Nursing Care Plan Ectopic Pregnancy 3t6p1a

ASSESSMENT DIAGNOSIS Subjective: “Masakit ang tiyan ko” (My tummy hurts) as verbalized by patient. Objective: • Facial mask of pain. • Guarding behavior.

• Acute pain related to distention or rupture of fallopian tube

INFERENCE • Ectopic pregnancy is gestation located outside the uterine cavity. The fertilized ovum implants outside of the uterus, usually in the fallopian tube. Predisposin g factors include adhesions of the tube , salpingitis, congenital and developmen tal anomalies of the fallopian tube, previous

PLANNING

INTERVENTION RATIONALE

EVALUATION

• After 8 hours of nursing interventions , the patient will be relieved or controlled

Independent: • Monitor maternal vital signs.

• After 8 hours of nursing intervention s, the patient was relieved or controlled

• To determine presence of hypotension and tachycardia caused by rupture or hemorrhage.

• Monitor for presence and amount of vaginal bleeding.

• To further assess the present situation indicating hemorrhage.

• Monitor for increase and pain and abdominal distention and rigidity.

• Increased pain and abdominal distention indicates rupture and possible intraabdominal hemorrhage.

• Monitor complete blood count (CBC). • Provide comfort

• To determine the amount of blood loss. • Promotes relaxation and

ectopic pregnancy, use of an intrauterine device for more than 2 years, multiple induced abortions, menstrual reflux , and decreased tubal motility.

measure like back rubs, deep breathing. Instruct in relaxation or visualization exercises. Provide diversional activities.

may enhance patient’s coping abilities by refocusing attention.

• Provide diversional activities.

• Diversional activities aids in refocusing attention and enhancing coping with limitations.

Collaborative: • ister analgesics as indicated.

• To maintain acceptable level of pain