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I.

Introduction

An ectopic pregnancy is a pregnancy that develops outside a woman's uterus
(womb). This happens when the fertilized egg from the ovary does not implant itself
normally in the uterus. Instead, the egg develops somewhere else in the abdomen. The
products of this conception are abnormal and cannot develop into fetuses.
The most common place that ectopic pregnancy occurs is in one of the fallopian
tubes (a so-called tubal pregnancy). These are the tubes that transport the egg from the
ovary to the uterus. Ectopic pregnancies also can be found on the outside of the uterus, on
the ovaries, or attached to the bowel.
The most serious complication of an ectopic pregnancy is intra-abdominal
hemorrhage (severe bleeding). In the case of a tubal pregnancy, for example, as
the products of conception continue to grow in the fallopian tube, the tube expands and
eventually ruptures. This can be very dangerous because a large artery runs on the outside
of each fallopian tube. If the artery ruptures, you can bleed severely.
None of these areas has as much space or nurturing tissue as a uterus for a
pregnancy to develop. As the fetus grows, it will eventually burst the organ that contains
it. This can cause severe bleeding and endanger the mother's life. A classical ectopic
pregnancy never develops into a live birth.
Ectopic pregnancy is usually found in the first 5-10 weeks of pregnancy.
II. Patients Profile

Name: ?

Age: 34 years old

Sex: Female

Civil Status: Married

Address: ?

Nationality: Filipino

Religion: Roman Catholic

Occupation: House Wife

Birth Place: ?

Birth Date: ?

Name of Father: ?

Name of Mother: ?

Name of Spouse: ?
III. Developmental Task

Freud theorized that the libido developed in individuals by changing its object,
through the process of sublimation. He argued that humans are born "polymorphous
perverse"[1], meaning that any number of objects could be a source of pleasure. Following
a biological logic, Freud established a rigid model for that "normal" sexual development
of the human being, or the "libido development". Each child passes through five
psychosexual stages. During each stage, the id focuses on a distinct erogenous zone on
the body. . The term "psychosexual infantilism," refers to those who become fixated in
this way and fail to mature through the psychosexual stages into heterosexuality. Freud
related the resolutions of the stages with adult personalities and personality disorders.
Despite their popularity among psychoanalytical psychologists, Freud's
psychosexual theories are commonly criticized as being sexist. For example, Freud stated
that young females develop "penis envy" toward the males during their psychosexual
development. In response, Karen Horney, a German Freudian psychoanalyst, argued that
young females develop "power envy" instead of "penis envy" toward the male.
Genital phase
The genital stage starts at puberty, allowing the child to develop opposite sex
relationships with the libidinal energy again focused on the genital area. According to
Freud, if any of the stages are fixated on, there is not enough libidinal energy for this
stage to develop untroubled. To have a fully functional adulthood, the previous stages
need to be fully resolved and there needs to be a balance between love and work.
Erikson’s theory of psychosocial development is one of the best-known theories
of personality in psychology. Similar to Freud, Erikson believed that personality develops
in a series of stages. Unlike Freud’s theory of psychosexual stages, Erikson’s theory
describes the impact of social experience across the whole lifespan.

One of the main elements of Erikson’s psychosocial stage theory is the develoment of
ego identity. Ego identity is the conscious sense of self that we develop through social
interaction. According to Erikson, our ego identity is constantly changing due to new
experience and information we acquire in our daily interactions with others. In addition to
ego identity, Erikson also believed that a sense of competence also motivates behaviors
and actions.
Each stage in Erikson’s theory is concerned with becoming competent in an area
of life. If the stage is handled well, the person will feel a sense of mastery. If the stage is
managed poorly, the person will emerge with a sense of inadequacy.

In each stage, Erikson believed people experience a conflict that serves as a turning point
in development. In Erikson’s view, these conflicts are centered on either developing a
psychological quality or failing to develop that quality. During these times, the potential
for personal growth is high, but so is the potential for failure.
Psychosocial Stage 6 - Intimacy vs. Isolation
• This stage covers the period of early adulthood when people are exploring
personal relationships.
• Erikson believed it was vital that people develop close, committed relationships
with other people. Those who are successful at this step will develop relationships
that are committed and secure.
• Remember that each step builds on skills learned in previous steps. Erikson
believed that a strong sense of personal identity was important to developing
intimate relationships. Studies have demonstrated that those with a poor sense of
self tend to have less committed relationships and are more likely to suffer
emotional isolation, loneliness, and depression.

Havighurst developmental Task
Developmental Tasks of Early Adulthood

1. 1. Selecting a mate

2. 2. Achieving a masculine or feminine social role

3. 3. Learning to live with a marriage partner

4. 4. Starting a family

5. 5. Rearing children

6. 6. Managing a home

7. 7. Getting started in an occupation

8. Taking on civic responsibility
IV. Anatomy and Physiology

ANATOMY
The Fallopian tubes are paired, tubular, seromuscular organs whose course runs medially
from the cornua of the uterus toward the ovary laterally. The tubes are situated in the
upper margins of the broad ligaments between the round and utero ovarian ligaments
(Fig. 2). Each tube is about 10 cm long with variations in length from 7 to 14 cm. The
abdominal ostium is situated at the base of a funnel-shaped expansion of the tube, the
infundibulum, the circumference of which is enhanced by irregular processes called
fimbriae. The ovarian fimbria is longer and more deeply grooved than the others and is
closely applied to the tubal pole of the ovary. Passing medially, the infundibulum opens
into the thin-walled ampulla forming more than half the length of the tube and 1 or 2 cm
in outer diameter; the isthmus, a round and cord-like structure constituting the medial
one-third of the tube and 0.5-1 cm in outer diameter, succeeds it. The interstitial or conual
portion of the tube continues from the isthmus through the uterine wall to empty into the
uterine cavity. This segment of the tube is about 1 cm in length and 1 mm in inner
diameter.
PHYSIOLOGY
The tubes act as ducts for sperm, oocyte, and fertilized ovum transport, in addition to
being the normal site of fertilization. These functions depend mainly on three factors:
tubal motility, tubal cilia, and tubal fluid.
V. Pathophysiology

Predisposing Factors:
• Sex – women of childbearing age are affected.
• Age – women of childbearing age are affected.

Precipitating Factors:
• Prior pelvic inflammatory disease
• Prior ectopic pregnancy
• Pregnancy in a woman with an intrauterine device (IUD) in place
• Pregnancy achieved by means of in vitro fertilization or fertility drugs
• Prior tubal surgery (reconstruction or tubal coagulation)
• Cigarette smoking
• Increasing age

Schematic Diagram:

Fertilized egg inability to work
it’s way quickly enough down the fallopian
tube into the uterus

infection or inflammation of the tube may have
partially or entirely blocked it

endometriosis or scar tissue from previous
abdominal or fallopian surgeries
can also cause blockages

alter the shape of the tube and disrupt
the egg’s progress
VI. Medical Management

Doctor’s Order
- refer to OR department for operation
o to prepare the patient for the operation
- insert D5LR 1liter at 120 gtts/min
- follow PNSS 1liter at KVO rate
o for IVTT medication purpose
- administer Tramadol 50 mg IVTT every 6 hours
o use for management of moderate to moderately severe pain
- administer Ketorolac 30 mg IVTT every 8 hours
o use for short term management of pain
- administer Ranitidine 50 mg IVTT every 8 hours NPO
o use for short term treatment of active duodenal ulcer
- administer Metoclopramide 10 mg IVTT every 8 hours
o use for symptomatic treatment of gastroesophageal reflux
- administer Nubain 3 mg IVTT 8 hours for severe pain (reserve dose)
- monitor I & O
o use to monitor if the intake and output of the patient is equal
- for blood transfusion
o to compensate blood loss
- refer accordingly

VII. Laboratory Results
o Blood Typing
Type: A+
o Hematology
CBC - 60
Hemoglobin - 25 - severe hemorrhage
WBC - 60 - surgery
Hematology - 25 - hemorrhage
Platelet - 60
VIII. Drug Study

Generic Name: Tramadol
Date Ordered: May 7.2007
Classification: Opioid Analgesics
Dosage, Frequency, Route: 50 mg IVTT every 6 hours
Mechanism of Action: Unknown. A centrally acting synthetic analgesic compound not
chemically related to opioids. Thought to bind to opioid receptor
and inhibit reuptake of norepinephrine and serotonin.
Specific indication: Moderate to moderately severe pain
Contraindication: Contraindicated in patients hypersensitive to drug or other opioids
Adverse Reaction: Vertigo, malaise, vasodilation, visual disturbances, constipation, and
menopausal symptoms
Nursing Precaution: Monitor CV and respiratory status. Withhold dose and notify
prescriber if respiration decrease or rate is below 12 breaths/minute

Generic Name: Ketorolac
Date Ordered: May 6, 2007
Classification: Nonsteriodal anti-inflammatory drugs
Dosage, Frequency, Route: 30 mg IVTT every 8 hours
Mechanism of action: Unknown. May inhibit prostaglandin synthesis, to produce anti-
inflammatory, analgesics and antipyretic effects.
Specific indication: Short term management of moderately severe, acute pain for single
dose treatment
Contraindication: Contraindicated as prophylactic analgesic before major surgery or
intraoperatively when hemostasis is critical and in patients currently
receiving aspirin
Adverse Reaction: Sedation, hypertension, and dyspepsia, prolonged bleeding time
Nursing Precaution: Correct hypovolemia before giving ketorolac

Generic name: Ranitidine
Date ordered: May 6, 2007
Classification: Antiulcer drug
Dosage, Frequency, Route: 50 mg IVTT every 8 hours NPO
Mechanism of action: Competitively inhibits action of histamine on the H2 at receptor
sites of parietal cells, decreasing gastric acid secretion
Specific indication: Duodenal and gastric ulcer; pathologic hypersecretory condition such
as Zollinger-Ellison syndrome
Contraindication: Contraindicated in patients hypersensitive to drug and to those with
acute porphyria
Adverse reaction: Malaise, blurred vision, jaundice, burning and itching at injection site
Nursing precaution: Assess patient for abdominal pain. Note for presence of blood in
emesis, stool or gastric aspirate.
Generic name: Metoclopramide
Date ordered: May 6, 2007
Classification: antiemetics
Dosage, Frequency, Route: 10 mg IVTT every 8 hours
Mechanism of action: Stimulates motility of upper GI tract, increases lower esophageal
sphincter tone and blocks dopamine, receptor at the chemoreceptor trigger zone
Specific Indication: Emesis during pregnancy
Contraindication: Contraindicated in patients hypersensitivity to drug and in those with
pheochromotoma or seizure disorder
Adverse reaction: Restlessness, hypotension, bowel disorder, urinary frequency, loss of
libido
Nursing precaution: Safety and effectiveness of drug haven’t been established for therapy
lasting longer than 12 weeks

Generic name: Nubain
Date Ordered: May 7, 2007
Classification: Opioid analgesics
Dosage, Frequency, Route: 3 mg IVTT 8 hours for severe pain
Mechanism of action: Unknown. Binds with opiate receptors in the CNS, altering
perception of and emotional response to pain
Specific indication: Moderate to severe pain
Contraindication: Contraindicated to patients hypersensitive to drug
Adverse reaction: Sedation, hypertension, blurred vision, dry mouth, cramps, urinary
urgency
Nursing precaution: Monitor circulatory and respiratory status and bladder and bowel
function. Withhold dose and notify prescriber if respirations
shallow or rate is below 12 breaths/minute.
IX. Ideal Nursing Management

Diagnosis: Knowledge deficient regarding condition, prognosis, and treatment related to
lack of exposure.

Intervention Rationale
1. Review specific pathology and - provides knowledge base from which
anticipated surgical procedure. Verify that patient can make informed therapy choices
appropriate consent has been signed and consent for procedure and presents
opportunity to clarify misconceptions
2. Use resource teaching materials, - specially designed materials can facilitate
audiovisuals as available patients learning
3. Implement individualized preoperative - enhances patient understanding/control
teaching program: and can receive stress related to the
preoperative/postoperative procedures and unknown/ unexpected
dietary considerations.
4. Implement individualized preoperative - helps reduce possibility of post operative
teaching program: preoperative instructions complications and promotes a rapid return
and which medication to take to normal body function.
5. Provide opportunity to practice - enhances learning and continuation of
coughing, deep breathing, and muscular activity postoperatively
exercises.

Diagnosis: Risk for infection related to broken skin or traumatized tissue

Intervention Rationale
1. Prepare operative site according to Minimizes bacterial counts and operative
specific procedure sites
2. Examine skin for breaks or irritation, Disruption of skin integrity at or near the
signs of infection operative sites are sources of contamination
to the incision
3. Identify breaks in aseptic technique and Contamination by environmental/personnel
resolve immediately on occurrence contact renders the sterile field unsterile,
thereby increasing the risk for infection
4. Apply sterile dressing Prevents environmental contamination of
fresh wound
5. Administer antibiotics as indicated May be given prophylactically for
suspected infection or contamination
Diagnosis: Acute pain related to disruption of the skin.

Intervention Rationale
1. Provide information about transitory Understanding the cause of the discomfort
nature of discomfort, as appropriate provides emotional reassuarance
2. Reposition as indicated e.g.,semi- May relieve pain and enhances circulation.
Fowlers position
3. Provide additional comfort measures Improve circulation, reduces muscle
tension and anxiety associated with pain.
4. Encourage use of relaxation technique Relieves muscle and emotional tension;
enhances sense of control and may improve
coping abilities
5. Provide oral care, occasional ice Reduces discomfort associated with dry
chips/sips of fluid as tolerated mucous membranes due to anesthetic
agents, oral restrictions.

IX. Actual Nursing Management

S “Natingala jud ko nganong nain-ani ko.”, as verbalized by the client.
O Looked confused
A Knowledge deficient regarding condition, prognosis, and treatment related
to lack of exposure.
P Long term: At the end of 2 days the patient will understand her condition.
Short term: at the end of 2 hours the the patient will be oriented with her
condition.
I 1. Reviewed specific pathology and anticipated
surgical procedure. Verify that appropriate consent has been signed.
2. Used resource teaching materials,
audiovisuals as available.
3. Implemented individualized preoperative
teaching program: preoperative/postoperative procedures and dietary
considerations.
4. Implemented individualized preoperative
teaching program: preoperative instructions and which medication to
take.
5. Provided opportunity to practice coughing,
deep breathing, and muscular exercises.
E At the end of 2 hours the clint was able to understand her condition.
S “Dili man ko kabalo mulimpyo sa akong inoperahan, mahadlok man gani
ko mutan-aw.”, as verbalized by the client.
O Facial expression (confused)
A Risk for infection related to broken skin or traumatized tissue
P Long term: At the end of 4 days the patient will be able to learn how to
maintain the incision site clean.
Short term: At the end of 2 hours the patient will be able to learn how to
clean the incision site.
I 6. Prepared operative site according to specific
procedure.
7. Examined skin for breaks or irritation, signs
of infection.
8. Identified breaks in aseptic technique and
resolve immediately on occurrence.
9. Applied sterile dressing.
10. Administered antibiotics as indicated.
E At the end of 2 hours the patient was able to learn how to clean and how to
maintain the incision site clean.

Diagnosis: Acute pain related to disruption of the skin.

S “kung mutukar na gani ang kasakit grabe jud,murag dili jud nako
makaya.”, as verbalized by the client.
O Facial grimace
Making a fist
Reports of pain
A Acute pain related to disruption of the skin.
P Long term: At the end of 2 days the pain felt by the client will be lessen.
Short term: At the end of 4 hours the pain felt by the client will be
alleviated.
I 11. Provided information about transitory nature
of discomfort, as appropriate.
12. Repositioned as indicated e.g.,semi-Fowlers
position.
13. Provided additional comfort measures.
14. Encouraged use of relaxation technique.
15. Provided oral care, occasional ice chips/sips
of fluid as tolerated.
E At the end of 2 hours the pain felt by the client was alleviated.
XI. Health Teaching

Prior to patient sent at OR, patient and the
significant others was encourage to do the
following simple exercises after one day:
• Encourage the patient to change
position every 30 minutes
- this is to prevent pulmonary
Exercise complication such as pneumonia
• if patient can handle herself,
encourage the patient to ambulate
- to promote proper blood circulation
- to increase energy requirements to
perform activities of daily living
The patient was encouraged to have the
following diet:
• increase protein intake – such foods
like meat, fruits and egg
Diet - this is to promote wound healing
• increase intake of fruits and
vegetables such as papaya, monggo,
cabbage
- this is to promote roughage in the
body in order to avoid constipation
The significant others and the patient was
encouraged to do the following treatment
after the operation:
If patient will have fever
- do the tepid sponge bath and
afterwards check the temp
• heat losses will occur as skin and
mucous membranes are exposed to
cool environment temperature
- give patient antipyretic medication
Treatment • this is to lower the patients
temperature
- encouraged the patient to increase
fluid intake
• it aids and help to mobilize internal
heat from the body through water
- do wound dressing
• this is to promote proper wound
healing and will decrease the
multiplication of the
microorganisms
The patient and the significant others of the
patient was encouraged to let the patient
take her medications religiously,
Medications medications such as:
- Tramadol
- Ketorolac
- Ranitidine
- Metoclopramide
- Nubain

XII. Referral and Follow-up

Because of the risk of subsequent ectopic pregnancies, the patient is advised to
seek preconception counseling before considering future pregnancies and to seek early
prenatal care. Psychological support and counseling may be advisable for woman and
thier partner to help them deal with the los of pregnancy. Follow-up contact enables the
nurse to answer questions and clarify information for woman and her partner. In addition,
it provides an opportunity to assess their ability to cope with the loss of the pregnancy.
The patient was advised to have an appointment with Dr. x 2 weeks after the
operation to check the patient for any complications and also to check the incision site for
any signs of infection.

XIII. Bibliography

1. Medical Surgical Nursing, Suzanne C. Smeltzer
Vol. 2, 10th Edition
Nursing 2006 Drug Handbook, Lippincott Williams and Wilkins
26th Edition