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ASSESSMENT Subjective: n/a Objective: abdomin al pain (lower right) p= no provoking factor, painful even at rest q= sudden, sharp,

, knifelike pain r= radiates to the right shoulder s= not mentioned (however, usual pain scale for

NURSING DIAGNOSIS

Acute pain r/t rupture of the blood vessels of the fallopian tube secondary to ectopic pregnancy Release of As evidenced chemical by verbal mediators report of pain (prostaglandin, on the lower bradykinin, right serotonin, Subs abdominal P) portion. Transmission of impulse from peripheral Nerves to Spinal Cord A fiber C Fiber Spino-thalamic Tract

SCIENTIFIC EXPLANATIO N Damage to the tissues and blood vessels of the fallopian tube

PLANNING Discharge Outcome Upon discharge, the client will be able to report manageable level of pain from pain scale of 6/10 to 2/10. Short Term Outcome Afte 8 hours of nursing interventions the client will be able to: a. Perform 3/5 nonpharmacolo gic ways to decrease pain such as effective breathing exercises, changing position, diversional activities and guided imagery.

NURSING INTERVENTION 1. assess level of pain (note location, scale, provoking factor, radiation, time and frequency) 2. demonstrate to the client proper breathing exercise

RATIONALE 1. assessing the pain will help in determining the interventions needed to relieve such pain. Breathing exercise is a relaxation technique that reduces pain by relaxing tense muscles that contribute to pain. 3. guided imagery is focusing intently in an object to keep sensory input from reaching the cortex of the brain 4. distraction or diversional activities

EVALUATION Discharge Outcome Outcome fully achieved. Recommendation: Terminate the plan Upon discharge, the client was able to report manageable level of pain from pain scale of 6/10 to 2/10. Short Term Outcome Outcome fully achieved. Recommendation: Terminate the plan Afte 8 hours of nursing interventions the client was able to: a. Perform 3/5 nonpharmacologic ways to decrease

3. instruct client to perform guided imagery

4. provide diversional

ectopic pregnancy is severe (810) t= not mentioned

Brain Stem and Thalamus Somatic Sensory Cortex Perception of Pain Acute Pain sudden, sharp, knifelike pain

Report decrease of pain, with the following criteria: - pain scale from 10/10 to 6/10

activities such as listening to mellow music, socialization

are though to reduce the perception of pain by stimulating the descending control system resulting to fewer painful stimuli being transmitted to the brain. 5. the gate controltheory of pain proposes that stimulation of fibers that transmit nonpainful sensations can block or decrease the transmission of pain impuses. Massage, touch and other type of pain management is based on this theory.

5. provide other nonpharmacologic interventions: - massage - therapeutic touch

pain such as effective breathing exercises, changing position, diversional activities and guided imagery. Report decrease of pain, with the following criteria: - pain scale from 10/10 to 6/10

collaborative 1. provide analgesic as ordered by the physician

Analgesic drugs act in various ways on the peripheral and c

entral nervous systems; they include paracetamo l (paraacetylaminophenol, also known in the US as acetaminophen), thenon-steroidal anti-inflammatory drugs (NSAIDs) such as the salicylates, and opioid drugs such as morphine and op ium. They are distinct from anesthetics, which reversibly eliminatesensation

NURSING DIAGNOSIS Subjective: Fluid volume deficit r/t rupture of n/a blood vessels of Objective: the fallopian tube secondary to G3P2 ectopic Vaginal pregnancy spotting As black in evidenced color by vaginal Adnexal mass/ pelvic spotting (black in mass posterior to color), bp of 80/ 50 the uterus mmHg, RR Bp= 80/ 50 of 35 cpm, mmHg Rr= 35 cpm PR of 120 bpm and Pr= 120 serum hgb of bpm 90. Serum Hgb= 90 Ultrasonohr aphy= confirmed implantation

ASSESSMENT

SCIENTIFIC EXPLANATION Fertilization occurs at the distal portion of the fallopian tube Zygote divides and grows normally Obstruction due to adhesion of fallopian tube, congenital ,malformation, scars from surgery, or uterine mass Proximal end of the tube is compressed Zygote can not travel the lenth of the tube. It lodges at the strictured site and implants there

PLANNING Discharge Outcome Upon discharge, the client will be able to maintain fluid volume at a functional level as evidenced by stable vital signs (BP from 100/70 mmHg to 110/80 or within normal, RR from 25 cpm to 15- 20 cpm and PR from 100 bpm to 60- 90 bpm) and normal hematocrit level Short Term Outcome Afte 8 hours of nursing interventions the client will be able to: a.receive at least 5 both nonpharmacologic and pharmacologic

NURSING INTERVENTION Independent 1. assess the amount of bleeding, use the rule of thumb (more than 1 sanitary pad in an hour is considered excessive. 2. monitor vital signs esp. the Bp, RR and PR 3. monitor intravenous fluid intake.

RATIONALE

EVALUATION Discharge Outcome

1. to determine extent and amount of bleeding

Outcome fully achieved. Recommendation: Terminate the plan Upon discharge, the client was able to maintain fluid volume at a functional level as evidenced by stable vital signs (BP from 100/70 mmHg to 110/80 or within normal, RR from 25 cpm to 15- 20 cpm and PR from 100 bpm to 60- 90 bpm) and normal hematocrit level Short Term Outcome Outcome fully achieved.

2. to detect for impending hypovolemic shock 3. intravenous fluid using a large gauge catheter is done to replace intravascular volume. 4. to facilitate venous return and to prevent excessive abdominal viscera shift and restriction of the diaphragm that occurs with the head-down position

4. position client in a Trendelenburg position

at the middle portion of fallopian tube.

Zygote grows large enough Ruptures the slender fallopian tube or trophoblast cells break through the narrow base. Tearing and destruction of blood vessels Hemorrhage Fluid volume deficit s/sx: >hypotension >tachycardia >tachypnea >low hgb, hct and rbc levels

interventions that will help in reestablishing functional level of fluid volume. b. demonstrate increased fluid volume as evidenced by increase in BP from 80/ 50 mmhg to 100/ 70 mmHg, RR frm 35 cpm to 25 cpm and pr from 120 bpm to 100 bpm increased serum hgb.

. Collaborative 1. transfuse blood as ordered by the Physician. 2. monitor CBC, blood typing, cross matching and hcg level results. 1. blood transfusion is done to replace the blood loss. 2. CBC will determine the amount of hemoglobin and rbc levels. Blood typing is necessary for blood transfusion and hcg level is done if pregnancy has not been confirmed yet. 3. Laparoscopy- three small puncture wounds; remove tubal pregnancy, Laparotomy- surgical incision made approx 4in long; tubal pregnancy removed Methotraxate is a chemotherapeutic drug, a folic acid

Recommendation: Terminate the plan Afte 8 hours of nursing interventions the client was able to: a.receive at least 5 both nonpharmacologic and pharmacologic interventions that will help in reestablishing functional level of fluid volume. b. demonstrate increased fluid volume as evidenced by increase in BP from 80/ 50 mmhg to 100/ 70 mmHg, RR frm 35 cpm to 25 cpm and pr from 120 bpm to 100 bpm and increased serum hgb.

3. prepare client for possible surgery Laparoscopy Laparotomy-

4. Administration of Methotrexate(ch

ref: Maternal and Child health nursing 5th edition Volume 1, pg. 408- 409

emo medication) po; inhibits cell division in embryo

antagonist that attacks and destroys fastgrowing cells.