circles under the eyes were noted.

3. Ears Able to understand and hear spoken language correctly, with minimal
yellowish cerumen build – up in the ear canal, sliver and intact
tympanic membrane. Both ears are symmetrical, no lesions and
masses noted.

4. Nose and sinuses Nose is patent, septum is located at the midline, no flaring noted, no
tenderness noted upon palpation. No presence of discharges.

5. Mouth Teeth are slightly yellow in color, and no mal-aligned tooth, no dental
caries noted. Oral mucosa is moist and pinkish, no lesions noted,
tonsils are not inflamed, uvula is located at the midline.

6. Neck ROM intact, able to change direction of head slowly without

complaints of pain, carotid pulse are bilaterally symmetrical, full and
strong pulses, 2+, jugular vein is not distended, superficial cervical
lymph nodes are palpable but non tender. Thyroid and trachea noted
to be located midline, no enlargement noted.

7. Chest Appearance is symmetrical, along with the rise and fall of the chest
during respiration. Normal lung sounds on all lobes of the lungs. No
crackles, wheezes, or stridor noted. Normal chest configuration, no
use of accessory muscles while breathing.

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 8. Cardiac Normal heart rate noted, no murmurs, no visible pulsations noted.

9. Breast/Chest Breasts appear symmetrical. Skin color is similar with the rest of the
body, nipple is dark colored, no discharges.

10. Abdomen Abdomen was soft and non-distended. Tenderness was noted on deep
palpation in the suprapubic and right iliac fossa regions. No rebound
tenderness and guarding noted.

11. Genitals Minimal to moderate amount of dark red bleeding noted. No rashes,
lesions and foul discharges noted.

12. Musculoskeletal Limited movements and slow ambulation noted. No visible tremors
noted, no complaints of pain.

13. Integumentary The skin is cool to touch with mild edema noted on upper and lower
extremities. Skin turgor is 3 seconds long with mild edema noted on
the lower extremities.

C. 13 Areas of Assessment

1. Psychosocial and Psychological Status

Patient X is a 31-year-old Filipina. She is a Roman Catholic and is a resident of Puguis, La Trinidad,
Benguet. According to Erik Erikson’s stages of psychosocial development, Patient X falls under the category
of Intimacy vs. Isolation, wherein the patient is more focused on forming intimate, loving relationships with
other people. The patient will start exploring relationships with someone other than a family member that will
lead to a long-term commitment. When intimacy is avoided, or because of the fear of commitment and
relationships, this will then lead to the feelings of isolation, loneliness, and sometimes depression.

2. Mental and Emotional Status

Patient X was conscious and responsive, although according to the patient, because of her poor pain
threshold, she tends to be irritated easily at times.

3. Environmental Status
Patient X stayed in the OB ward in Benguet General Hospital, along with her husband. The
surroundings are clean and properly ventilated. Her bed was 2 nd from the last cubicle at the end of the ward.
There also seemed to be adequate lighting shining through the entire ward and also adequate distances between
each cubicle – providing a comfortable space and allowing for privacy of the patient.

4. Sensor Status
a. Visual Status – Corrective glasses were noted for near sightedness. Sunken eyes noted with pinkish
conjunctiva. Able to follow the six fields of gazes with ease. Dark circles were noted under the eyes.

b. Auditory – Color of the pinna is the same as the rest of the face, top of the ear is aligned with the
outer cantus of the eye. Able to understand words properly without the need to repeat.

c. Olfactory Status – the nose is positioned on the midline of the face, size is proportional to the face
and has the same color with the rest of the face. Septum is located at the midline with no visible lesions
noted. Patient was able to differentiate the different scents.

d. Gustatory Status – Teeth are yellowish in color, lips are slightly brown in color and no lesions were
noted. Able to distinguish various tastes.

e. Tactile Status – No masses, no wounds. Cool to the touch with mild edema noted on her upper and
lower extremities. Slow skin turgor of 3 seconds long.

5. Motor Status
The patient has limited movements and slow ambulation.

6. Thermoregulatory Status – Normal temperature for 31-year-olds is 36.5 – 37.5 degrees Celsius. The
patient’s temperature ranges from 36.5 – 37.5 degree Celsius which is within the normal range.

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 Date Time Temperature
8am 37 °C
November 5, 2020 10am 37.5 °C
2pm 37 °C
4pm 37.3 °C
8am 36.5 °C
November 6, 2020 10am 37.4 °C
2pm 37.3 °C
8am 36.7 °C
November 7, 2020 10am 37 °C
2pm 37 °C

7. Respiratory Status - Normal respiratory rate for 31-year-olds is 16 – 20 cpm while the normal oxygen
saturation ranges from 95 – 100%. The patient’s respiratory rate ranges from 16 – 20 cpm which is within the
normal range.

Date Time RR SPO2

8am 20 cpm 98%
November 5, 2020 10am 18 cpm 95%
2pm 20 cpm 97%
4pm 19 cpm 97%
8am 20 cpm 97%
November 6, 2020 10am 16 cpm 96%
2pm 16 cpm 97%
8am 18 cpm 98%
November 7, 2020 10am 19 cpm 96%
2pm 20 cpm 97%

8. Circulatory Status - Normal cardiac rate for 31-year-olds is 60 – 100 bpm, while the normal range for
capillary refill is 1-2 seconds. The patient’s cardiac rate ranges from 78 – 99 bpm which is within the normal
range for adults. The patient’s capillary refill also, is 1-2 seconds long which is within the normal capillary
refill range.

Date Time CR Capillary

8am 97 bpm
November 5, 2020 10am 85 bpm 1-2 seconds
2pm 99 bpm
4pm 78 bpm
8am 82 bpm
November 6, 2020 10am 80 bpm 1-2 seconds
2pm 82 bpm
8am 82 bpm
November 7, 2020 10am 78 bpm 1-2 seconds
2pm 82 bpm

9. Nutritional Status
The patient noted that she has had a change in appetite.

10. Elimination Status

The patient reported to have a decreased urine output wherein she only urinated thrice a day. She also
verbalized that she defecates once or twice a day, except for the previous day wherein she did not yet have any
bowel movement.

11. Sleep, Rest and Comfort Status

The patient reported that she was able to sleep less than 5 hours due to the discomfort she felt. She
tried taking naps but was unable to do so.

12. Fluids and Electrolytes Status

The patient reported that she often drinks 5 cups of coffee a day, 1-2 cans of coke every after two days
and minimal daily water intake. She also added that he only drinks 3 glasses maximum of water a day. The
patient also had 1L of PLRS, set to a rate of 20 gtts/min.

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13. Integumentary Status
The patient’s skin feels cool to touch with mild edema noted on her upper and lower extremities. Skin turgor is
3 seconds long.

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XII. Diagnostics
XII. Diagnostics

Diagnostic Description of Procedure Significance/Purpose of the Date of Procedure Findings Implications

Procedure Procedure
Complete A complete blood count is a blood Is a very common test to help November 05, 2020 Red Cell Count – 4.18 x 1012/L
Blood Count test used to evaluate the client’s determine general status and can
Mean Platelet Volume 8.0 Fl
overall health and detect a wide help diagnose a broad range of
range of disorders, including anemia, conditions, from anemia and Platelet 302 x 109 /L
infection and leukemia. And to infection to cancer.
determines if there are any increases Haemoglobin 12.3 g/dL RBC, MPV, Platelet, Haemoglobin,
or decreases in your blood cell Eosinophils 0.4 x 109 /L Eosinophils, Lymphocytes, and
counts. Normal values vary Nucleated RBC are within normal range
depending on your age and your Lymphocytes 2.6 x 109 /L
gender. Your lab report will tell you Nucleated RBC 0 x 109 /L
the normal value range for your age
and gender.

White Cell Count + 14.2 x

109/L WBC, MCH,MCHC, RDW,
MCH 88.7 Fl neutrophils, monocytes are above
MCHC 29.3 Pg normal range signs that there is a
RDW 33.0 g/dL presence of infection. And the body is
Neutrophils ++ 10.3 x 109 /L not able to get as much as oxygen to go
throughout the body.
Monocytes 0.9 x 109 /L

Basophils – 0.0 x 109 /L Basophils and MCV are within below

normal indicates that there is low
MCV 37.1% oxygen in the blood due to imbalance

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 between demand and supply of the
blood and presence of infection.
Urinary A human chorionic gonadotropin The hCG urine test is a November 05, 2020 6,500 mIU per Ml ; positive Having a positive test means that you
pregnancy test (hCG) urine test is a pregnancy test. qualitative test, which means that are pregnant. False-positive urine
A pregnant woman's placenta it will tell you whether or not it pregnancy tests may put patients at risk
produces hCG, also called the detects the hCG hormone in your for unnecessary treatment. It is
pregnancy hormone. If you're urine. It's not intended to reveal important to confirm a suspected false-
pregnant, the test can usually detect specific levels of the hormone. positive urine hCG test using a
this hormone in your urine about a The presence of hCG in your quantitative serum hCG test.
day after your first missed period. urine is considered a positive
sign of pregnancy

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Urinalysis A urinalysis is simply an analysis of Urinalysis can disclose evidence November 05, 2020 Protein trace, blood negative, Urine is normally clear. Bacteria, blood,
the urine. It is a very common test of disease even some that have nutrites negative and leukocytes sperm, crystals, or mucus can make
that can be performed in many not caused significant signs or negative. urine look cloudy.
health care settings including symptoms. Therefore, a
doctor’s offices, urgent care, urinalysis is commonly a part of
facilities, laboratories, hospitals, and routine health screening.
even at home.

Sodium This test is performed on a blood A sodium test checks how much November 05, 2020 139 mmol/L Normal sodium levels are usually
sample, obtained by venipuncture. A sodium is in the blood. Sodium between 136 and 145 millimoles per
technician will insert a small needle is both an electrolyte and liter (moll/L). Blood sodium levels
into a vein on your arm or hand. This mineral. It helps keep the water below 136 mmol/L may mean you have
will be used to fill a test tube with (the amount of fluid inside and low blood sodium “hyponatremia”
blood. outside the body's cells) and
electrolyte balance of the body.
Sodium is also important in how
nerves and muscles work.

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Potassium Potassium is an electrolyte. A potassium test is used to November 05, 2020 4.0 mmol/L Normally, your blood potassium level is
Electrolytes become ions when measure the amount of 3.6 to 5.2 millimoles per liter (mmol/L).
they’re in a solution, and they potassium in your blood.
conduct electricity. Our cells and Potassium is an electrolyte that's
organs require electrolytes to essential for proper muscle and
function normally. A potassium test nerve function. Even minor
is performed as a simple blood test increases or decreases in the
and carries few risks or side effects. amount of potassium in your
The blood sample drawn will be sent blood can result in serious
to a laboratory for analysis. Your health problems.
doctor will review the results with
you.

Urea A blood urea nitrogen (BUN) test The urine urea nitrogen test November 05, 2020 2.3 mmol/L In general, around 7 to 20 mg/dL (2.5 to
measures the amount of nitrogen in determines how much urea is in 7.1 mmol/L) is considered normal. Low
your blood that comes from the the urine to assess the amount of urea levels are not common and are not
waste product urea. Urea is made protein breakdown. The test can usually a cause for concern. They can
when protein is broken down in your help determine how well the be seen in severe liver disease or
body. Urea is made in the liver and kidneys are functioning and malnutrition but are not used to
passed out of your body in the urine. whether your intake of protein is diagnose or monitor these conditions.
too high or low. Additionally, it Low urea levels are also seen in normal
can help diagnose whether you pregnancy.
have a problem with protein
digestion or absorption from the
gut.

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Creatinine A creatinine blood test measures the A creatinine test is used to see if November 05, 2020 54 umol/L The normal range for creatinine in the
level of creatinine in the blood. your kidneys are working blood may be 0.84 to 1.21 milligrams
Creatinine is a waste product that normally. It's often ordered per deciliter (74.3 to 107 micromoles
forms when creatine, which is found along with another kidney test per liter), although this can vary from
in your muscle, breaks down. called blood urea nitrogen lab to lab, between men and women,
Creatinine levels in the blood can (BUN) or as part of a and by age.
provide your doctor with comprehensive metabolic panel
information about how well your (CMP). A CMP is a group of
kidneys are working. tests that provide information
about different organs and
systems in the body.

Liver function A liver function test measures Liver function tests are blood November 05, 2020 Albumin – 33 g/L Albumin, Total protein, Bilirubin, ALT,
test enzymes, proteins, and other tests used to help diagnose and Total Protein 68g/L ALP are in a normal range.
substances that are produced or monitor liver disease or damage. Bilirubin total 6 umol/L
excreted by the liver, such as alanine The tests measure the levels of ALT 19 u/L
aminotransferase (ALT), alkaline certain enzymes and proteins in ALP + 141 u/L
phosphatase (ALP), aspartate your blood.
aminotransferase (AST), gamma-
glutamyl transpeptidase (GGT),
bilirubin, and albumin.

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Serum uric acid A uric acid blood test, also known as Uric acid blood test can help November 05, 2020 Uric Acid 371 umol/L Uric acid level is normal
a serum uric acid measurement. The determine how well your body
test can help determine how well produces and removes uric acid.
your body produces and removes
uric acid. Uric acid is a chemical
produced when your body breaks
down foods that contain organic
compounds called purines.

Laparoscopic A laparoscopy is a type of surgery Laparoscopy is often used to November 05, 2020 Distended right uterine tube, An ectopic pregnancy is when a
test that checks for problems in the identify and diagnose the source showing the typical bluish fertilised egg implants itself outside of
abdomen or a woman's reproductive of pelvic or abdominal pain. It’s bulge. There is no evidence of the womb, usually in one of the
system. Laparoscopic surgery uses a usually performed when blood in the pouch of Douglas fallopian tubes. The fallopian tubes are
thin tube called a laparoscope. It is noninvasive methods are unable to suggest rupture of the ectopic the tubes connecting the ovaries to the
inserted into the abdomen through a to help with diagnosis. pregnancy. womb. If an egg gets stuck in them, it
small incision. An incision is a small won't develop into a baby and your
a cut made through the skin during health may be at risk if the pregnancy
surgery. continues.

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Transvaginal A transvaginal ultrasound, also Transvaginal ultrasound is an November 05, 2020 A pregnancy in the adnexa. Adnexa refer to the anatomical area
ultrasound scan called an endovaginal ultrasound, is examination of the female adjacent to the uterus, and contains the
a type of pelvic ultrasound used by pelvis. It helps to see if there is fallopian tube, ovary, and associated
doctors to examine female any abnormality in the uterus vessels, ligaments, and connective
reproductive organs. This includes (womb), cervix (the neck of the tissue.
the uterus, fallopian tubes, ovaries, womb), endometrium (lining of
cervix, and vagina. “Transvaginal” the womb), fallopian tubes, Majority of the adnexal masses
means “through the vagina.” This is ovaries, bladder or the pelvic diagnosed in pregnancy are benign and
an internal examination. cavity. will resolve spontaneously.
Consequently, in the absence of
symptoms or sonographic findings
concerning malignancy, patients should
be managed expectantly.

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XIII. Comprehensive Pathophysiology
This is a diagrammatic presentation of the course of the disease with emphasis of information relevant to nursing
care. Predisposing factors (Modifiable), Precipitating factors (Non-modifiable), course of illness or condition, relevant
diagnostic findings, signs & symptoms, management and appropriate nursing diagnoses presented must be in line
with actual events that occurred with the patient.
PREDISPOSING FACTORS PRECIPITATING FACTORS

Exposure to 2nd hand Smoking & Pollution Height (tall person), Male, 19 years old

Chemicals (Tar) Gradient of Pleural pressure increases from

lung base to apex
Blocks airway passages and degrade
elastic fibers of the lungs

Influx of neutrophils and macrophages Alveoli of lung apex receives the

is induced greater distension pressure

Imbalanced enzymes (protease & anti-protease)

and antioxidant system

________________Bullae/Blebs Formation______________________

Inflammation-induced obstructions of the airway Shearing forces

Increased alveolar pressure

Leakage to the lung interstitium, hilum and pneumomediastinum Rupture of blebs

Increased mediastinal pressure

Rupture of the mediastinal parietal pleura

_______________Pneumothorax____________________

Disequilibrium in the intrapulmonary and intrapleural pressure

Activation of the receptors that monitor Tidal volume affected Changes in the thoracic pressure
lung volume
Distortion of movement of air
Sympathetic stimulation in and out of the lungs

Tachypnea Air flows out of the alveoli

into the Pleural space

Lung collapse during recoil

Dyspnea Sudden, sharp, stabbing pain

Admission to the Hospital

---INEFFECTIVE BREATHING PATTERN---
Partial collapse of the affected lung

Impairment of gas conduction Air trapping in the collapsed lung Ruptured bleb and lung collapse
in the lower respiratory airways activate inflammatory response

Decreased tactile fremitus Hyper resonance on percussion Lung asymmetry

---------------------IMPAIRED GAS EXCHANGE-------------------

Transudation of fluid and blood from surrounding Axillary Thoracotomy

blood vessels of the injured lung and Bleb
Excision

-------PAIN RELATED TO TISSUE TRAUMA-------

Pleural Effusion

Transudate accumulation in the pleural space

Further restriction of lung expansion Collapse of alveoli Disequilibrium in pulmonary and pleural pressures

Increased respiratory difficulty Bleeding Surgical Incision and Insertion of CTT

Stasis of pulmonary sections Decreased Hct and Hgb Tissue trauma and injury

Growth of microorganisms Decreased oxygen carrying Pain on the incision site

capacity of the lungs
--- RISK FOR INFECTION--- ---IMPAIRED MOBILITY---
---ACTIVITY INTOLERANCE---

15
16
XIV. Treatment/Management

A. Drugs

DRUG NAME MECHANISM OF ACTION INDICATION / ADVERSE EFFECT NURSING RESPONSIBILITIES

CONTRAINDICATION
Generic Name: -Thought to produce analgesia CONTRAINDICATION: CNS: Agitation, cerebral -Monitor salicylate level.
ASPIRIN and exert it’s anti- -Contraindicated in those with edema, coma, confusion, -Assess hematocrit, Hb level, PT,
inflammatory effect by NSAID- induced sensitivity dizziness, headache, lethargy, INR, and renal function.
Brand Name: Inhibiting prostaglandin and reactions, G6PD deficiency or seizures, subdural or -Monitor patient for sensitivity such
Asaphen, Asatab other substances that sensitize bleeding disorders such as intracranial hemorrhage. as anaphylaxis and asthma.
pain receptors. Drug may hemophilia, Von Willebrand CV: Arrythmias, hypotension, -Introduce low salt diet (1 tab of
Pharmacologic Class: relieve fever through central disease, bleeding ulcers and tachycardia, Aspirin contains 553 mg of sodium).
Salicylates action in the hypothalamic hemorrhagic states. EENT: Tinnitus, hearing loss. -Remind patient not to stop
Therapeutic Class: NSAIDs heat- regulating center. In low -Severe hepatic impairment and GI: Nausea, GI bleeding, medication without first discussing
doses, drug also appears to active peptic ulcer disease. dyspepsia, GI distress, occult to the prescriber.
Dosage: interfere with clotting by -Chicken pox and Flulike bleeding, pancreatitis, -Advise patient to take drugs with
81 mg OD keeping a platelet-aggregating symptoms. vomiting. food, milk, antacid, or large glass of
substance from forming. GU: Antepartum and post- water to reduce GI reactions.
Route: INDICATIONS: partum bleeding, interstitial -Advise patient to take the drug
Oral -Mild pain or fever nephritis, prolonged pregnancy same time each day.
and labor, proteinuria, renal -Encourage the use of soft-bristle
failure. brush.
HEMATOLOGIC: Prolonged
bleeding time, leukopenia,
thrombocytopenia.
HEPATIC: Hepatitis
METABOLIC: Dehydration.
Hyperkalemia, metabolic
acidosis, hyperglycemia,
hypoglycemia(children),
respiratory alkalosis.

17
 SKIN: Rash, bruising,
urticaria, hives.
OTHER: Angioedema, Reye
syndrome, low birth weight
(infants), stillbirth.

DRUG NAME MECHANISM OF ACTION INDICATION / ADVERSE EFFECT NURSING RESPONSIBILITIES

CONTRAINDICATION
Generic Name: -Replaces calcium and CONTRAINDICATIONS: CNS: Tingling sensation -Monitor calcium level frequently.
Calcium maintains calcium level. -Bone metastases, and in those CV: Bradycardia, arrythmias, -Monitor symptoms of
with ventricular fibrillation, cardiac arrest, vasodilation hypocalcemia.
Brand Name: hypophosphatemia, renal calculi GI: Constipation, Irritation, -Monitor pulse, blood pressure, and
Cal-Citrate chalky taste, nausea, vomiting ECG frequently.
INDICATIONS: thirst, abdominal pain -Administer drugs after meals and at
Therapeutic Class: -Hypocalcemia GU: Polyuria, renal calculi bedtime.

18
Calcium Supplements -Dietary supplement METABOLIC: -Check the medication to be
-Hyperphosphatemia Hypercalcemia administered.
Pharmacologic Class: SKIN: Local reactions, -Tell patient to take oral calcium 1 to
Calcium Salts necrosis, tissue sloughing, 1 and half hours after meals if GI
cellulitis upset occurs.
Dosage: -Advise patient to notify the
1.5g OD prescriber if taking OTC products
such as iron.
Route: -Tell patient to report anorexia,
Oral nausea, vomiting, constipation,
abdominal pain, dry mouth, thirst
and polyuria.

DRUG NAME MECHANISM OF ACTION INDICATION / ADVERSE EFFECT NURSING RESPONSIBILITIES

CONTRAINDICATION
Generic Name: -Interferes with folic acid CONTRAINDICATION: CNS: Arachnoiditis, malaise, -Monitor pulmonary function test
Methotrexate metabolism. Result is -Hypersensitivity fatigue, dizziness, fever, and fluid intake and output.
inhibition of DNA synthesis -Pregnancy and Lactation aphasia. -Monitor uric acid level.
Brand Name: and cell reproduction. Also has -Active infections CV: Chest pain, Hypotension, -Monitor for symptoms of
Trexall immunosuppressive activity. -Chronic debilitating illnesses pericarditis. pulmonary toxicity.
-Renal and Hepatic impairment EENT: Pharyngitis, blurred -Clarify all ambiguous order, check
Therapeutic Class: vision single, daily, and course of therapy
Antineoplastics GI: Gingivitis, stomatitis, GI dose limits.
INDICATIONS: bleeding -Observe the patient for any
Pharmacologic Class: -Trophoblastic neoplasms GU: Renal failure, tubular symptoms during administration.
Folate Antagonist necrosis. Nausea, vomiting -Inform the patient that this may

19
Dosage: HEMATOLOGIC: cause dizziness and blurred vision.
15mg Leukopenia, thrombocytopenia -Advise patient to avoid caffeine-
HEPATIC: Acute toxicity, containing beverages.
Route: chronic toxicity, hepatic -Emphasize the importance of
Oral fibrosis follow-up exams to monitor
METABOLIC: Diabetes progress.
MUSCULOSKELETAL:
Arthralgia, myalgia,
RESP: Pulmonary interstitial
infiltrates, pneumonitis
SKIN: Urticaria, pruritis,
hyperpigmentation, alopecia,
acne, photosensitivity reactions
and ecchymoses.
OTHERS: Septicemia, sudden
death.

20
 DRUG NAME MECHANISM OF ACTION INDICATION / ADVERSE EFFECT NURSING RESPONSIBILITIES
CONTRAINDICATION
Generic Name: -A direct- acting peripheral CONTRAINDICATION: CNS: Headache, dizziness, -Monitor patients BP, pulse rate, and
Hydralazine Hydrochloride vasodilator that relaxes -Hypersensitivity peripheral neuritis weight frequently.
arteriolar smooth muscle. -Mitral valvular rheumatic heart CV: Angina pectoris, -Monitor patient closely for signs
Brand Name: disease palpitations, tachycardia, and symptoms of lupus like
Apresoline -Cardiac disease, stroke orthostatic hypotension, edema syndrome.
-Severe renal impairment EENT: Conjunctivitis. Nasal -Monitor frequency of prescription
Therapeutic Class: congestion refills to determine adherence.
Antihypertensives INDICATION: GI: Nausea, vomiting, -Obtain CBC, lupus erythematous
-Hypertension diarrhea, constipation, cell preparation and ANA titer
Pharmacologic Class: paralytic ileus determination before therapy
Peripheral dilators GU: Difficult urination -Don’t confuse hydralazine with
HEMATOLOGIC: hydroxyzine.
Dosage: Neutropenia, leukopenia, -Administer the medication with
10mg q 6˚ x 3 days agranulocytosis, meals to the patient.
10mg IV PRN thrombocytopenia -Advise patient to take drug in the
MUSCULOSKELETAL: morning to avoid need to urinate at
Route: Muscle cramps, arthralgia night.
Oral RESP: Dyspnea -Advise patient to report all adverse
IV SKIN: Rash reactions and to avoid sudden

21
OTHERS: Hypersensitivity, posture changes and to rise slowly to
chills avoid dizziness upon standing.
-Advise patient to consult health
provider before taking Rx, OTC and
herbal medicines.

22
 DRUG NAME MECHANISM OF ACTION INDICATION / ADVERSE EFFECT NURSING RESPONSIBILITIES
CONTRAINDICATION
Generic Name: -Thought to inhibit calcium ion CONTRAINDICATIONS: CNS: Dizziness, headache, -Monitor BP and HR regularly.
Nifedipine influx across cardiac and -Hypersensitivity light- headedness, -Monitor intake and output ratios
smooth muscle cells, -Angina, MI nervousness, sleep disturbance daily and weight.
Brand Name: decreasing contractility and -Hepatic Failure CV: Flushing, heat sensation, -Assess signs of CHF such as
Adalat CC, Procardia oxygen demand. Drug may -Major surgery peripheral edema, palpitations peripheral edema, dyspnea and
also dilate coronary arteries -Severe aortic stenosis EENT: Nasal congestion, sore rales/crackles.
Therapeutic Class: and arterioles. -chronic renal failure throat, blurred vision. -Administer drug with meals if GI
Antihypertensives GI: Nausea, heartburn, irritation becomes a problem.
INDICATIONS: diarrhea, constipation, -Raise side rails, because this may
Pharmacologic Class: -Hypertension flatulence cause drowsiness.
Calcium channel blockers -Vasospastic angina MUSCULOSKELETAL: -Watch for symptoms of HF.
-Ureteral Calculi Muscle cramps, tremor, joint -Advise patient to take medication
Dosage: stiffness exactly as directed, even if feeling
30 mg RESP: Dyspnea, cough, well.
wheezing, shortness of breath -Advise patient to avoid driving or
Route: SKIN: Dermatitis, pruritus, doing other activities.
Oral sweating -Advise patient to notify physician if
OTHERS: difficulties in irregular heartbeat, dyspnea,
balance, chills, sexual swelling of hands and feet,
difficulties dizziness, constipation or
hypotension occurs.

B. IV Fluids

Name Classification Component/s Use & Effects Nursing Responsibilities

23
1. PLRS Isotonic - calcium chloride: 0.02 - to treat dehydration. - Observe for signs of fluid overload.
grams. - Monitor manifestation of continued
- to facilitate the flow of IV
hypovolemia.
-potassium chloride: 0.03 medication during surgery.
grams. - Check and regulate the drop rate.
- to restore fluid balance after - Elevate the head of the bed at 35 to 45
-sodium chloride: 0.6 grams. significant blood loss or burns. degrees.
-sodium lactate: 0.31 grams. - to keep a vein with an IV catheter - Change the IV Fluid Solution
open. - Check the level of IV Fluid.
-water - Elevate the patient’s leg.
- Check integrity of IV Solutions.
Effects: - Educate Patient and Watcher to recognize
signs and symptoms of fluid overload.
- swelling
- edema
- chronic kidney disease
- congestive heart failure
- hypo-albuminemia
- cirrhosis

24
XV. Nursing Care Plans

A. Prioritization of Problems

a.1. List of Problems

This portion lists the health problems according to priority (No. 1 having the highest priority).

Health Problems are stated as Nursing Diagnoses using the Basic 3-Part Statement : PES Format
- Problem Statement + Etiology + Signs and Symptoms
-
- Ex: Self-Esteem Disturbance related to rejection by husband as manifested by hypersensitivity to
criticism, stating "I don't know if I can manage by myself", and rejecting positive feedback
- Variations to the PES format in order to make the problem statement more descriptive
(e.g. adding "Secondary to") is acceptable as long as the part following “secondary to” is a
disease process
(Ex: High-Risk for Impaired Skin Integrity related to decreased peripheral circulation secondary to
Diabetes)

Problems should comprise AT LEAST 3 Actual Problems and 2 Potential Problem ranked in order of
priority.

a.2. Basis for Prioritization

NURSING DIAGNOSES JUSTIFICATION
1. PES Format as stated in your Why is it number 1 out of your 5 problem, you can use nursing
list of problem theories or concepts.
2. PES Format as stated in your Why is it number 2 out of your 5 problem, you can use nursing
list of problem theories or concepts. Relate it with number 1 or 3.
3. PES Format as stated in your Why is it number 3 out of your 5 problem, you can use nursing
list of problem theories or concepts. Relate it with number 2 or 4.
4. PES Format as stated in your Why is it number 4 out of your 5 problem, you can use nursing
list of problem theories or concepts. Relate it with number 3 or 4.
5. PES Format as stated in your Why is it number 5 out of your 5 problem, you can use nursing
list of problem theories or concepts. Relate it with previous problems.

25
 B. Nursing Care Plans

NCP 1: Acute Pain related to Abdominal Discomfort

Assessment Explanation of the Problem Objective Nursing Intervention Rationale Evaluation
SUBJECTIVE: Ectopic pregnancy is gestation STO: DX: DX: STO:
located outside the uterine
- “Masakit ang cavity. The fertilized ovum After 8 hours of nursing Assess the client’s perception, level of -To identify and assess the nursing Goal is met - After 5
tiyan ko” as intervention, the patient will be understanding and needs interventions to be done hours of nursing
implants outside of the uterus,
verbalized by the able to: intervention, the pain is
patient usually in the fallopian tube.
Predisposing factors includes relieved and controlled and
- The patient  demonstrate the use of the patient was able to
Assess the severity, frequency, and
reported to have adhesions of the tube, diversional activities and
a poor pain saltingitis, congenital and relaxation skills to manage characteristic of pain -Pain is a subjective data that should be demonstrate the use of
threshold developmental anomalies of pain. reported and to determine patient’s level watching movies and
of pain listening to music to distract
the fallopian tube, review  be relieved from the pain
ectopic pregnancy. Use of an or will be able to control herself from the pain.
intrauterine device for more the pain felt.
than 2 years, multiple induced Monitor for increase and pain and -Increased pain and abdominal distention
OBJECTIVE:
abortions, menstrual reflux, abdominal distention and rigidity indicates rupture and possible intra-
- Facial mask of and deceased tubal motility. abdominal haemorrhage
pain (grimacing)
- Tenderness on Monitor complete blood count (CBC) LTO:
deep palpation in LTO: -To determine the amount of blood loss
the suprapubic Goal partially met -
and right iliac After 72 hours of nursing After 72 hours of nursing
fossa regions intervention, the patient will be intervention, the patient still
- Easily irritated Reference: able to maintain the absence of showed occasional signs of
TX:
- Limited signs and symptoms of pain TX: pain but was able to display
movements https://www.webmd. and will display an Provide comfort measure like back an improvement in mood.
- Slow ambulation improvement in mood. rubs, deep breathing.
- BP- 140/60 com/baby/
mmHg -Promotes relaxation and ease the pain
pregnancy-ectopic-pregnancy
felt.

Instruct in relaxation or visualization

exercise.

26
 -Promotes relaxation and may enhance
patient’s coping abilities by refocusing
NURSING attention
DIAGNOSIS: Provide directional activities

Acute pain related to

abdominal discomfort
-Diversional activities aids in refocusing
attention and enhancing coping with
Administer analgesics as indicated limitations

-To maintain acceptable level of pain

EDX:

Encourage early ambulation

EDX:

-To promote blood circulation

Instruct the client to avoid strenuous
activities and exercise

-To prevent for further bleeding

NCP 2: Ineffective tissue perfusion related to vasoconstriction of blood vessels

Assessment Explanation of the Problem Objective Nursing Intervention Rationale Evaluation
Subjective: Increased in cardiac output STO: DX: DX: Short term:
that injures the endothelial
“Sumasakit ulo ko at cells of the arteries and the Within 5 hours of nursing Monitor blood pressure regularly -To have a baseline data of blood Goal met - After 8 hours of
nahihilo naman ako” as action of prostaglandins. interventions, the patient will pressure nursing interventions, the
verbalized by the patient Vasoconstriction occurs and be able to reduce the blood patient’s blood pressure was
due to stressful experiences or pressure within the normal reduced from 140/100
negative mood states the range. -To prevent fluid and sodium retention in mmHg to 120/80 mmHg.
Monitor intake and output of the
Objective: blood pressure increases. patient the body and reduce BP

27
 - Mild edema on
upper and lower
extremities LTO: TX: Long term:
- Skin is cool to TX:
Reference: Within 48-72 hours of giving -Gently repositioning patient from a Goal met - After 48-72
touch
effective nursing interventions, Assist with position changes. supine to sitting/standing position can hours of giving effective
- Basophils – 0.0 x Traum, A., & Somers, M.,
109 /L the patient will be able to reduce the risk of orthostatic BP nursing interventions, the
(2007). Blood Pressure. Blood maintain adequate tissue changes. patient was able to maintain
- MCV 37.1% pressure-an overview l
- BP: 140/100 perfusion. adequate tissue perfusion as
Science Direct Topics. evidenced by absence of
mmHg
Retrieved from edema on the upper and
-It conserves energy lowers tissue
https://www.science lower extremities, warm
Provide a quiet and restful oxygen demand
direct.com/topics/ skin and normal MCV
environment
levels.
immunology-and-
-Antihypertensive drugs help decrease
NURSING DIAGNOSIS microbiology/blood-pressure
Administer antihypertensive drugs as and control blood pressure
Ineffective tissue ordered
perfusion related to
vasoconstriction of blood EDX:
vessels EDX: -To maintain a normal BP and reduce
Advice low-fat and low self-diet weight

-Increasing intake of fruits and

vegetables can lower blood pressure,
Emphasize increase intake of fruits reduce the risk of heart disease and have
and vegetables a positive effect upon blood sugar.

28
NCP 3: Hyperthermia related to infectious process
Assessment Explanation of the Problem Objective Nursing Intervention Rationale Evaluation
Subjective: Infections occur when the STO: DX: DX: STO:
natural defense mechanism of
The patient reported an individual are inadequate to After 4 hours of nursing Assess fluid loss and facilitate oral -Increase metabolic rate and diaphoresis Goal met - After 4 hours of
discomfort on the right protect them. Organisms such intervention the patient’s intake nursing intervention, the
hand side of the as bacteria, viruses, fungus, temperature will be reduced patient’s temperature was
suprapubic area. and other parasites invade from 38 degrees Celsius to the -Notes progress and changes in condition reduced from 38 degrees
susceptible hosts through normal levels. Monitor vital signs Celsius to 37.5 degrees
inevitable injuries and Celsius.
Objective: exposures. Infections prolong -Prevents dehydration
healing and can result in death
- Weak in appearance
- Warm to touch if treated inappropriately. Maintained IV fluid as ordered by
- Mild edema noted on physician LTO:
her lower and upper LTO:
extremities -Indicates presence of infection and Goal Met - After 72 hours
After 78 hours of nursing dehydration of nursing intervention, the
- Nausea and vomiting
for four days Reference: intervention, the patient will be patient was free from any
able to remain free from any Monitor hematologic test and other
- White Cell Count + pertinent lab results signs and symptoms of
Vera, M. (2020). Risk for signs and symptoms of
14.2 x 109/L TX: infection as manifested by
- MCH 88.7 Fl Infection Nursing Care Plan. infection as evidenced by
Retrieved on 15 November absence of fever, normal
- MCHC 29.3 Pg normal vital signs and normal -Enhances heat loss by evaporation and temperature and normal
- RDW 33.0 g/dL from https://nurseslabs. laboratory results. TX: conduction laboratory findings.
- Neutrophils ++ 10.3 x com/risk-for-infection/
109 /L Provided tepid sponge bath
- Monocytes 0.9 x
109 /L -Dissipates heat by convection
- Presence of protein in
the urine (proteinuria) Provided cool circulating air using fan
- T: 38 degrees Celsius Reduces fever
Administer antipyretic as ordered

29
 Administer antibiotic as ordered -Treats underlying cause

NURSING
DIAGNOSIS: Promote bed rest
-Reduces body heat production
Hyperthermia related to
infectious process

EDX:
EDX:
Encourage ample fluid intake by
-If the patient is dehydrated or
mouth
diaphoretic, fluid loss contributes to
fever

Educate patient and family members -Providing health teachings to the patient
about signs and symptoms of and family aids in coping with disease
hyperthermia and help in identifying condition and could help prevent further
factor related to occurrence of fever complications of hyperthermia

NCP 4: Disturbed sleeping pattern related to abdominal pain

Assessment Explanation of the Problem Objective Nursing Intervention Rationale Evaluation
SUBJECTIVE: Pain feels less control over STO: DX: DX: STO:
sleep affecting the health and
“Nakatulog lang ako ng exhibit greater sleep After 8 hours of nursing Observe and obtain feedback from -To determine usual sleep pattern and Goal Met
mga less than 5 hours sensitivity. Time-limited intervention, the client will client regarding usual bedtime, rituals provide comparative baseline
kase panay sakit ng tyan report decreased feeling of and number of hours of sleep After 8 hours of nursing
disruption of sleep (natural, intervention, the patient
ko” as verbalized by the periodic suspension of discomfort as manifested by an
client improved sleeping pattern. reported feeling relieved
consciousness) amount and from discomfort and was

30
 quality. This may result for Assess patient’s perception of cause of -Knowing the specific etiologic factor able to sleep for at least 6
the body where it is unable to sleep difficulty and possible relief will guide appropriate therapy hours.
OBJECTIVE: function at an optimal level. LTO: measures to facilitate treatment
- Restlessness After 72 hours of nursing
intervention the client will: LTO:
- Presence of eye bags TX:
TX:
 Be able to be free from any Goal Met
- Yawning -To alleviate discomfort
Reference: signs and symptoms of Position client in a comfortable
disturbed sleep patterns position After 72 hours of nursing
- Easily irritated interventions, the client was
https://nandadiagnosis  Achieve 7-8 hours of
continuous sleep per day able to establish normal
.blogspot. sleeping patterns of
Provides comfort measures (touch, -To distract attention on pain, reduce
tension and to promote non- continuous 8 hours of sleep
quite environment, dim light, light daily and was seen to have
music) pharmacological pain management
an absence of eye bags and
yawning with improved
mood throughout the day.
NURSING -To help in providing better sleep/rest
DIAGNOSIS:
Provide a quiet and peaceful
Disturbed sleeping pattern environment during sleep periods
related to abdominal pain EDX:

-This contains ingredients that decreases

EDX: the ability to fall asleep
Instruct patient in limiting of caffeine
and soft drinks use
-Verbalizing concerns may promote
relaxation
Encourage the client to verbalize
concerns when unable to sleep

-Relaxation techniques can help to fall

Teach relaxation techniques, pain asleep more quickly
relief measures, or the use of imagery
31
 before sleep

NCP 5: Risk for deficient fluid volume

Assessment Explanation of the Problem Objective Nursing Intervention Rationale Evaluation
Subjective: Risk for deficient fluid STO: DX: DX: STO:

“Konti lang iniinom ko sa volume or fluid volume After 4 hours of nursing Monitor intake and output, character, -Provides information about overall fluid Goal met
isang araw, mga 3 baso ng deficit is a state or interventions, the patient will and amount of stools. balance, renal function, and bowel
tubig” as verbalized by be able: disease control. After 4 hours of nursing
condition where the fluid intervention, the patient:
the patient
output exceeds the fluid  To verbalize
 Verbalized that
intake. It occurs when understanding on the
importance of -Indicator of overall fluid and nutritional adequate water
Objective: the body loses both Monitor weight daily. status intake helps the
adequate water intake
water and  To demonstrate body function
- Skin turgor of 3 properly and
seconds electrolytes from the ECF lifestyle changes to
avoid progression of maintain the body’s
- Sunken eyeballs in similar proportions. -Indicates excessive fluid loss or fluid balance.
dehydration Observe for excessively dry skin and
- Decreased urine resultant of dehydration. 
Common sources of fluid mucous membranes, decreased skin Was able to
output (3x a day) turgor and slowed capillary refill. demonstrate the
- Minimal daily water loss are the
LTO: lifestyle changes to
intake gastrointestinal tract, avoid dehydration
- Vomiting for four polyuria, and increased After 72 hours of nursing such as drinking at
days
32
- Nausea perspiration. It also interventions, the patient will TX: TX: least 2 liters of
- Presence of bleeding maintain adequate fluid volume water daily.
pertains to decreased Provide oral restrictions, bed rest and -Colon is placed at rest for healing and to
and be free from signs of
intravascular, interstitial, and avoidance of exertion decrease intestinal fluid losses.
dehydration.
intracellular fluid. LTO:

NURSING Goal Met

DIAGNOSIS: -Fluids are necessary to maintain
Administer parenteral fluids as After 72 hours of nursing
hydration status
Risk for deficient fluid ordered intervention, the patient was
volume Reference: able to maintain adequate
Marily E., et al. Nurses pocket -Drop situations where patient can fluid volume as evidenced
Provide comfortable environment by
Guide p.90 experience overheating to prevent further by balanced intake and
covering patient with light sheets output and was free from
fluid loss
any signs of dehydration.

EDX:
EDX:
Encourage to drink bountiful amounts
-Patient may have restricted oral intake
of fluid as tolerated or based on
in an attempt to control urinary
individual needs
symptoms, reducing homeostatic
reserves and increasing risk of
dehydration.

Enumerate interventions to prevent or -Patient needs to understand the value of

minimize future episodes of drinking extra fluid during bouts of
dehydration fever, vomiting and other conditions
causing fluid deficits.

Enumerate the relevance of -Increasing the patient’s knowledge level

maintaining proper nutrition and will assist in preventing and managing
hydration the problem

33
34
 C. Discharged Plan
Health Teaching
Diet/Nutrition

Activity

Medication

Other

XVI. Learning Insights

A. Belly, Audrey Rose T.

B. Caragan, Mac Cristian A.

While doing this case presentation and caring for the patient for straight
three days shift I’ve learned the many causative agents of ectopic pregnancy and PIH
the different ways to manage it, medications to treat the patient and the diagnostics
done to confirm if the patient is really having a ectopic pregnancy and PIH and more
importantly I’ve learned the signs and symptoms of it which is very important for us
because when we know it we will be able to guard ourselves from those patients who
have it while we are caring for them.

C. Ibanez, Alice Joy S.

D. Medenilla, Gemalyn B.

E. Ogundeji, Ayomide F.

F. Prendol, Ryna Kryzzea B.

From the case that was given to us, honestly, it was challenging to fill in the
information needed because of the lack of data from the given scenario along with
the fact that we weren’t there first-hand to actually assess and monitor the patient.
However, it is eye-opening that all pregnant women are actually at risk of having an
ectopic pregnancy especially if they are not careful with their lifestyle choices –
much more so since they are susceptible to pregnancy induced hypertension, which is
the first sign of an upcoming eclampsia. Therefore, as student nurses, it is important
to properly educate our patients on the preventive measures to reduce the chances of
an ectopic pregnancy to occur.

G. Rafael, Hajime Melchor W.

H. Rebolledo, Osdrei Marion S.

I. Tabios, Shaira Annie A.

J. Tiyad, Emily B.

K. Tolero, Kenji F.
The knowledge I obtain about the ectopic pregnancy made me understand
the causes, proper treatment and different conditions of such disease which is
essential; and, enabling student nurses like me to provide proper care to the patients
who has same condition. Researching and class discussions provided us a deeper
understanding about ectopic pregnancy which established a good foundation to our
knowledge as to how we can properly handle patients with similar case and how we
can properly execute the treatments that must be given to the patients in order for
them to have a fast recovery.

L. Valledo, Denielle T.

M. Veloria, Mikko DC.

35
36
XVII. List of References
This portion cites all books, journals and other references that were used as shown in the
example below. Use APA Format and as much as possible use updated book source.
Gudeta et al, (2019). Pregnancy Induced Hypertension and Associated Factors among
Women Attending Delivery Service at Mizan-Tepi University Teaching Hospital, Tepi
General Hospital and Gebretsadik Shawo Hospital, Southwest, Ethiopia. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6341446/

MNPI, (N.A.). Philippines. Retrieved from

http://www.policyproject.com/pubs/MNPI/Philippines_MNPI.pdf

CDC, (2015). Pelvic Inflammatory Disease (PID) - CDC Fact Sheet. Retrieved from
https://www.cdc.gov/std/pid/stdfact-pid.htm

CDC, (2019). What is Assisted Reproductive Technology?. Retrieved from

https://www.cdc.gov/art/whatis.html

Ali, S. et al (2019). Diagnosis and Management of Ectopic Pregnancy-A Basic View Through
Literature. Retrieved from https://obstetrics.imedpub.com/diagnosis-and-management-of-
ectopic-pregnancya-basic-view-through-literature.php?aid=24242

N.A. (2018). Pre-eclampsia or pregnancy induced hypertension (PIH). Retrieved from

https://www.healthdirect.gov.au/pre-eclampsia-pregnancy-induced-hypertension

Thomas, A. (2016). A Brief Introduction Of Ectopic Pregnancy. Retrieved from

https://medium.com/@alithomas072/a-brief-introduction-of-ectopic-pregnancy-
4781bc913ad1

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 XVIII. APPENDICES

Appendix A

Approval/Letter Request

To:

Thru: Juliet Avena

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Clinical Coordinator

Dear Ma’am,

Greetings!

We, the Level III Section F Group B, would like to reserve the case with a diagnosis of
Ectopic Pregnancy, PIH for our case presentation this first semester of school year
2020-2021. This case was presented to us for our virtual case presentation on November
18, 2020. Our clinical instructors for the virtual case presentation are Ma’am Jessica
Bentayen and Ma’am Gaeserica Leah Mae Salic-o.

We have selected this case to further enhance our knowledge and management
regarding this problem that we have chosen.

Thank you very much for your kind consideration and God Bless!

Respectfully yours,

_______________________________ _____________

Belly, Audrey Rose T. Ogundeji, Ayomide F.

_______________________________ _____________

Caragan, Mac Cristian A. Prendol, Ryna Kryzzea B.

_______________________________ _____________

Ibanez, Alice Joy S. Rafael, Hajime Melchor W.

_______________________________ _____________

Medenilla, Gemalyn B. Rebolledo, Osdrei Marion S.

_______________________________ _____________

Tabios, Shaira Annie A. Valledo, Denielle T.

_______________________________ _______________________________

Tiyad, Emily B. Veloria, Mikko DC.

_______________________________

Tolero, Kenji F.

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