Repubic of the Philippines

Tarlac State University

College of Science
Department of Nursing
Lucinda Campus, Brgy. Ungot, Tarlac City Philippines 2300
Level 1 accredited by AACCUP

A Clinical Case Analysis Presented to the Faculty of the

Department of Nursing, Tarlac State University
Lucinda Campus, Brgy.
UngotTarlacCity
Philippines
In Partial Fulfillment
Of the Requirements of the Subject
NCM 10 2 RLE
ECTOPIC PREGNANCY
S.Y. 2014 - 2015
BSN level 2
(GROUP A1)
Angeles, Christsha Ann
Galicia, Alexis
Gamboa, Joyce Ariane
Giron, Frances Niciole
Lagmay, Douglas

Ocampo, Marcela
Valeroso, Eloisa Ann
Villanueva, Ameera Mae
TABLE OF CONTENTS
I.
II.

III.
IV.
V.
VI.

I.

Introduction ---------------------------------------------------------------------- 3-4

Objectives of the study------------------------------------------------------- 5
Nursing process----------------------------------------------------------------6
a.) Assessment
1.) Personal data----------------------------------------------------------- 7
2.) Family history of health and illness---------------------------7
3.) History of past illness-----------------------------------------------8
4.) History of present illness------------------------------------------8
5.) 11 Gordons functional health patterns----------------------9-15
6.) Laboratory and diagnostic procedure------------------------16-18
7.) Anatomy and Physiology------------------------------------------19-23
b.) Planning
Nursing Care Plan-------------------------------------------------------- 24-26
SOPIE charting------------------------------------------------------------ 27-29
c.) Implementation
1.) Drugs-------------------------------------------------------------------- 32-36
2.) Medical management---------------------------------------------- 36
3.) Surgical management--------------------------------------------- 36-37
4.) Diet----------------------------------------------------------------------- 37
5.) Activity/exercise-----------------------------------------------------38
d.) Evaluation
- Discharge planning------------------------------------------------- 38-40
Conclusion----------------------------------------------------------------------40
Recommendation--------------------------------------------------------------41
Review of related literature/studies-------------------------------------- 41-43
Bibliography---------------------------------------------------------------------- 44

Introduction :
Normal pregnancies develop inside a womans uterus. Ectopic means out of

place. In an ectopic the fertilized ovum is implanted outside the uterine cavity. It
accounts for 2% of all pregnancies in the United States. Approximately 95% of ectopic
pregnancies occur in the uterine(fallopian) tube, with most located on the ampular or
largest portion of the tube. Other sites include the abdominal cavity (3%-4 %,), ovary

(1%), and cervix (1%). Ectopic pregnancy is responsible for 10% of all maternal
mortality, and is the leading pregnancy-related cause of first trimester maternal mortality
(Simpson, 2002). Moreover, ectopic pregnancy is a leading cause of infertility. Only
about 60% of women who have been treated for ectopic pregnancy are able to conceive
afterward, and approximately 40% of those pregnancies are ectopic (Powell and
Spellman 1996). The reported incidence of ectopic pregnancy is increasing as a result of
improved diagnostic technique, such as more sensitive beta-HCG assays and the
availability of transvaginal ultrasound. An increased incidence of sexually transmitted
infections, better treatment of Pelvic Inflammatory Disease (which formerly would have
caused sterility), increased number of tubal sterilizations, and surgical reversal of tubal
sterilizations also have resulted in more ectopic pregnancies (Simpson, 2002).
Ectopic pregnancy is classified according to site of implantation (e.g., tubal or
ovarian). The uterus is the only organ capable of containing and sustaining a term
pregnancy. However, abdominal pregnancy with birth by laparotomy may result in a
living infant in 5% to 25% of such pregnancies: the risk of deformity is as high as 40%
(Gilbert & Harmon, 2003).
Ectopic pregnancies happen in about 2 out of every 100 pregnancies. However,
they become much more common in the past 30 years. Experts think the increase
maybe due to an increase sexually transmitted infections that can scar the fallopian
tubes and infertility treatments. For year medicate ectopic pregnancy rates were 2.38%
of pregnancies in New York, 2.07% in California, and 2.43% in Illinois. Risk was higher
among black women compared with whites in all states.(American Journal of Obstetrics
& Gynecology).
Ectopic pregnancy occurs in about 1 in 250 pregnancies amounting
approximately 70,000 cases annually, 5,833 per month, 1346 per week, 191 per day, 7
per hour. In the Philippines unpublished reports have estimated the incidence to be just
about 22,194 each year.
This case study will serve as another experience for us to develop our skills,
attitude and knowledge of what ectopic pregnancy all about. We chose this to further
understand and to broaden our knowledge about ectopic pregnancy.

OBJECTIVES OF THE STUDY

General Objective:
At the end of the rotation we the BSN- 2A, Group A1 will develop
knowledge, skills and attitude in the care of postpartum client utilizing the nursing
process.
Specific Objectives:

1. To assess the health status of postpartum client

2. To plan effective nursing care to solve identified problems of patient during
Puerperium.
3. To implement appropriate nursing care in the care of postpartum patient.
4. To evaluate the effectiveness of nursing care rendered.

II.

NURSING PROCESS

A. ASSESSMENT
1.) PERSONAL DATA:
Name: Mrs. E
Age: 34 years old
Address: Caluluan Concepcion, Tarlac.
Gender: Female
Civil Status: Married

Date of birth: May 15, 1980

Place of birth: Ilo-ilo City
Nationality: Filipino
Religion: Roman Catholic
Occupation: Housewife
Highest Educational Attainment: High School
undergraduate
Chief Complaint : Vaginal Bleeding (spotting)
Last Menstrual Period:
Admitting Diagnosis: Ectopic Pregnancy, week of
Gestation G5P3
Date Admitted: November, 17 2014
Time admitted: 11:16pm

2.) Environmental status

Mrs. E lives in a rural community in Caluluan, Concepcion Tarlac. Their house is
made up of concrete materials mixed with cement and wood. It has two main doors, 3
bedroom doors. Their house is properly ventilated,it has 7 windows. Their source of
water is from deep well. They buy mineral water for their water consumption. They have
their own comfort room.Their waste disposal management is by the collection of the
dump truck. Their means of transportation is jeepney, bus and tricycle. They
communicate their family members by the use of cellular phones.
3.) Lifestyle

She wakes up at around 5:00 oclock in the morning. She prapares breakfast and
washes the dishes after eating. Her normal routine is cooking, cleaning their house,
doing the laundry, and watering their plants.They usually have their lunch at around
11:00 a.m.-12:00 noon. Her favorite viand is ginisang gulay .She takes a nap for about
an hour and a half in the afternoon, and watches T.V at night. She usually sleeps at
around 9:00pm. She also stated that she socializes with her neighborhood and not
active joining community organization.She smokes 2 sticks a day, and drinks alcoholic
beverages occassionally. She stated that she started smoking when she was 30 years
old.

Family history of health and illness

GENOGRAM

4.) History of past illness

Mrs. E is a premature baby (7 months). She stated that she had her first menstrual
period when she was 14 years old. According to her, she had an apendectomy last
December, 14 2013. She said her last normal menstrual period was June 12, 2014. She
had her abnormal bleeding 4 months ago, according to her dinudugo ako na parang
spotting . Patient went to their local clinic about her condition last July, she was given
medication for blood loss. According to nurse on duty it is normal to have an abnormal
menstruation because she had her appendectomy last December. October 17, 2014, her
husband took her to the Hospital because she couldnt bear the pain on her lower
abdomen and lower back.

5.) History of present illness

Mrs. E is on her G5P3T3P0A1L3. Upon admission,on November 17, 2014,
11:16 in the evening at Tarlac Provincial Hospital she was complaining of abnormal
vaginal spotting. Her last normal menstrual period was June 12, 2014. The patient
stated that she started feeling the pain on her lower abdomen and lower back a week
before she was admitted. She usually feels it every afternoon until evening. The pain
aggravates whenever she walks, and when she rests, it alleviates the pain. Assessment
was done by Doulas Lagmay. During her second day, Patient complains pain from her
swollen right hand because of stopped Intravenous Fluid, with pain scale of 8/10 as
evidenced by crying and complaining to us (student nurses).

Physical Assessment
11 GORDONS FUNCTIONAL HEALTH PATTERNS

III.

AREAS OF ASSESSMENT
1. Health perception

Mrs. E recently having pain from her lower back and lower abdomen. She is having hard
time in walking. She has a guarding behavior by supporting her back and abdomen
when walking. She is also having pain on her swollen right hand. During the conduct of
our physical assessment, she stated that she is suffering from asthma, but unrecalled
when it is started. She stated too that she consulted a physician and gave her
salbutamol as a medicine to treat her asthma. This action helped her according to her.
She verbalized that she sometimes get colds and cough for the past year, she managed
it with over the counter cough and cold remedies, such as paracetamol, neozep and
alaxan. She drinks plenty of water too. She usually eats vegetables and meat on meals
as her important thing to keep healthy. She smokes 2 sticks per day, and drinks alcoholic
beverages occasionally as claimed. She doesnt have any accidents at home. She had
her abnormal bleeding 4 months ago, according to her dinudugo ako na parang
spotting . Patient went to their local clinic about her condition last July, she was given
medication for blood loss. According to the nurse, it is normal to have an abnormal
menstruation because she had her appendectomy last December. November 17, 2014,
her husband took her in the Hospital because she couldnt bear the pain on her lower
abdomen and lower back. She does what doctors said and follows what they advise.
Whenever she is not feeling well, she went to their barangay health center for a checkup, and this action helped.
2. Nutritional metabolic
In her everyday meal she eats noodles, rice, scrambled egg, and drinks coffee for her
breakfast. On their lunch time, she eats some vegetables, meat, and rice, sometimes
same meal with her dinner. She likes eating chips (chit-chirya) on her snacks every day.
In her daily fluid intake she drinks water about 15 glasses a day. Four months ago, her
weight was 68 kilograms, now her actual weight is 58 kilograms, and her height 5. Her
appetite is good, and does not have any eating discomfort. Her skin is brown . She have
dental problems. Her skin is smooth and a little bit sticky. Her oral mucous membranes
are pinkish. Her BMI is 24.9.
DATE

TIME

TEMPERATURE

November 20, 2014

10:00 am

36.4C

November 21, 2014

08:00 am

37.2C

Body mass index:

58 x 2.2
'
5 0 x 12

60
127.6 lbs

2.13
60

= 0.035x 703 = 24.91.

Norms:
According to Dorothy Jones from her Medical Surgical Nursing Book year 2000, 18 and
below is under nourished, the normal BMI of adult is 19 to 24.5, 25 to 29 is overweight,
then 30 and above is obessed.
Analysis:
Mrs. K has body mass index of 24.9. She is in the normal range. She doesnt
have a balanced nutrients because she eats a lot of chips.

Elimination Pattern
Mrs. E defecates at least twice a day and urinates 7-8 times a day. She doesnt
have any problems with bowel movement and doesnt use laxatives. Four months ago
she started having spotting instead of regular menstruation. Since she got admitted 4
days ago, she only defecated twice, once after she underwent dilatation and curettage
and once the day after her D and C. The color of her stool is yellow to brown, soft and
easy to pass.
Norms
Normal bowel habits vary considerably from person to person. Anything from
several times a day, to several times a week can be quite normal. It is a consistency of
the stools rather than the frequency that is more important. The stool should be soft and
easy to pass (thewomens.org.au)
Analysis

Mrs. Ks stool elimination and urination is normal in color and frequency. Her
spotting became irregular 4 months ago.

Activity Exercise
Prior to confinement, the patient said she cooks, cleans the house, does the
laundry and waters the plants as her daily routine activity. When she is bored she will
just watch television to spare her time. Her household duties are enough for her daily
exercise. Patient claims that she is not limited with general mobility and can do her
chores without discomfort. The patient can feed and bath herself without assistance.
During the assessment, on the second day shes is having discomfort on her
right hand. According to her it is painful and it is swollen due to stopped intravenous fluid
as evidenced by crying and complaining. She cant perform active range of motion like
abduction and adduction on her right arm and shoulder, flexion and extension general
appearance is pale and irritated in the hospital because of her condition.
Date & time
November 20,

20 bpm

RR
83 bpm

PR
100/70

BP

2014
November 21,

22 bpm

96 bpm

110/80

2014

Norms
Exercise is a type of activity defined as a planned, structured and repetitive body
movement performed to improve or maintain one or more components of physical
fitness. It involves contraction and relaxation of muscles. (cozier and erbs 8th edition
volume)

Analysis

Patients can perform active range of motion except on her right arm and
shoulder due to stopped intravenous fluid and characterized by swollen, that affects her
in daily activity.

Sleep Rest
Prior:
Mrs. E stated that she sleeps around 9pm and wakes up at 5am. She takes a
nap for about an hour at noon. She never had any sleeping disturbances and has sweet
dreams. Since she felt the pain due to her condition, she just sleeps to alleviate the pain
During:
On the first day of assessment she complains of lack of sleep with 4hours of
sleep. Patient stated that she easily awakens because of the overcrowded hospital
environment.
Norms:
The normal sleep pattern for adults and older adults must have 7-9 hours.
(Nursing Care for the Community Book by Zenaida U. Famorca)
Analysis:
During the assessment the patient doesnt have enough sleep and rest because
she easily awakens due to overcrowded environment.

Cognitive Perceptual
Prior:
Mrs. E was able to understand all my questions. She was attentive and was able
to retain the information given to her. She hears me and understands my questions
within 1-2 feet away. She was able to read the questions I gave her without difficulty. On
the first day of assessment she was complaining of the intermittent pain on her lower
abdomen and lower back minsan may sumisiksik n dumudukol as verbalized by the
patient.

During:
On the second day of assessment, after dilatation and curettage she was complaining
of her intravenous fluid which was stopped but not yet taken off and it is painful because
it was swollen with pain scale 8/10. She said after her appendectomy last year, she
became forgetful.

Norms:
Pain is a highly unpleasant sensation that affects a persons physical health,
emotional health, and well being. Health care professionals include pain as a component
a vital signs assessment. Pain assessment is identified as the fifth vital sign. An
individuals perception of pain is influenced by age, gender, culture, and previous
experience with pain.
Pain has been defined as whatever the experiencing person says it is, existing
whenever he or she says its does (McCaffery and Pasero, 1999,p.5). Pain is a universal
experience. Everyone experiences pain at some time and to some degree. It is a highly
subjective, unpleasant, and personal sensation that cannot be shared with others. This
sensation can be associated with actual or potential tissue damage. Pain can be the
primary problem or associated with a specific diagnosis, treatment, or procedure. (An
Introduction to Health and Physical Assessment in Nursing by DAmico and Barbarito,
(2007)
Analysis
The patient was responsive and attentive all throughout the interview. The
pain is specifically on her swollen intravenous sight with pain scale of 8/10.
Self-perceptual/ self concept
The patient feels good about herself. According to her shes kind with people
around her. She is depressed, when she cant get through the pain that she is having
right now. The patient said before she was taken to the hospital last Monday, she usually
just stops whatever she is doing and rest whenever the pain starts.
Role-relationship

Mrs. E lives has nuclear family, she lives with her husband and 3 kids. They live
on their own house. Her family is supportive on her condition. They budgeting her
husbands income to be sufficient for their needs as patient claims. Whenever they have
problems financially, they ask help from their neighbors which are her husbands
relatives.
Sexuality reproductive
The patient claims that she is satisfied with her sexual relationship and does it
twice a week. She does not have any problems sexually. She started her menstruation
when she was in 6th grade. Her last menstrual period was June 12 2014, she was having
her continued spotting since July 2014. She got pregnant 5 times now, 3 living children
and 2 abortion.
Norms
Approximately every 28 days the pituitary gland releases a hormone that
stimulates some of the ova to deveop and grow. One ovum is released and it passes
through the fallopian tube into the uterus. Hormones produced by the ovaries prepare
the uterus to receive the ovum. The lining of the uterus called the endometrium, and
unfertilized ovum are shed each cycle through the process of menstruation. If the ovum
is fertilized by the sperm, it attaches to the endometrium and the fetus develops.
(http.//en.wikipedia.org)
Analysis
Mrs. Es menstrual flow is not normal. She had abnormal spotting since
July 2014.

Coping-stress tolerance
Mrs. E had appendectomy last December 14, 2013. Her husband has been there
helping her to talk things over whenever she has problems. Most of the time it works but

sometimes it doesnt. When she got admitted to the hospital, her husband and her kids
are there to support her. She was depressed about her lost child, but theyre trying to
overcome through acceptance.
Norms
According to Folkman and Lazarus (1991), coping is the cognitive and
behavioral effort to manage specific internal or external demands that are appraised as
taxing or exceeding the resources of the person (kozier and erbs volume 2)
Analysis
The patient is able to cope with her stress in the way that she can. She asks help
from her husband and family members.

Value belief pattern

The patient said she is a Roman Catholic and grew up with it. She said she prays
to God almost about everything. Her purpose in life and most important is her family. Her
religion does not interfere with her health decisions according to her.
Norms
Spiritual well being is manifested by a feeling of being generally alive,
purposeful and fulfilled (elison 1983).according to Pitch (1998) spiritual wellness is a way
of living a lifestyle that views the lives life purposely and pleasurable, that seek out lifesustaining and life-enriching options to be chosen freely at every opportunity and sinks
its roots deeply into spiritual value and/or specific religious beliefs. (kozier and erbs
volume 2)
Analysis
The patent believes in God who made the heaven and earth. The patient
believes in prayers, so her value and belief is normal.

Nursing diagnoses identified:

1. Acute pain r/t swollen venipuncture site at right hand due to stopped intaravenous fluid

2. Sleep disturbance r/t overcrowded hospital environment.

3. Risk for fluid volume deficit r/t minimal vaginal bleeding.

Diagnostic/

Date

Indicated

laboratory

ordered/

purposes

procedure

date done

Result

Analysis and
interpretation of
results

ULTRASOUND

November

>to outline the

>normal sized

19, 2014

shape and

anteverted

determine the

uterus with intra

consistency of

endometrial

various organ.

contents as

>used to

described

determine the

suggestive of

exact position,

blood clot and/or

size and gender

retained

of the fetus.

products of

>used to identify

conception.

some
developmental
anomalies.

Diagnostic/

Date

Indicated

laboratory

ordered/

purposes

procedure

date done

Result

Normal

Analysis and
interpretation
of results

Hematology

11/17/14

>One of the

RBC:3.59

3.60-4.69

Normal

WBC: 15.4

3.70-10.1

Abnormal

most ordered
blood test . It is
the calculation

presence of

of the cellular

infection

(formed)
elements of the

HGB: 103 g/l

108-142

blood

Abnormal due to
blood loss

components
and the

HCT: .302

response to

L/L

.377-.537

Abnormal due to
blood loss

inflammatory
process or if

EOS: .032

there is
presence of

.
030-.0440

LYM: 1.29

bacteria.

Normal
1.09-2.99
Normal

MONO: .
580

7. Anatomy and physiology

Normal

.240-.790

Mons Pubis
Is rounded, soft fullness of subcutaneous fatty tissue, prominence over the symphisis
pubis that forms the anterior border of the external reproductive organs.
It is covered with varying amounts of pubic hair.
Labia Majora&Minora
The labia majora are two rounded, fleshy folds of tissue that extended from the mons
pubis to the perineum.
It is protect the labia minora, urinary meatus and vaginal introitus.
The labia minora is located between the labia majora, are narrow.
The lateral and anterior aspects are usually pigmented.
The inner surfaces are similar to vaginal mucosa, pink and moist.
Clitoris.
The term clitoris comes from a Greek word meaning key.
Erectile organ.
Its rich vascular, highly sensitive to temperature, touch, and pressure sensation.

Vestibule.
Is oval-shaped area formed between the labia minora, clitoris, and fourchette.
Vestibule contains the external urethral meatus, vaginal introitus, and Bartholins glands.
Perineum
Is the most posterior part of the external female reproductive organs.
It extends from fourchette anteriorly to the anus posteriorly.
And is composed of fibrous and muscular tissues that support pelvic structures.

Uterus

The uterus is a hollow, muscular organ that is shaped like an inverted pear. It has 3
parts:

fundus (top)

body (the main parts of the uterus, including the uterine cavity)

cervix (lower, narrow part)

The uterus is located above the vagina, above and behind the bladder and in front of
the rectum. It is about 7 cm long and 5 cm wide (at the widest point).

The wall of the uterus is thick and has 3 layers:

endometrium The inner layer that lines the uterus. It is made up of glandular
cells that produce secretions.

myometrium The middle layer, which is made up mostly of smooth muscle.

perimetrium The outer serous layer that covers the body of the uterus and part
of the cervix.

Ovaries

the ovaries are for oogenesis the production of eggs (female sex cells) and for
hormone production (estrogen and progesterone).

The ovaries are about the size and shape of almond. They lie against the lateral
wall of the pelvis one on each side. They are enclosed and held in place by the
broad ligament. There are compact like tissues on the ovaries, which are called
ovarian follicles.

Fallopian tubes

Each tube is about 4 inches long and extends medially on each ovary to empty
into the superior region of the uterus

The fallopian tubes transport ovum from the ovaries to the uterus. There is no
contact of fallopian tubes with the ovaries.

Vagina

The vagina is the thin walled vascular tube about 6 inches long leading from the
uterus to the external genitalia. It is located between the bladder and the rectum

The vagina provides the passageway for childbirth and menstrual flow; it receives
the penis and semen during sexual intercourse.

Pathophysiology
Book based

Female , 20 years old

Second hand smoker in time

of conception increase risk of
impaired immunity, which
predisposes to impaired
functioning of the fallopian

Dysfunctional of the
cilia which normally
propel egg to uterus.
Disruption/ scaring of fallopian
tube.

Blockls/slow the
movement of
fertilized egg through

Fertilized egg attaches to an

area outside the uterus where

Sudden severe
abdominal pain.

Abnormal bleeding from the

vagina, usually scanty amount
i
Abdominal ultrasound
findings: no
intrauterine
gestational sac

 Client Based

Non-modifiable

Modifiable

Age
Female
Had an
ASSESMENT
appendectomy

Smoking
Drinking alcoholic
beverages occasionally
Diagnosis
Planing
Had miscarriage once.

. Subjective:

Objective :

Acute pain r/t

Within 1-2hrs of

>Indepe

masakit itong

>with swollen right

swollen

rendering appropriate

1.) Rep

hand
venipuncture site at
June 12, 2014 last normal menstrual
nyo pa tanggalin period.
>with no content IV
right hand due to
as verbalized by
fluid.
stopped

nursing interventions,

position

the patient, with

pain scale of 8/10 to

swero ko, bat di

>crying and

intaravenous fluid

the patient will verbalize

of decrease of pain from

pain scale
of
complaining
July 2014,
started
abnormal menstruation with spotting 2/10.
8/10. scanty amount.
>irritability noted.

Interve

RATION

2.) Prov

RATION

impair a

3.)Prov

environ

RATION

pain ma

July 2014, went to local clinic , given medication for anemia,

said it was because her appendectomy last year.

4.) Inst

RATION

provide

>Depen

November 10, 2014 felt abdominal pain, sumisikip na kumukirot as

RATION

associa

EVALUATION
Within
1-2hrs
of unbearable
rendering appropriate
nursing
interventions, the patient
November :17,
2014
felt
pain with
spotting.
verbalized the decrease from pain scale of 8/10 to 2/10 as evidenced by absence of crying and
complaining.

November 17, 2014 patient was taken to the hospital . 11:16pm

ASSESMENT

Diagnosis

Planing

Interven
1.

. Subjective:

Objective :

Sleep disturbance

Within 1-2hrs of

Hindi ako

> yawning

r/t overcrowded

rendering appropriate

makatulog ditto

>Dark pigments

hospital

nursing interventions,

karami kasing tao

around the eyes.

environment.

the patient will verbalize

as verbalized by

>4 hours of sleep

increase of sleep from 4

the patient.

>irritabilty noted

hours to 6-8 hours.

Man

red

Rationa
2.

Pro

Rationa
sleep.
3.

Adv

Rationa
4.

Sug

Rationa
5.

Inst

bed

rou

and

Rationa

EVALUATION: Within 1-2hrs of rendering appropriate nursing interventions, the patient

verbalized increase of sleep from 4 hours to 6-8 hours as decreased yawning, less darkness
pigment around the eyes, and less irritability

ASSESMENT

Diagnosis

Planning

Interven

. Subjective:

Objective :

Risk for fluid volume

Within 12-4 hours of

Meron pang

> pale looking

deficit r/t minimal

rendering appropriate

lumalabas sa

>changed pads twice

vaginal bleeding.

nursing interventions,

pwerta ko as

since 7am.

the patient fluid volume

verbalized by the

> voided once since

deficit will be back into

patient.

7am

normal range.

> decreased skin

turgor
> active perspiration
BP : 100/70 mmHg
PR: 106
RR: 22
T: 37.5

EVALUATION: Within 12-4 hours of rendering appropriate nursing interventions, the patient fluid
volume deficit back into normal range as evidenced by using 1-2 pads a day and stable vital
signs.

1.) Mo

los

RAT

pro

2.) Mo
3.) Mo

RAT

dep

blee

4.) Mo

RAT

be u

5.) Pr

SOAPIE
1.)
S > masakit itong swero ko, bat di nyo pa tanggalin as verbalized by the patient, with
pain scale of 8/10.
O> irritability noted.
>with swollen right hand
> with no content IV fluid
>crying and complaining.
A> Acute pain r/t swollen venipuncture site at right hand due to stopped intaravenous
fluid
P> Within 1-2hrs of rendering appropriate nursing interventions, the patient will verbalize
of decrease of pain from pain scale of 8/10 to 2/10.
I > >Independent Nursing Function
1.) Reposition as indicated and/or place to position of comfort.
2.) Provide adequate rest periods.
3.)Provide comfort measures, quiet environment and calm activities.
4.) Instruct to do deep breathing exercises
>Dependent Nursing Function
1.) Administer pain medication as ordered by the physician.
E> Within 1-2hrs of rendering appropriate nursing interventions, the patient verbalized the
decrease from pain scale of 8/10 to 2/10 as evidenced by absence of crying and complaining.

2.)
S > masakit itong swero ko, bat di nyo pa tanggalin as verbalized by the patient, with
RATIONALE: a wide range of analgesics and associated agents can relieve pain.
E- Within 1-2hrs of rendering appropriate nursing interventions, the patient verbalized the
decrease from pain scale of 8/10 to 2/10 as evidenced by absence of crying and complaining.

O- > yawning
S> Hindi ako makatulog
ditto karami kasing tao as
verbalized by the patient.

>Dark pigments around the eyes.

>4 hours of sleep

>irritabilty noted
A- Sleep disturbance r/t overcrowded hospital environment.

1. Manage environment to minimize noise by reducing chatting with each others.

Rationale; to provide relaxation

2. Provide sponge bath and change clothing.

Rationale; to promote comfort and facilitates sleep.

3. Advise to drink hot milk.

Rationale; to hiders the inability to sleep.

4. Suggest abstaining from the time naps.

Rationale: to avoid impair ability to sleep or rest.

5. Instruct bedtime care such as straightening bed sheets and encourage usual bedtime routines such as
washing face and hands and brushing teeth.

p- Within 1-2hrs of rendering appropriate nursing interventions, the patient will verbalize increase
of sleep from 4 hours to 6-8 hours.

I-

Rationale; to promote physical comfort.

E- Within 1-2hrs of rendering appropriate nursing interventions, the patient verbalized increase of

sleep from 4 hours to 6-8 hours as decreased yawning, less darkness pigment around the eyes,
and less irritability

O-> pale looking

S- Meron pang lumalabas
sa pwerta ko as verbalized
by the patient.

>changed pads twice since 7am.

> voided once since 7am

T: 37.5

> decreased skin turgor

A- Risk for fluid volume

> active perspiration

BP : 100/70 mmHg
P- Within 12-4 hours of
rendering appropriate

deficit r/t minimal

vaginal bleeding.

PR: 106

nursing interventions, the

RR: 22
1.) Monitor color, amount and frequency of fluid loss.
RATIONALE: to know further condition and to provide baseline.

2.) Monitor vaginal bleeding, changing of pads

3.) Monitor intake and output.
RATIONALE: fluid replacement solution depends on the degree and duration of bleeding.

4.) Monitor vital signs.

RATIONALE: changes in blood pressure can be used for rough estimated of blood loss.

5.) Provide health teachings as follows:

Encourage to eat nutritious and rich in iron foods
patient fluid volume deficit will be back into normal range.

Instruct top increase fluid intake.

E- Within 12-4 hours of rendering appropriate nursing interventions, the patient fluid volume

deficit back into normal range as evidenced by using 1-2 pads a day and stable vital signs.

Name of

Date

Route of

General Action/

Indications/

Clients

Drugs

Administ

Administration,

Mechanism of

Purposes

Response to

ered

Dosage and

Action

Frequency of

Medication

Generic

11/ 20/14

Administration
1 tablet, OD, HS

Iron supplement.

Prevention

RBC count

name:

Elevates the

and treatment

normal

Ferrous

serum iron

of iron

Sulfate

concentration,

deficiency

which then helps

anemia.

Brand

to form Hgb or

Dietary

Name:

trapped in the

supplement of

Feosol

reticuloendothile

iron.

al cells for
storage and
eventual
conversion to a
usable form of
iron.
IMPLEMENTATION
1.) DRUGS
Nursing responsibilities:
Prior to:

Assess allergy to drug

Encouraged the patient to avoid taking antacids or antibiotics within 2 hours

before taking ferrous sulfate.

Advice the patient to follow all directions on the product or take as directed by her

doctor.
Assess the patient if she has allergic reactions like skin rash, or itching.

During:

After:

Encouraged the patient to take the drug after meals.

Monitor for possible drug induced adverse reaction.
Encouraged the patient to take vitamin C.

Assess patient and familys knowledge on drug therapy.

Advice the patient to take the drug prescribed by her doctor.
Encouraged the patient to eat nutritious food.
Advise the patient to take this medication regularly in order to get the most
benefit from it.

Name of

Date

Route of

General Action/

Indications/

Clients

Drugs

Administ

Administration

Mechanism of

Purposes

Response to

ered

, Dosage and

Action

Medication

Frequency of
Administration
500mg, 1

decreases

Reduce

capsule TID

maternal

perinatal

No allergic

Cephalexin

possible viral

transmission

reaction noted.

Brand

infection in

by several

Name:

blood and

mechanisms,

Keflex

genital

including

secretions,

lowering

which is a

maternal

particularly

antepartum

important

viral load

mechanism of

and

action in

providing

women with

infant pre-

high viral loads

and post-

Generic

11/20/14

name:

exposure
prophylaxis.
Nursing responsibilities:
Prior to:

Obtain patient history of allergy.

Assess the patient if she has stomach or bowel problems(e.g inflammation)
Assess patient for previous sensitivity reaction to penicillin or other antibiotics.
Instruct the patient not to take this medication if she is allergic.

During:

After:

Advised to take cephalexin with a full glass of water.

Encouraged to follow instructions on her prescription label.
Assess for allergic reactions during therapy; rash, chills, fever and joint pain.

Monitor the patient for any signs of allergy.

Advised to take the medication for the entire length of time prescribed by her
doctor.

Name of

Date

Route of

General

Indications/

Clients

Drugs

Administe

Administration,

Action/

Purposes

Response to

red

Dosage and

Mechanism

Frequency of

of Action

Medication

Administration
Generic

500 mg. one cap

Non-steroidal

Relief of pain

She can now

TID.

anti-

including

move without

Mefenamic

inflammatory

muscular..

pain.

Acid

drug. Aspirin-

name:

11/20/14

like drug that

Brand

has

Name:

analgesic,

Anthramilic

antipyretic

acid

and antiinflammatory
activities.
These
activities
appear to be
due to its
ability to
inhibit
cyclooxygena
se and also
antagonist
certain effects
of
prostaglandin
s. Mefenamic
acids display
central and

peripheral
activities.
Nursing responsibilities
Prior to:

Assess patients pain before therapy.

During:

Monitor for possible drug induced adverse reactions.

After:

Assess patients knowledge on drug therapy.

2.) Medical Management

Medical

Date Performed/

General

Indication/

Client's

Management/

Changed/

Description

Purpose

Response to

Treatment
Intravenous Fluid

Discontinued
11/17/14

Hooked at

This will provide

Treatment
The patient

the right

nutrients,

consumed the

hand to be

rehydration and

IVF without

regulated at

administration

adverse effects.

30-32 gtts

of medications

The patient well

per minute.

via IVP

hydrated as

of D5LR

manifested by
no skin turgor
and sunken
eyes. Patient
was in pain
after IVF was
stopped but not
discontinued so

it become
swollen.
3. Surgical management

Name
of procedure

Date

Brief description

performed

Indication/

Clients

purposes

response

DILATATION

November

Refers to dilatation

To resolve

operation
Client was well

and

20, 2014

of cervix and

abnormal

and no signs of

surgical removal of

uterine

infections from

part of the lining of

bleeding (too

the procedure.

uterus or contents

much or too

by scrapping and

often) to

scooping

remove excess

(curettage)

uterine lining in

CURETTAGE

woman who
have conditions
such as
polycystic
ovary
syndrome.

Nursing responsibilities:
PRIOR:
Explain the procedure to be done.
Check clients vital sign
Instruct patient to refrain eating and drinking 8 hours before procedure

DURING
Prepare the patient

 Check vital signs.

AFTER
Prepare the patient if experiencing backache and mild cramps
Instruct patient to resume normal activities almost immediately and avoid
sexual intercourse, douching for at least 2 weeks to prevent infection.

4.) Diet

Type of diet
Nothing per orem

Date
November 20,2014

Indication
No food or drink 8 hours
before dilatation and curettage
procedure.

5.) Activity / exercise

Type of exercise

General

Indication/purpose

Clients response

Active range of

description
Daily exercise is

To maintain muscle

The patient

motion exercise.

any bodily that

strength and it is

maintain good

enhances or,

essential for improving

muscle strength

maintains

overall health,

and promote

Deep breathing

physical fitness

maintaining fitness and

circulation.

exercise

and overall

helping to prevent the

health.

development of obesity,
hypertension, and
cardiovascular disease.

D. Evaluation
- discharge planning

After delivery Mrs. Boo Tit is happy with her first baby. Exhaustion is experienced by the
patient as she completed giving birth. Her body temperature is 36.8 degrees celcius per
axilla respiratory rate of 17cpm, blood pressure of 120/80 mmHg, and pulse rate of
84bpm.
MEDICATION:
Ferrous Sulfate- I tab. OD HS PO
Cephalexin- 500mg. 1 cap. TID PO
Mefenamic acid- 500 mg. 1 cap. TID PO

EXERCISE:
As a daily routine, she cleans their house and do walking as her daily exercise and other
activities of daily living.
TREATMENT:
Dilatation and curettage
HEALTH TEACHING:

Encourage to eat nutritious and rich in iron foods.

Encouraged to increase fluid intake.
Teach the importance of adequate fluid intake, daily exercise and proper diet rich
in vitamins and minerals like fruits and green and leafy vegetables and so with

meat and poultry.

Advise to avoid from intercourse, or used contraceptives
Provide information about her condition.
Encourage to stop cigarette smoking and alcohol consumption.
Advise the patient to take the medications prescribed by the physician.
Teach how to clean properly the perineal area and proper hand hygiene in
preventing infection.

OPD: November 29, 2014

DIET: Diet as tolerated.

CONCLUSION
At the end of our exposure, there were benefits both the patients and the student
nurses.
On the part of the patient, she was able to have an increase understanding about
her condition. She also understood that complying with the doctors orders would help
her to recover faster. She also learned the importance of cooperating with the nurses
whenever they do certain interventions and carry out orders. She stated that she learned
from the teaching of the nurses and how to cope up after delivery.
As the student nurses, the group establishes rapport with the patient. We also
gathered knowledge regarding ectopic pregnancy. Even if we are not skillfully enough it
is because, it is the groups first time to expose in this area; at least we practiced them
ideally and through that we will able to formulate appropriate nursing diagnosis plan
effective patient care, implement the proper nursing interventions to resolve the patients
identified problems, evaluate outcome of proper patient and established self-reliance
within the patient case identifying and understanding.
The group learned so many things. We got bright ideas from plenty of books, to be
able to have more references to expand our knowledge regarding the study and with the
help of our Clinical Instructor. At the same time, we established a good relationship with
the patient and this was made us understand what normal spontaneous delivery is all
about. Skills can be read from many materials and lectures but actual performing them in
an actual case is very significant to us student nurses.

IV. RECOMMENDATIONS
To the persons involve, the group highly recommends the following:

The client must have an adequate intake of foods that are high in calories, high
protein, and vitamins and minerals especially iron, and vitamin A.

Encourage the client to limit alcohol consumption.

The client must be encouraged to take all the Medicines that prescribed by her
OB Gynecologist

Advised the mother for proper hygiene and do daily exercise to maintain a good
health.

Instruct the patient to follow the doctors order regarding her follow up check-up.