Ectopic Pregnancy Case Study PDF

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Case study...

Description

SKINNY Reasoning

Ectopic Pregnancy

Jean Simmons, 22 years old © 2018 Keith Rischer/www.KeithRN.com

Primary Concept Perfusion Interrelated Concepts (In order of emphasis) •

Reproduction •

Pain

•

Clinical Judgment

•

Patient Education

NCLEX Client Need Categories

Percentage of Items from Each Category/Subcategory

Covered in Case Study

 Management of Care

17-23%

✔

 Safety and Infection Control

9-15%

Health Promotion and Maintenance

6-12%

✔

Psychosocial Integrity

6-12%

✔

 Basic Care and Comfort

6-12%

✔

 Pharmacological and Parenteral Therapies

12-18%

✔

 Reduction of Risk Potential

9-15%

✔

 Physiological Adaptation

11-17%

✔

Safe and Effective Care Environment

Physiological Integrity

SKINNY Reasoning

Part I: Recognizing RELEVANT Clinical Data History of Present Problem: Jean Simmons is a 22-year-old-college student who presents to the emergency department with RLQ abdominal pain and intermittent vaginal bleeding. Her pain started suddenly two hours ago and has been severe and persistent. She noticed a small amount of bright red vaginal bleeding in the last hour. Jean has irregular cycles and it has been six weeks since her last menses, which is not unusual for her. She admits to feeling more fatigued the last couple weeks with intermittent nausea. Jean is 5’ 8” and weighs 74 kg (163 lbs.).

Personal/Social History: Jean has been sexually active since the age of 16 and has had three male partners in the last six months. She insists that they use condoms which she provides. She has a history of an ovarian cyst and was treated for pelvic inflammatory disease (PID) six months ago. © 2018 Keith Rischer/www.KeithRN.com

What data from the histories is RELEVANT and has clinical significance to the nurse? RELEVANT Data from Present Problem: Clinical Significance: Sudden severe and persistent RLQ abd pain

Intermittent bright red vaginal bleeding (small amount)

Has a history of irregular menstrual cycles

- Shows that the pregnancy is developing outside of the expected area (uterus) and that the site of attachment (fallopian tube) has ruptured

- Fluctuating hormone levels caused vaginal bleeding from the endometrium

- Irregular menstrual cycles are indicative of abnormal hormone levels. Abnormal hormonal factors can contribute to the cause of an ectopic pregnancy. Absence of menstruation is also a sign of pregnancy.

RELEVANT Data from Social History:

Clinical Significance:

Sexually active since age 16

- Provides sexual history

Has had 3 male partners in the last 6 months with the use of condoms

- Increases chances of getting pregnant. Condoms are not 100% effective in protecting one from pregnancy.

History of an ovarian cyst

- Abnormal hormone levels places the patient at risk for ectopic pregnancy

Was treated for pelvic inflammatory disease 6 months ago

Patient Care Begins: © 2018 Keith Rischer/www.KeithRN.com

- Pelvic inflammatory disease is a risk factor for ectopic pregnancy

Current VS:

P-Q-R-S-T Pain Assessment (5th VS):

T: 98.4 F (36.9 C) oral

Provoking/Palliative: Movement of any kind/Lying still in fetal position

P: 98 (regular)

Quality:

Sharp/stabbing

R: 20 (regular)

Region/Radiation:

RLQ abdomen

BP: 102/52

Severity:

9/10

O2 sat: 98% room air

Timing:

Constant

What VS data is RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Assessment Data: Clinical Significance: ●

The Blood Pressure of 102/52 is on the lower side

-

The patient is actively bleeding which could cause lower blood pressure, this is also a sign of ectopic pregnancy.

●

Sharp, stabbing pain and pain with movement

-

●

Cramping, RLQ pain

A pregnant woman with possible ectopic pregnancy might move and some uterine ligaments might be pulled which cause pain in the abdomen.

●

9/10 constant pain

-

Lower abdominal pain is a sign of ectopic pregnancy

-

This is a very high pain rating and is from the abdominal pain, cramping, or vaginal bleeding all pointing to an ectopic pregnancy

Current Assessment: GENERAL

Appears uncomfortable, body tense

APPEARANCE: RESP:

Breath sounds clear with equal aeration bilaterally, nonlabored respiratory effort

CARDIAC:

Pink, warm and dry, no edema, heart sounds regular with no abnormal beats, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks

NEURO:

Alert and oriented to person, place, time, and situation (x4)

GI:

Abdomen soft/tender to gentle palpation in RLQ, bowel sounds audible per auscultation in all four quadrants

GU/REPRODUCTIVE :

Voiding without difficulty, urine clear/yellow, small amount of red vaginal bleeding present on maxi pad. Pad is NOT soaked.

SKIN:

Skin integrity intact

© 2018 Keith Rischer/www.KeithRN.com

What assessment data are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Assessment Data: Clinical Significance: ●

Appears uncomfortable, body tense

●

Abdomen is soft/tender to gentle palpation in RLQ

●

Small amount of red vaginal bleeding present on maxi pad

-

Patient is in severe pain, is bleeding, she is most likely stressed.

-

This is one of the symptoms which tell that a tube has already ruptured.

-

With an ectopic pregnancy there is spotting and slow leak bleeding. This could be a sign of rupture.

Diagnostic Results: Complete Blood Count (CBC) WBC

% Neuts

HGB

PLTs

Current:

8.8

70

9.9

155

Most Recent:

9.5

68

12.8

225

MISC.

Current:

Pelvic

Urine Preg

Serum HCG

Rh Factor

Pos

9250

Neg

No gestational sac observed. Cannot exclude ectopic pregnancy.

Ultrasound:

© 2018 Keith Rischer/www.KeithRN.com

What data must be interpreted as clinically significant by the nurse ? (Reduction of Risk Potential/Physiologic Adaptation) RELEVANT Clinical Significance: TREND: Diagnostic Data:

No gestational sac observed

Rise in WBCs (8.8 to 9.5)

Rise in HGB (9.9 to 12.8)

Rise in PLTs (155 to 225)

Improve/Worsening/Stable:

- The uterus has no presence of a fetus.

Diagnosis of pregnancy

- WBC of 8.8 to 9.5 is normal during pregnancy. The increase in WBCs could indicate a possible infection or damage to the body.

Worsening

- Normal Hgb range is 12-16 g/dL. The patient’s initial Hgb level of 9.9 means that the patient was experiencing an iron deficiency caused by the unmet nutritional needs of the first trimester of pregnancy. The low Hgb levels may have also been from the blood loss due to the rupture of the ectopic pregnancy. The rise of Hgb levels to 12.8 shows that the patient is now within normal range. This is due to the success in treatment during hospitalization.

Stable

- Normal platelet count during the first trimester of pregnancy is 174-391. The patient’s initial platelet level was 155, possibly indicating gestational thrombocytopenia. The rise in platelet levels could be a reaction to the ectopic pregnancy rupture or the miscarriage with successful treatment.

- Confirmation that the patient is pregnant.

© 2018 Keith Rischer/www.KeithRN.com

Stable

Urine pregnancy

- Confirmation that the patient is pregnant and shows gestational age.

Diagnosis of pregnancy

Serum HCG 9250 Diagnosis of pregnancy

Part II: Put it All Together to THINK Like a Nurse! 1. After interpreting relevant clinical data, what is the primary problem? (Management of Care/Physiologic Adaptation)

Problem:

Pathophysiology in OWN Words:

Ectopic pregnancy

In ectopic pregnancy, implantation occurs in a site other than the endometrial lining of the uterine cavity, in the fallopian tube, uterine cornua, cervix, ovary, or abdominal or pelvic cavity. Ectopic pregnancies cannot be carried to term and eventually rupture or involute

Collaborative Care: Medical Management 2. State the rationale and expected outcomes for the medical plan of care. (Pharm. and Parenteral Therapies) Medical Management:

Rationale:

Expected Outcome:

Establish large bore (18 g.) peripheral IV

Preparation to administer IV fluids or medications.

IV site will be clean, dry, and non infiltrated. Patient will be comfortable with placement of the IV.

0.9% NS 1000 mL IV bolus To restore blood volume that was a result of bleeding during ectopic pregnancy rupture.

Patient’s blood pressure and blood levels will be stable.

Patient will report little to no pain. © 2018 Keith Rischer/www.KeithRN.com

Hydromorphone 0.5-1 mg IV every hour prn

To manage or relieve pain.

Transvaginal ultrasound To assess the damage of the rupture and investigate possible interventions to repair affected organs.

Rupture of the fallopian tube will result in the removal of all or parts of the tube depending on the severity of the case.

Collaborative Care: Nursing 3. What nursing priority (ies) will guide your plan of care? (Management of Care) • Acute pain Nursing PRIORITY: •

PRIORITY Nursing Interventions: ●

Assess vital signs

●

Assess for signs of dehydration and monitor I+Os

●

Maintain adequate hemodynamics

Rationale: -

If an ectopic pregnancy occurs in the fallopian tube that ruptures, the patient may go into shock.

-

Blood loss and vomiting may cause hypovolemia and dehydration.

Assess for abdominal pain and tenderness -

●

Monitor blood loss and administer blood products as necessary -

●

To maintain renal function, especially in the case of shock. -

●

Administer medications as appropriate and monitor for adverse reactions

© 2018 Keith Rischer/www.KeithRN.com

Check vitals for rapid heart rate, rapid breathing, and low blood pressure and stabilizing.

Patient will have an IV and rehydrate

Position patient for comfort and assist with movement as needed -

●

Expected Outcome:

Patients should be supine to help reduce movement, stabilize vitals, and comfort them.

Stabbing or sharp pain is a sign of ectopic pregnancy and even could be that a fallopian tube has ruptured.

Vaginal bleeding may range from spotting to heavier than a normal menstrual cycle

Methotrexate may be given to absorb the pregnancy tissue and save the fallopian tube.

This will help the patient’s pain level

Patient will receive medication to help with abdominal pain

Patient will receive a transfusion to make up for blood lost

The medication will absorb the pregnancy tissue and help patient

●

●

Prepare the patient for surgery

Provide patient education of ways to prevent future ectopic pregnancies

-

If the fallopian tube has ruptured, surgery to remove part or all of the tubes will most likely happen

Patient will be educated to stop smoking, how multiple sex partners increase the risk of pelvic infections and ectopic pregnancies, and proper birth control methods

from getting infection

Patient will go to surgery will be NPO, have a catheter and IV inserted

The patient will leave educated and this will prevent further ectopic pregnancies

4. What psychosocial/holistic care PRIORITIES need to be addressed for this patient? (Psychosocial Integrity)

Psychosocial PRIORITIES:

Keep low anxiety levels Encourage patient to express fears, anger and grief

PRIORITY Nursing Interventions:

© 2018 Keith Rischer/www.KeithRN.com

Rationale:

Expected Outcome:

●

I will consistently be the nurse caring for Jean so she does not have to explain the situation or how she feels several times

-

This will give me a level of trust with Jean

●

I will let her know any updates I have as soon as possible

-

This will show Jean I care

●

I will make sure she receives her pain medication

-

This gives her physical comfort and relieves pain

●

I will provide emotional support through genuine conversation. I will talk with Jean, listen and understand her, hear her story, and truly get to know her.

-

This provides a safe environment for the patient to speak

SPIRITUAL CARE/SUPPORT:

●

I will provide information about a chaplain. Chaplains are specially trained to help hospital patients and their family members. They provide spiritual support regardless of faith. Without imposing personal beliefs or practices, our chaplains will attend to any spiritual needs

-

This will help Jean work through any spiritual matters she will need and receive encouragement in this process

CULTURAL CARE/SUPPORT:

●

The patient can join a support group at college for those who have gone through a similar situation.

-

This will give the patient a sense of community and have more people to go to.

CARING/COMFORT: How can you engage and show that this pt. matters to you?

Physical comfort measures:

EMOTIONAL SUPPORT: Principles to develop a therapeutic relationship

(If Applicable)

5. What educational/discharge priorities need to be addressed to promote health and wellness for this patient and/or family? (Health Promotion and Maintenance) The patient needs to be educated on how to prevent ectopic pregnancies and how to keep this situation from happening again. The patient needs to be informed to engage in safe sexual practices, avoid STIs and keep good hygiene to avoid infections that could further damage the fallopian tubes. Currently, the patient needs to limit activity, get plenty of rest, increase fluid intake, and maintain good hygiene. The patient needs to refrain from getting pregnant for at least 3 months to allow for healing. The nurse should make sure to educate about birth control. If the patient is having a hard time dealing with the loss, the nurse should refer to a support group or receive counseling. © 2018 Keith Rischer/www.KeithRN.com

© 2018 Keith Rischer/www.KeithRN.com...