OMAN COLLEGE OF HEALTH SCIENCES

Nursing Program
Maternal Health Nursing- Practicum
(NUR 213)

Ectopic Pregnancy

Student Name: Lujaina Ahmed Hamed Almanji

Student ID: BSCN616
Submission Date: 7/11/2019
Clinical Instructor Ms.kausar
 Comprehensive Case Study Format

1. Personal information:
(2Marks)
Patient initials: Z.S.S.R
Age: 33 years old Address: Amerat Hospital NO: 1076307
Date of Admission/ OPD Visit: 21/9/2019 Date of Discharge: -

2. Family History:
(1Mark)
All her family members are healthy.

3. Medical and Surgical History:

(2Marks)

Patient is healthy, she is not suffering from any disease. There is no past
surgical history.

4. Obstetrical History (Fill for ANC/PNC cases. If newborn case fills for the
Newborn’s mother):
(2 Marks)

 Gravida: 1 Para: 0 Abortion: 1 Fetal death: -

 Died: - Alive: 0

 L.M.P: 2/8/2019 EDD (Scan): EDD (history): 5/9/2020

5. Medical Diagnosis: (2 Marks)

Ectopic pregnancy
fetus 7 weeks +3 days.

6. Chief Complain: (Admission and present complain with duration) (2 Marks)

On admission 15/9/2019 patient started to have spotting, the color was dark brown.
Then after these 5 days on Thursday she started to feel pain (flank pain) in the left side.
 Pain was sever and like pricks. On Saturday 21/9/2019 the pain was still there but is
radiated to her left thigh and back area. Now 24/9/2019 there is no pain but she feels
nausea and dizziness because of side effect of the medication (methotrexate).

7. Definition of final diagnosis:

(3Marks)

Ectopic pregnancy: An ectopic pregnancy is an early embryo (fertilized egg) that

has implanted outside of the uterus the normal site for implantation, usually in the
fallopian tube.
An ectopic pregnancy can occur in places other than a fallopian tube, such as in the
ovary (rarely) or inside the abdomen (very rarely).

8. Etiology of the disease:

(4Marks)

SI. According to text book In your patient

N
O
1. Pelvic inflammatory disease.
2. Increased the use of IUDds
(intrauterine device).
3. Congenital anomalies such as None of these reasons is present in my
patient, the reason is unknown until now.
webbing (fibrous bands).
4. Oral contraceptive.
 9. Clinical manifestations:
(4Marks)

SI. According to text book In your patient

N
O
1. A sharp, stabbing pain in one of her
lower abdominal quadrants at the time
of rupture.
 A sharp, stabbing pain in one of her
2. Scant vaginal spotting.
lower abdominal quadrants, and scant
3. If internal bleeding progress to acute
vaginal spotting were there during
hemorrhage, a women may experience
admission but now none of these
light headiness and rapid pulse, signs
symptoms are present.
of shock.

10. Management: (4 Marks)

SI. According to text book

N In your patient
O
 An unruptured ectopic pregnancy can
be treated
1. Medically by oral administration
of methotrexate followed by  Medically by oral administration
leucovorin. of methotrexate, later on they will
2. Hyterosalpingogram or do dilation and evacuation if
ultrasound. needed.
3. Mifepristone.

 If an ectopic pregnancy ruptures:

1. IV fluid.
2. Laparoscopy.

11. Pathophysiology of the disease:

(4 Marks)

For a pregnancy to occur, the sperm and egg meet in the fallopian tube (the tube that
carries the egg from the ovary to the uterus).
 Usually, the fertilized egg moves into the uterus for the pregnancy to grow and
develop.
But because of an obstruction is present, such as an adhesion of the fallopian tube
from a previous infection, congenital malformations, scars from tubal surgery, or
uterine tumor, so the zygote cannot travel the length of the tube.
It lodges on that constricted part and implantation takes place at that area instead of
the uterus.

12. Investigation: (8 Marks)

Investigation Result Normal findings Interpretation

1. CBC
*WBC 11.05 (2.4-9.5) 10*3/uL Increase, because
my patient was
*absolute neutrophil 7.38 (1-4.8) 10*3/uL taking
count immunoglobulin
anti-d.

Increase, because
2. Liver function test 81.13 (64-73)g/L my patient take
*total protein immunoglobulin.

3. Renal function test Decrease, due to

*electrolytes 132.00 (136-145) mmol/L patient not eating
{sodium} well because she
feels nausea.

99.60 (98-107) mmol/L Normal.

 {chloride}

15. Focused physical examination: (5 Marks)

Head-to-Toe Physical Examination

Gender: Female Age: 33 years Weight: 73 kg Height: 155cm

old
General Appearance: The patient is
Hint: Grooming / clean and well
facial expression grooming, has
smiley face.
Patient looks
little bit tired.
Client feels sad
because she lost
her first
pregnancy, but
she can cope with
the situation.

Vital Signs:
Temp: Pulse rate: RR: BP: 110/76 SPO2:
36.7 C 86 bpm 20 cpm mmHg 100 %

Neurological Assessment:
Assessment Patient’s findings
Level of Consciousness (LOC): Alert, oriented to time, place, person, and situation.
(alertness & Orientation) She can answer the questions.

Eyes: Eyes are symmetrical, Sclera is white, and conjunctiva is pink.

(inspection external & Internal, No redness and no discharges or abnormal colours.
visual fields, inner eye & Patient able to follow the pen light by moving it away from the
extraocular muscles) patient’s face in the six cardinal fields of gaze. No abnormalities with
vision.
Pupils: Normal shape and size of pupils, equal on both sides. Absent of
(size, reaction to light & drainage.
accommodation) The pupils constrict and equally move to cross while doing the
accommodation exam.
Ears: Normal shape and size. Equal in both sides. No tenderness,
(inspection of external & internal, lesions, redness, discharges. Patient can hear me clearly while
hearing test) asking her question.
Extremities: She was able to grip my hand and push my foot.
(hand grip & foot push)
Cranial nerves: Olfactory; patient can smell and recognize odours.
(CN: I – XII) Optic: patient can read and she doesn’t wear glasses.
Occulomotor, trochlear, abducens: Patient can move her eyes
without difficulties.
Trigeminal: patient can feel pain.
Facial: patient can smile and frown.
Vestibulocochlear: patient can hear clearly.
Glossopharyngeal: patient can recognize the taste.
Vagus: patient can swallow.
Accessory: Patient was able to shrug her shoulder against my hand.

Pain: COLDSPA No pain.

(character, onset, location,
duration, severity, pattern &
associated factors)

Cardiovascular Assessment:
Skin & Mucous membranes: Skin is in normal colour. Mucous membrane is pink, no
(colour) bleeding, and no discoloration.
Pulses: The radial pulse is normal and strong, it is 86 bpm.
(location, sounds, rhythm,
abnormal sounds)
Jugular vein: No enlargement, not visible.
Capillary refill: Return to its normal colour within 2 seconds.
Edema: (location / No edema.
character)
Risk factors:
No risk factors.

Respiratory Assessment:
Nose: Nose is symmetrical, no deviation. No discharges. No lesions
(inspection, patency, drainage) or redness. No nasal congestion.
Respirations: Chest is symmetric while breathing. No effort or accessory or
(inspection, palpation, percussion & abdominal muscle use. No tenderness on the chest, presence
auscultation) of vibration on both sides while performing tactile fremitus.
Absence of abnormal breathing sounds.
Cough: No cough.
Character of cough
Risk factors: No risk factors.

Gastrointestinal Assessment:
Oral: Lips are pink no blue/cyanotic or cracked, and free from
(Mucous membrane, Teeth, gums, lesions. Colour of mucous membranes and gums are pink. The
 tongue, palate & uvula) teeth are white and free from cavities.no broken or loose teeth
too. The tongue is moist and pink no lesions or sores. no
exudate on tonsils, no tonsillitis and uvula is in the midline
Abdomen: Abdomen is flat and symmetric, no hernia no scar no lesions.
(inspection, auscultation, percussion & Reduced bowel sounds.
palpation)
Bowel sounds: Hypoactive bowel sounds.
Bowel movement: Patient did not eliminate for 4 days, and her normal bowel
(frequency, colour, consistency) movement is twice a day.
Nutrition: She is eating everything, no specific diet.
(lifestyle & type of diet)

Musculoskeletal Assessment:
Mobility: She has a steady gate, can maintain balance. No assistance
(gait, assistance devices, ADLs, ROM & devices used. Can perform ADLs independently. She can
positioning) move and change her position by himself.
Circulation, Sensation & movement Capillary refill return to its normal colour within 2 seconds.
(CSM): Patient can respond to a stimuli and can move.

Risk for fall: High risk of fall because of dizziness.

Score / precautions

Integumentary Assessment:
Appearance: (colour, temperature, Colour is normal no changes, no rashes, no redness, no
turgor, texture, integrity) wounds, the temperature is normal (warm), skin texture is
smooth and skin turgor is normal.
Wound dressing: No wound
(site & wound character, drainage)
Pressure ulcers: No pressure ulcer
(location, size, stage)

Genitourinary Assessment:
Urine: Voiding 5-6 times a day, no sense of incomplete voiding.
(Frequency, colour & clarity) The colour is slightly light yellow to dark yellow urine and it
is clear. She voided with her normal frequency during
hospitalization.
Genitalia: Female, no abnormal discharge, no spotting or vaginal bleeding.
(gender, discharge, LMP – if female) LMP is 2/8/2019, EDD is 9/5/2020.
Intake & output: Patient intake orally.
(route & total I&O amount)
 15. Medications: (8 Marks)
Drug Name Classifications Action Side Effect Nursing
Dose Responsibility
Route
Frequency
Methotrexate antimetabolites Interferes with 1. Dizziness.  Tell the patient about
folic acid 2. Nausea. risk of fall
90 Mg metabolism. 3. Drowsiness. precautions because
Result is she feel dizziness.
IV inhibition of  Check IV site for
DNA synthesis signs of phlebitis,
STAT and cell because I observed
reproduction. In that the IV site
an ectopic became red.
pregnancy
methotrexate
works by
stopping the
growth of the
fertilized egg
before a rupture
occurs
Immunoglobul  Immunoglobulins. Anti-D works by 1. Anemia.  Monitor CBC
in binding to 2. Intravascular {RBC&HB & WBC}
(ANTI-D) Rhesus D antige hemolysis. levels.
3. Renal
n expressed on  Titrate rate slowly to
insufficiency.
300Mcg/2Ml red blood cells, prevent infusion
which leads to reaction.
Stat their recognition
by Fc receptors
on cells of the
reticuloendotheli
al system. The
coated red cells
compete with
the antiplatelet-
antibody-coated
platelets for the
activated Fc
receptors,
thereby slowing
 platelet
clearance
Paracetamol Analgesic Inhibit 1. Rash.  Give it with food or
1000Mg prostaglandin 2. Vomiting. milk if patients feels
Orally synthesis 3. Nausea. GI distress.
Stat in CNS.  Monitor if there is
any rashes.

16. List of all nursing diagnosis with prioritization use PES format:
(4 Marks) Note: Include appropriate nursing diagnosis for the mother and newborn
in case of postnatal case study.

1. Nausea R/T side effect of medication ”methotrexate” A.E.B Patient feels Sever nausea
and not feeling the urge to eat, and increased swallowing.
2. Constipation R/T lack of activity A.E.B Patient did not pass stool for 4 days, and
hypoactive bowel sounds.
3. Risk for fall R/T dizziness secondary to side effect of medication “methotrexate”.
4. Grieving R/T loss of first pregnancy A.E.B patient verbalize ”feel sorrowful because of
losing my first pregnancy, and I was waiting for this pregnancy for 2 years”

17. Nursing care plan: (20 Marks)

Nursing diagnoses Goals / Outcome Nursing Rationale Evaluation
(Actual) Criteria orders/interventions
(2.5 marks) (2.5 marks)
(3 marks) (2 marks) (5 Marks)
*Subjective data: Goal: 1. Provide an emesis 1. Nausea and vomiting Goal is met.
basin within easy reach are closely related.
-Patient verbalize: Within 2 days of Within 2 days of
of the patient. Keep emesis basin out
nursing intervention nursing intervention
”I feel sever nausea of sight but within the
patient will report patient reports
because of patient’s reach if
decrease severity of decrease severity of
medication” nausea has a
nausea. nausea.
psychogenic
“I cannot eat component.
Outcome:
properly because of
this sensation, I am A.E.B
not feeling the urge 2. Tell patient to avoid
* Patient well eat 2. Strong and noxious
to eat” foods and smells that
small amount of food odors can contribute to
trigger nausea. nausea.
with decrease level of
nausea.
*Objective date:
* Patient identifies 3. Encourage patient to
I observed 3. This approach will
which triggers take frequent, small
Increased help maintain
nausea. amounts of foods.
swallowing in my nutritional status.
patient. * Decrease swallowing

4. Position the patient 4. This can be helpful

upright while eating and in reducing nausea and
Nausea
for 1 to 2 hours post- prevent vomiting.
R/T meal.
Side effect of
medication
5. Educate patient the
“ Methotrexate” use of non- 5. Teaching the patient
pharmacological nausea methods to control
control techniques such nausea increases the
A.E.B as relaxation, guided sense of personal
imagery, music therapy, efficacy in managing
- Patient feels Sever distraction, or deep nausea.
nausea and not breathing exercises.
feeling the urge to
eat.
-Increased 6. Keep rooms well-
6. A well-ventilated
swallowing. ventilated. If possible,
room or having a fan
assist the patient to go
close by promotes
outside to get some fresh
easier breathing.
air.
Nursing diagnoses Goals / Outcome Nursing Rationale Evaluation
(Actual) Criteria orders/interventions (2.5 marks) (2.5 marks)
(3 marks) (2 marks) (5 Marks)
*Subjective data:  Goal: 1. Check on the usual 1. It is very crucial to Goal partially met.
pattern of elimination, carefully know what is
Patient verbalize ”I Within 2 days of including frequency and “normal” for each Patient was not able to
didn’t pass stool for nursing intervention consistency of stool. patient. The normal eliminate one time
4 days now” patient will be able to frequency of stool during nursing shift
eliminate at least one passage ranges from but, she was able to
time During these 2 twice daily to once identify measures that
days. every third or fourth treat constipation.
*Objective date:
day. Dry and hard
Hypoactive bowel Outcome:
feces are common
sounds A.E.B characteristics of
constipation.
* Patient maintains
passage of soft, 2. Irregular mealtime,
Constipation 2. Check out usual
formed stool at a type of food, and
dietary habits, eating
R/T frequency perceived interruption of usual
habits, eating schedule,
as “normal” by the schedule can lead to
and liquid intake.
Lack of activity patient. constipation.

A.E.B * Patient identifies

measures that treat 3. Encourage patient to
* Patient did not 3. Exercise strengthen
constipation. do regular exercise and
pass stool for 4 abdominal muscles and
activity.
days. * Bowel sound will be stimulate peristalsis.
normal.
* Hypoactive bowel
sounds.
4. Enough fluid is
needed to keep the
fecal mass soft. But
4. Encourage the patient take note of some
to increase fluid intake, patients or older
if not contraindicated patients having
medically. cardiovascular
limitations requiring
less fluid intake.

5. Fiber adds bulk to

5. Encourage patient to the stool and makes
eat dietary food which defecation easier
are high in fiber (e.g.raw because it passes
fruits, fresh vegetable, through the intestine
whole grains). essentially unchanged.

6. Administer Stool 6. Laxatives soften

softeners as prescribed. stool and lubricate
intestinal mucosa.
Nursing diagnoses Goals / Outcome Nursing Rationale Evalua
(Actual) Criteria orders/interventions (2.5 marks) (2.5 ma
(3 marks) (2 marks) (5 Marks)
*Subjective data:  Goal: 1. For patients at risk for 1. Signs are vital for Goal is
falls, provide signs or patients at risk for
Patient verbalize ”I Within 2 days of secure a wristband falls. Healthcare Patient was
feel dizziness” nursing intervention identification to remind providers need to free from i
patient will be safe. healthcare providers to acknowledge who has
implement fall the condition for they
Outcome:
*Objective date: precaution behaviors. are responsible for
A.E.B implementing actions
to promote patient
* Patient will be free safety and prevent
Risk for fall
from injuries. falls.
R/T
* Patient will
Dizziness demonstrate selective
secondary to side prevention measures
effect of medication to prevent falls.
“methotrexate” 2. Move items used by
2. Items that are too
the patient within easy
far from the patient
reach, such as call light,
may cause hazard and
urinal, water, and
can contribute to falls.
telephone.

3. This is to prevent
3. Respond to call light
the patient from going
as soon as possible.
out of bed without any
assistance.

4. Ask the patient to sit 4. To prevent risk of

when she feel dizzy. fall.

5. Put said rails up. 5. To reduce the risk of

fall.
 18. Health education plan: (4 Marks)

Include health teaching points under heading which is appropriate for all the needs
of the mother and newborn with rational.

*Natural ways to treat constipation*

 Gradually increase the amount of high-fiber foods in your diet, such as fruits and
vegetables (banana, strawberry, potato, and broccoli). Because fiber keep your bowel
movements soft and regular.

 Do regular activity or exercise, because exercise helps constipation by decreasing the

time it takes food to move through the large intestine, thus limiting the amount of water
absorbed from the stool into the body.

 Take more fluid, because fluid leads to an increase in bowel transit time by bulking up
fecal matter.

19. Evidence: (8 Marks)

Provide best evidence from the literature to support nursing care plan, health
education, treatment or investigations. (Use recent publication not more than 5
years). The evidence should be analyzed:

1 How it is related to your patient

2 Summary of literature finding (PICO)
3Compare literature finding with real practice
4 Implication in practice

1. The study of this evidence was on the role of possible effect of fluid intake and
fiber intake in the prevention and treatment of for patients with constipation.
Constipation is associated with many factors such as lack of activity, decrease
fiber intake, surgery or any health problems. My patient develops constipation
during hospitalization because of lack of activity. I choose many interventions to
 treat constipation such as encouraging patient to take increase fluid intake, and
fiber intake, so this article aimed to study the effect of fluid intake and fiber
together to treat constipation because in a study conducted by general
practitioners in German there was no evidence that an increased in fluid intake
alone had any therapeutic effect in case of constipation. In contrast a study
conducted in a healthy non constipated subjects showed that enough fluid intake
has a significant on both bowel movement frequency and fecal masses.
2.
population Intervention comparison Outcome
33 years old Encourage intake Increased in fluid The result was
patient, with of fiber and fluid intake with and the bowel
medical diagnosis intake together to without increase movement was
ectopic pregnancy, treat constipation. fiber intake. significantly
develops increase in both
constipation groups, but the
during changes observed
hospitalization. in group 2 which
was about using
both methods
together treat
constipation fluid
and fiber intake

3. Group 1 & Group 2 all take high fiber intake but group 1 was without fluid intake
and group was both. The result was the bowel movement was significantly
increase in both groups, but the changes observed in group 2 which was about two
methods to treat constipation fluid and fiber intake. Within the study population as
a whole, the changes observed in bowel movement frequency displayed a positive
correlation with the changes in fluid intake. In my patient I encouraged her to take
enough fluid and fiber intake but because she was nauseated she was not able to
take enough fluid and fiber. So that’s she was not able to pass stool.

4. I tried to include these two methods to treat constipation in my patient, but my

patient was not able to take enough fluid and fiber because of nausea.
 20. Reflection: (Use Gibbs reflective cycle)
(3 Marks)

 Description:
On the third week of this semester I was posted on gynecology department at Khoula
hospital to do my case study which was about ectopic pregnancy, and this was my first time
to do assessment in this semester for Maternity and health nursing. Actually first I was afraid
because I don’t know what is ectopic pregnancy, this was my first time to hear this term. I
entered to my patient and started to greet her. First I observed that the facial expression of
her was sad or like she loss something but she stilled smile. I started to ask her question, and
she answered very well about her condition, she started to explain everything well and
expectorate her feeling and emotions regarding her condition. She stated that feel sorrowful
because of losing my first pregnancy, and I was waiting for this pregnancy for 2 years I, but
it is ok Allah will give me another pregnancy Insha’Allah. I faced a difficulty on responding
to her condition and feelings but I gave her my full attention while talking and tried to
answer her that you will get another pregnancy Insha’Allah.

 Feelings:
I felt very sad about her condition, and I felt guilty because I faced difficulty in
responding to her condition. I felt that I cannot do anything, and I don’t know how to
give a reaction to her situation. After I finished to communicate with her I thought that I
should search how to deal with patients on situations like this.

 Evaluation:
Actually, on the first day the event did not went good because I was not good enough in
giving a good response to situation like this, I felt difficulty on it. But on the second day
I tried to be good when dealing with her because I searched about how to deal with this
patient.

 Analysis:
The positive thing I learned from this experience that we as a nurse we have to know
how to deal with different patients with different diagnosis. We do not only need to
know how give care to the patient, also we need to know how to communicate and to
deal with them emotionally also, especially patients who faced grieving.

 Conclusion:
In conclusion, the positive point I learned from this situation that we have to know how
to deal with patients like this, and with all patient because as a nurse we can try our best
to do everything for the patients. “I cannot do everything; but still I can do something.
And because I cannot do everything, I will not refuse to do the something that I can do”.
 Action:
Actually, when I will face like this situation in the future. I will use some strategies to
communicate with the patients. I will try to use some statements to improve comfort such
as I am so sorry for your loss, I am here for you if you need to talk, what can I do for
you? And anytime you need me call me. In addition to that I will identify feelings and
thoughts, acknowledge the Loss, and listen carefully giving my full attention while the
patient talking.

21. References:
(3 Marks)
(Use Harvard or APA format for referencing)

 Gil Wayne (2017) constipation, Available at: https://nurseslabs.com/constipation/

(Accessed: 22 October 2019).

 Anti-D immunoglobulin, Available at: https://www.drugs.com/mmx/anti-d-

immunoglobulin.html(Accessed: 2 November 2019).

 Pillitteri, A. (2010). Maternal & child health nursing (6th ed., pp.559-601).
Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.

 May 2015 water supplementation enhances the effect of high fiber diet on stool
frequency in adult patients with constipation, Available at:
https://www.researchgate.net/publication/13601287_Water_supplementation_enh
ances_the_effect_of_high-
fiber_diet_on_stool_frequency_and_laxative_consumption_in_adult_patients_wit
h functional constipation (assessed 1 November 2019).

 By Dr. Claire Nicogossian(2017)9 Ways to Support Someone Who’s Experienced

Pregnancy Loss, Available at https://thriveglobal.com/stories/9-ways-to-support-
someone-who-s-experienced-pregnancy-loss/ (assessed 2 November 2019.)
 22. Organization of case study:
(2 Marks)

Follow the general guidelines of case study.

Marks obtained = _____________ X 35 % =

100

Teacher’s Signature: ______________________________ Date: _________________