ASSESSMENT Subjective: n/a Objective: abdomin al pain (lower right) p= no provoking factor, painful even at rest q= sudden, sharp, knifelikepain 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 Report decrease of pain.pain scale from 10/10 to 6/10 activities such as listening to mellow music. knifelike pain Report decrease of pain.pain scale from 10/10 to 6/10 collaborative 1. with the following criteria: . provide analgesic as ordered by the physician Analgesic drugs act in various ways on the peripheral and c . touch and other type of pain management is based on this theory.ectopic pregnancy is severe (810) t= not mentioned Brain Stem and Thalamus Somatic Sensory Cortex Perception of Pain Acute Pain sudden. diversional activities and guided imagery. 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. provide other nonpharmacologic interventions: .massage . changing position. sharp. Massage. 5. 5. the gate controltheory of pain proposes that stimulation of fibers that transmit nonpainful sensations can block or decrease the transmission of pain impuses.therapeutic touch pain such as effective breathing exercises. with the following criteria: . which reversibly eliminatesensation . 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. .entral nervous systems. they include paracetamo l (paraacetylaminophenol. They are distinct from anesthetics. mmHg Rr= 35 cpm PR of 120 bpm and Pr= 120 serum hgb of bpm 90. RATIONALE EVALUATION Discharge Outcome 1. position client in a Trendelenburg position . It lodges at the strictured site and implants there PLANNING Discharge Outcome 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. use the rule of thumb (more than 1 sanitary pad in an hour is considered excessive.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). Recommendation: Terminate the plan Upon discharge. intravenous fluid using a large gauge catheter is done to replace intravascular volume. or uterine mass Proximal end of the tube is compressed Zygote can not travel the lenth of the tube. to facilitate venous return and to prevent excessive abdominal viscera shift and restriction of the diaphragm that occurs with the head-down position 4. 2.90 bpm) and normal hematocrit level Short Term Outcome Outcome fully achieved.20 cpm and PR from 100 bpm to 60. assess the amount of bleeding. 4. RR Bp= 80/ 50 of 35 cpm. scars from surgery. RR from 25 cpm to 15. monitor vital signs esp. the Bp.20 cpm and PR from 100 bpm to 60. RR from 25 cpm to 15. to determine extent and amount of bleeding Outcome fully achieved. bp of 80/ 50 the uterus mmHg. 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 . RR and PR 3.receive at least 5 both nonpharmacologic and pharmacologic NURSING INTERVENTION Independent 1.malformation.90 bpm) and normal hematocrit level Short Term Outcome Afte 8 hours of nursing interventions the client will be able to: a. to detect for impending hypovolemic shock 3. monitor intravenous fluid intake. 2. 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. demonstrate increased fluid volume as evidenced by increase in BP from 80/ 50 mmhg to 100/ 70 mmHg. transfuse blood as ordered by the Physician. . Administration of Methotrexate(ch . Blood typing is necessary for blood transfusion and hcg level is done if pregnancy has not been confirmed yet. demonstrate increased fluid volume as evidenced by increase in BP from 80/ 50 mmhg to 100/ 70 mmHg. 3.surgical incision made approx 4in long. tubal pregnancy removed Methotraxate is a chemotherapeutic drug. Zygote grows large enough Ruptures the slender fallopian tube or trophoblast cells break through the narrow base. Laparotomy. RR frm 35 cpm to 25 cpm and pr from 120 bpm to 100 bpm increased serum hgb. cross matching and hcg level results. monitor CBC. RR frm 35 cpm to 25 cpm and pr from 120 bpm to 100 bpm and increased serum hgb.at the middle portion of fallopian tube. 1. b. Collaborative 1. 2. Laparoscopy. 2. b. prepare client for possible surgery Laparoscopy Laparotomy- 4. CBC will determine the amount of hemoglobin and rbc levels.three small puncture wounds. a folic acid Recommendation: Terminate the plan Afte 8 hours of nursing interventions the client was able to: a. remove tubal pregnancy. 3. blood transfusion is done to replace the blood loss. Tearing and destruction of blood vessels Hemorrhage Fluid volume deficit s/sx: >hypotension >tachycardia >tachypnea >low hgb. blood typing. hct and rbc levels interventions that will help in reestablishing functional level of fluid volume.receive at least 5 both nonpharmacologic and pharmacologic interventions that will help in reestablishing functional level of fluid volume. .409 emo medication) po. inhibits cell division in embryo antagonist that attacks and destroys fastgrowing cells. 408. pg.ref: Maternal and Child health nursing 5th edition Volume 1.