University of Perpetual Help-DJGTMU Sto.

Nio, Bian Laguna

COLLEGE OF NURSING

CASE STUDY Ectopic Pregnancy2 (Ruptured Tubal Pregnancy) In Partial Fulfilment on Nursing Care Management 101

Group22 Lambojon, Monica Erielle F. Lavapiez, Maria Regina A. Lee, Bo Eun L Llames, Keodevico A. Lubrin, Errol N. Mendoza, Jessa B. Mindanao, Dianne Louis J. Miraflor, John Michael D. Pattugalan, Eugene R. Polancos, Chriatian Yeoj Ramos, Raymond Carlou M.

September 2010

Introduction Tubal pregnancy is the implantation of the fertilized ovum in a site in the fallopian tube. It is the most common type of ectopic gestation and it occurs when the fertilized ovum is prevented or slowed in its passage through the tube and thus implants before it reaches the uterus. The most common location for implantation is the ampulla of the fallopian tube. . The tubal pregnancy does not usually proceed beyond 8-10 weeks due to the lack of decidual reaction in the tube, the thin wall of the tube, the inadequacy of tubal lumen, bleeding in the site of implantation as trophoblast invades. It has many causative factors including tubal damage caused by pelvic inflammatory disease, previous tubal surgery, congenital anomalies of the tube, endometriosis, previous ectopic pregnancy, presence of an IUD, and in utero exposure to diethylstilbestrol (DES). Initially, the normal symptoms of pregnancy may be present, specifically amenorrhea, breast tenderness, and nausea. The woman may also experience lower abdominal pain. This is a case of patient G.D. 25 yrs old female, presently residing at 512, Sto. Nino, Binan, Laguna. Prior to admission, patient is experiencing acute pain, dizziness and internal bleeding. She was initially diagnosed to consider Ectopic Pregnancy 9wks G3P2 (2000) and finally diagnosed with Ruptured R Tubal Pregnancy and Severe Anemia secondary to Acute Blood Loss. And she had undergone R Salpingectomy Evacuation of Hemoperitoneum Blood Transfusion. Incidence (annual) of Ectopic pregnancy: 70,000 cases annually; about 1 in 250 pregnancies. Incidence Rate for Ectopic pregnancy: approx 1 in 3,885 or 0.03% or 70,000 people in USA Country/Region Extrapolated Incidence Philippines 22,194 Population Estimated Used 86,241,6972

PATIENT PROFILE NAME: Mrs. G.D. AGE: 25y/o BIRTHDAY: October 13, 1984 SEX: Female CIVIL STATUS: Married NATIONALITY: Filipino ADDRESS: 512 Sto.Nino Binan, Laguna RELIGEON: Catholic CHIEF COMPLAIN: abdominal pain and dizziness ADMISSION DATE: August 18,2010 ADMISSION DIAGNOSIS: T/C Etopic Pregnancy 9wks G3P2 (2000) ATTENDING PHYSICIAN: Dr. Diaz OPERATION PERFORM: Ex Lap, Salphyngectomy (R) FINAL DIAGNOSIS: Ruptured tubal pregnancy right severe anemia secondary to acute blood loss

Patients History .BRIEF BACKGROUND HISTORY: This is a case of patient G.D. 25 yrs. old Female, presently residing at 512, Sto. Nino, Binan, Laguna was admitted for the first time to Hospital of Binan on August 18, 2010. Prior to admission patient is experiencing acute pain, dizziness and internal bleeding. She has the initial vital signs of: BP: 80/30; CR: 50; RR: 20; TEMP: 36. She is diagnosed with status initially to consider Ectopic Pregnancy 9wks G3P2 (2000) and finally Ruptured Tubal Pregnancy R severe anemia secondary to Acute Blood Loss.

And her operation is Salpingectomy R Evacuation of Hemoperitoneum Blood Transfusion,.

History of Present Illness: Few hours PTA (+) abdominal pain,(RLQ), +dizziness hence wheeled in an hospital and subsequent admission. Physical Assessment

Vital Signs: BP: palpatory 60 CR: 99 bpm RR: 25 cpm temp.: 34.8 0

BODY PART 1. Skin

ASSESSMEN T TECHNIQUE Inspection

NORMAL FINDINGS Fair complexion, absence of scars & lesions. Good skin turgor. No lice & nits.

ACTUAL FINDINGS

Fair complexion, absence of scars & lesions. Good skin turgor. No edema.

Palpation

2. Scalp

Inspection

No lice & nits.

Palpation 3. Hair Inspection

No lumps and lesions. Evenly distributed hair, color varies mostly

No lumps and lesions. Evenly distributed black hair.

Palpation

in black. Smooth in texture & Shiny.

Dry and oily.

4. Face

Inspection

Symmetrical face movement, symmetrical nasolabial folds round cornea, black color ; white sclera. Reacts to light & accommodati on. Hair evenly distributed with skin intact ,symmetrically aligned with equal movement. Skin intact, no discharge, no discoloration. Lids able to close symmetrically.

Symmetrical face movement, symmetrical nasolabial folds

5. Eyes

Inspection

round cornea, black color ; white sclera. Reacts to light & accommodation

6.Eyebro ws

Inspection

Hair evenly distributed with skin intact ,symmetrically aligned with equal movement.

7. Eyelids

Inspection

Skin intact, no discharge, no discoloration. Lids able to close symmetrically.

8. Ears

Inspection

Same color as facial skin, symmetrical. Auricle with outer canthus of eyes about 10 degree of vertical, mobile firm and not tender, free from lesions. No voice tone audible & able to understand spoken words. Midline & Symmetrical to face, no lesions, no nasal discharges or flaring uniform in color, air moves freely. Proportional and symmetrical with face. Pink in color, smooth, no lesions. Complete without dentures.

Same color as facial skin, symmetrical. Auricle with outer canthus of eyes about 10 degree of vertical, mobile firm and not tender, free from lesions.

Palpation

9. Hearing Acuity

Inspection

No voice tone audible & able to understand spoken words.

10. Nose

Inspection

Clear nostril

11. Mouth

Inspection

Proportional and symmetrical with face.

12. Lips

Inspection

no lesions. Crack lips Complete without dentures.

13. Teeth

Inspection

14. Tongue

Inspection

Tongue floor is in central position, pink in color, moist, no lesions or swelling. Symmetrical during lung expansion & recoil. No lesions and abnormal grating sound. Resonance.

Tongue floor is in central position, pink in color, moist, no lesions or swelling.

15. Chest

Inspection

Symmetrical during lung expansion & recoil. No lesions and abnormal grating sound. Resonance. No abnormal breath sounds.

Palpation

Percussion

Auscultation

No abnormal breath sounds. Normal rate, rhythm, no murmur. No lesions, masses & tenderness. No abnormal bowel sounds. Tympany. No lesions, masses or tenderness Abnormal rate, rhythm, no murmur.

16.Heart

Auscultation

17. Abdomen

Inspection

No lesions, masses & tenderness. No abnormal bowel sounds. Tympany. No lesions, masses or tenderness

Auscultation

Percussion Palpation

18.Upper Extremitie s

Inspection

Symmetrical to the body & no lesions.

Symmetrical to the body & no lesions. Delayed capillary refilled test (5secs) No tenderness, no palpable mass noted. Palpable Brachial & Radial Pulse. Able to move freely without discomfort; able to adduct, abduct, flex, and extend.

Palpation

Inspection on abduction, adduction, flexion, extension.

No tenderness, no palpable mass noted. Palpable Brachial & Radial Pulse. Able to move freely without discomfort; able to adduct, abduct, flex, and extend. Pink in color hand, no lesions. Nails are clean. Pink nail beds.

19. Palms

Inspection

White in color hand, no lesions.

20. Fingernail s

Inspection

Nails are dirty. Pallor Nail beds.

21. Lower Extremitie s

Inspection

Palpation

Symmetrical to the body, no lesions noted, muscle appear equal with good muscle tone.

Symmetrical to the body, no lesions noted, muscle appear equal with good muscle tone.

22. Toenails

Inspection

Pink nail beds with capillary refill of 1-3 seconds.

White nail beds with capillary refill of 4 seconds.

ANATOMY and PHYSIOLOGY

The Female Reproductive System (or female genital system) contains two main parts: the uterus, which hosts the developing fetus, produces vaginal and uterine secretions, and passes the male's sperm through to the fallopian tubes; and the ovaries,

which produce the female's egg cells. These parts are internal; the vagina meets the external organs at the vulva, which includes the labia, clitoris and urethra. The vagina is attached to the uterus through the cervix, while the uterus is attached to the ovaries via the Fallopian tubes. At certain intervals, the ovaries release an ovum, which passes through the Fallopian tube into the uterus. If, in this transit, it meets with sperm, the sperm penetrate and merge with the egg, fertilizing it. The fertilization usually occurs in the oviducts, but can happen in the uterus itself. The zygote then implants itself in the wall of the uterus, where it begins the processes of embryogenesis and morphogenesis. When developed enough to survive outside the womb, the cervix dilates and contractions of the uterus propel the fetus through the birth canal, which is the vagina. The ova are larger than sperm and have formed by the time a female is born. Approximately every month, a process of oogenesis matures one ovum to be sent down the Fallopian tube attached to its ovary in anticipation of fertilization. If not fertilized, this egg is flushed out of the system through menstruation, female's internal reproductive organs are the vagina, uterus, fallopian tubes, cervix and ovary. The vagina is a fibro muscular tubular tract leading from the uterus to the exterior of the body in female mammals, or to the cloaca in female birds and some reptiles. Female insects and other invertebrates also have a vagina, which is the terminal part of the oviduct. The vagina is the place where semen from the male is deposited into the female's body at the climax of sexual intercourse, commonly known as ejaculation. Around the vagina, pubic hair protects the vagina from infection and is a sign of puberty. The vagina is mostly used for sexual intercourse. The cervix is the lower, narrow portion of the uterus where it joins with the top end of the vagina. It is cylindrical or conical in shape and protrudes through the upper anterior vaginal wall. Approximately half its length is visible, the remainder lies above the vagina beyond view. The vagina has a thick layer outside and it is the opening where baby comes out during delivery. The cervix is also called the neck of the uterus. The uterus or womb is the major female reproductive organ of humans. The uterus provides mechanical protection, nutritional support, and waste removal for the developing embryo (weeks1-8) and fetus (from week 9-delivery). In addition, contractions in the muscular wall of the uterus are important in ejecting the fetus at the time of birth.

The uterus contains three suspensory ligaments that help stabilize the position of the uterus and limits it's range of movement. The uterosacral ligaments, keep the body from moving inferiorly and anteriorly. The round ligaments, restrict posterior movement of the uterus. The cardinal ligaments, also prevent the inferior movement of the uterus. The uterus is a pear-shaped muscular organ. Its major function is to accept a fertilized ovum which becomes implanted into the endometrium, and derives nourishment from blood vessels which develop exclusively for this purpose. The fertilized ovum becomes an embryo, develops into a fetus and gestates until childbirth. If the egg does not embed in the wall of the uterus, a woman begins menstruation and the egg is flushed away. The Fallopian tubes or oviducts are two tubes leading from the ovaries of female mammals into the uterus. On maturity of an ovum, the follicle and the ovary's wall rupture, allowing the ovum to escape and enter the Fallopian tube. There it travels toward the uterus, pushed along by movements of cilia on the inner lining of the tubes. This trip takes hours or days. If the ovum is fertilized while in the Fallopian tube, then it normally implants in the endometrium when it reaches the uterus, which signals the beginning of pregnancy. The ovaries are small, paired organs that are located near the lateral walls of the pelvic cavity. These organs are responsible for the production of the ova and the secretion of hormones. ovaries are the place inside the female body where ova or eggs are produced. The process by which the ovum is released is called ovulation. The speed of ovulation is periodic and impacts directly to the length of a menstrual cycle. After ovulation, the ovum is captured by the oviduct, after traveling down the oviduct to the uterus, occasionally being fertilized on its way by an incoming sperm, leading to pregnancy and the eventual birth of a new human being. The Fallopian tubes are often called the oviducts and they have small hairs (cilia) to help the egg cell travel. The external components include minora, Bartholin's glands, and clitoris. the mons pubis, labia majora, labia

TUBAL PREGNANCY (ECTOPIC PREGNANCY) visualization of an isthmic ectopic pregnancy.

Laparoscopic

Tubal pregnancy, also referred to as ectopic pregnancy, is the number one cause of death of women in the first trimester of pregnancy. With the numbers of tubal pregnancy on the rise, it is important to understand more about tubal pregnancies. Tubal pregnancy, occurs when a fertilized egg is implanted outside the uterus, typically in one of the fallopian tubes. Once conception has taken place the now fertilized egg will usually take four or five days to travel from the ovary to the uterus. However, should the tube be blocked or damaged, or the egg simply fails to reach the uterus, the egg may be implanted in the tube and continue to develop there instead of the uterus. About one of every 50 pregnancies results in a tubal pregnancy. Unfortunately, no one has yet figured how to transplant the embryo from the fallopian tube to the uterus, so unfortunately the pregnancy needs to be terminated. If it is not picked up and treated, the embryo will simply continue to grow where it is. The damage that can be caused from an tubal pregnancy going unnoticed is serious and in fact can end in death. In most tubal implantations, the proliferating trophoblast invades the tubal wall. Ectopic pregnancies in the ampullary portion of the tube are often within the tubal lumen and have not caused tubal rupture, while those in the isthmic portion are more likely to be found outside the lumen, having caused tubal rupture. The degree of trophoblastic invasion of maternal tissues, the age and viability of the pregnancy, and the site of

implantation determine the sequence of clinical events. As the trophoblasts proliferate, the growth may extend from the luminal mucosa, into the muscularis and lamina propria, through to the serosa and, ultimately, full thickness even into large blood vessels in the broad ligament. With vascular disruption, bleeding takes place that distorts the tube, stretches the serosa, and causes pain. The embryo is abnormal and degenerates in about 80% of cases. If left untreated, spontaneous tubal abortion occurs in about 50% of tubal ectopic pregnancies and may often be clinically silent. Likewise, spontaneous tubal abortion with hemorrhage can occur with bleeding that is self-limited. However, the remaining cases of ectopic pregnancy will eventually cause tubal rupture and are associated with significant and possibly life-threatening hemorrhage. As noted previously, this complication is most likely to occur in the isthmic part of the tube, which has limited distensibility. Chronic tubal rupture with extension into the broad ligament can produce a pelvic hematoma that can last for several weeks. Unruptured ectopic pregnancies can produce a chronic course, with persistently elevated -human chorionic gonadotropin (-hCG) levels that may last for weeks.

PATHOPHYSIOLOGY
Modifiable: Pill User (ethnylestradiol and levenorgestrel ) Non-Modifiable: Age Sex

Increase the level of estrogen and progesterone to slow the movement of fertilized egg

Dysfunction of the Right Fallopian Tube

Occurances of Fetal Development of Right Fallopian Tube

Swelling of the Right Fallopian Tube

Results of a Ruptured Right Fallopain Tube

Massive Internal Bleeding

Symptoms: Dizzinnes R/T Severe Blood Loss

Symptoms: Acute Lower Abdominal Pain

RUPTURED TUBAL PREGNANCY

Medical Management PROGRESS NOTES/DATE DOCTORS ORDER RATIONALE

Aug. 18, 2010

Admit to ROC under the receiving Dra. Diaz

For strict of observation

9:45am Secure consent for admission and management

For legality purpose

NPO

To prevent aspiration

CC: Abdominal Pain Insert line (R) D5LR 1L, FD 200 cc then run 6mg for 2hrs To replenish fluid loss

A: T/C Ectopic Pregnancy 9wks G3P2 (2002)

Diagnostics: CBC Bloodtyping Pregnancy test -

Laboratory test were done to verify the nature of the disease. To check for any abnormal findings To prevent blood coagulation, when blood transfusion is necessary To check for any signs of pregnancies.

Pt conscious and coherent BP= 90/60 CR= 98 RR= 20 T= 35.0

Ampicillin 2g IV ANST (-) stat

To prevent infection

Secure 3 PRBC properly typed and crossedmatched -

For replenishing of blood loss Cross-matching is to prevent coagulation.

1:00pm

02 inhalation 2-3cpm via n/c -

To prevent respiratory distress. To provide sufficient oxygen.

VS every 30 mins. For EXLAP

For strict monitoring. To provide visualization area

Secure consent

For legal documentation

Refer accordingly

IVF to following: (L) PNSS 1Lx6hrs (R) D5LR 1Lx8hrs

To maintain sodium and electrolytes Further provides fluid, calories and electrolytes

replacement.

POST OPERATIVE ORDERS 10:05pm S/P EXPLAP, Salphyngectomy, RIGHT

To provide visualization of abdominal cavity. For inhalation of asthesia.

Aug. 18, 2010

To PACU now (RR)

For recovery room from anesthesia.

02 inhalation at 5-6cpm via FC

To prevent respiratory distress. To provide oxygenation.

Flat in bed x 1pillow for 8hrs

Recovery position

Regulate present IVF at 3031 gtts/min

Considering that the patient is on NPO PNSS was ordered to provide calories and sodium chloride. To prevent aspiration.

IVF to follow: D5LR 1L x 8hrs D5LR 1L x 8hrs To provide calories and electrolytes. To provide calories

PNSS 1L x 10hrs

and electrolytes. To maintain Sodium and electrolytes balance.

NPO Meds: Ketorolac 30mg TIV every 6hrs (-) ANST x 4 doses For treatment of severe acute post operative pain management. To prevent pneumonia aspiration.

Tramadol 100mg TIV as loading dose then 50mg TIV every 6hrs x 4 doses (-) ANST w/ BP precautions, defer if BP 90/60 mmHg Ranitidine 1amp TIV every 8hrs while on NPO

For treatment of moderate to sever pain. It inhibits gastric acid secretions.

Continue Ampicillin 1g TIV (-) ANST as additional loading dose then 500 mg TIV every 8hrs x 3 more doses ( Oral)

For treatment of infection.

Transfuse 2units PRBC properly typed xx matched. For post BT Hgb & Het & seper buds to AP

To prevent medical errors. To replace blood loss.

Monitor vital signs q 15mins for 2hrs then q 30mins then q 1hr therefore and record. Monitor vital signs q 1hr and record , refer <30cc/min
-

To assess and supervise the condition of the patient. To assess and supervise the condition of the patient

Watch out for respiratory distress, cyanosis, hypertension, tachycardia, bradycardia, etc Refer 8/19 5:00AM 7:30AM IV to ff. L arm ; PNSS 1L x KVO

To monitor and note clients condition.

May give Paracetamol 1 amp PRN

To facilitate medication administration. To decrease fever the effects of pyrogens on the hypothalamic heat regulating center and by hypothalamic action leading and vasodilatation.

May give Diphenhydramine 1 amp PRN11:40AM

To decrease occurrence of allergy.

To promote comfort

Moderate to high back rest.

and wellness.

Apply abdominal binder please.

To prevent wound dehiscence and evisceration.

For billing purposes

Count all IVF orders and BT order.

Cut IV needs as ordered this shift to oral :

To prevent over dosage.

To prevent infection. To prevent infection. To relief pain This is the proper

- Amoxicillin 50g by TID - Metronidazole 50g by TID - Mefenamic acid 50g by TID May have general liquids now, the DAT once with flatus -

diet before soft diet. Flatus indicates DAT

To lessen the pain.

IFC out now. Encourage deep breath and ambulatory Refer - L : IVF PNSS 1L x KVO R : D5LR 1L x q 8hrs -

KVO is to facilitate medication administration. To provide calories and electrolytes. It is an analgesic muscle relaxant and urticosuric drug

8:25PM Temperature : 38.3 Paracetamol 500g/tab 1 tab q 4hrs P.O. for fever >37.8

To produce friction thus opening the pores to release heat.

TSB

Refer IVF To consume -

To ensure the patient receives required fluids and electrolytes.

For Iron- deficiency.

2:50PM BP : 110/60 Ferrous sulfate 1 tab OD Refer accordingly 8/23 3:20PM MGH continue medications at

The patient recovered from complicated conditions.

To check for

home

changes.

FF. up at Sept. 1, 2010 at Marina Hospital 1PM to 3PM For charge of dressing prior to discharge

To prevent infection and promote wellness.

Diagnostic Test TEST HEMOGLOBIN RESULT 110 NORMAL VALUES M (120-150 gm/L) F HEMATOCRIT 0.33 M F RED BLOOD CELLS 3.5 (4.5-6 x 10/L) (110-140 gm/L) (0.40-0.54) (0.37-0.47)

TOTAL WHITE BLOOD CELLS

24.0

(5.0x10/L-10x10/L)
200-400 x 109 /L

0.88 0.10 0.02

(0.50-0.70) (0.20-0.40) (0-0.09) (0-0.04) (0-0.01) (0-0.04) 2mins - 6mins 1min - 5mins F <50Y/O = <20mm/hr >50y/o M = <30mm/hr

<50y/o = <20mm/hr >50y/o = <20mm/hr

*** Increse in WBC indicates indection Nursing Management

Rationale

1. Determine the data and description of the patients last menstrual period

Predicting the pregnancy due date based on conception is the most accurate way to calculate ones due date, but usually the date of conception is not known. Therefore, due date is generally calculated from the first day of the last menstrual period. To note whether there are changes To determine the cause of abnormal uterine bleeding To monitor the patients condition To monitor imbalances or dehydration To replace blood that was lost and to reduce the pain So the patient will feel comfortable So the patient will feel comfortable and will feel safe Expressions of feelings can facilitate grieving process, but destructive behaviour can be damaging To facilitate the return of a balance state: to develop specific responses to help deal with the stressor or seeking diversion

2. Monitor vital signs 3. Assess vaginal bleeding, including amount and characteristics 4. Assess pain scale 5. Monitor intake and output 6. Administer prescribed blood transfusions and analgesic 7. Provide emotional support 8. Provide a quiet and relaxing environment 9. Encourage the patient to express feelings of fear, loss and grief

10. Help the patient develop effective coping strategies