Nursingcrib.com Nursing Care Plan Ectopic Pregnancy 3u6g10

NURSING CARE PLAN ASSESSMENT Subjective: “Masakit ang tiyan ko” (My tummy hurts) as verbalized by patient. Objective: •

Facial mask of pain.

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Guarding behavior.

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V/S taken as follows: T: 36.4 P: 85 R: 22 Bp: 110/90

DIAGNOSIS •

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 ectopic pregnancy,

PLANNING •

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

INTERVENTION

RATIONALE

Independent: • Monitor maternal vital signs.

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Monitor for presence and amount of vaginal bleeding.

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Monitor for increase and pain and abdominal distention and rigidity.

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Monitor complete blood count (CBC). Provide comfort measure like back rubs, deep breathing. Instruct in relaxation or visualization exercises. Provide diversional activities. Provide diversional

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To determine presence of hypotension and tachycardia caused by rupture or hemorrhage. To further assess the present situation indicating hemorrhage. Increased pain and abdominal distention indicates rupture and possible intraabdominal hemorrhage. To determine the amount of blood loss. Promotes relaxation and may enhance patient’s coping abilities by refocusing attention.

Diversional activities aids in

EVALUATION •

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

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

refocusing attention and enhancing coping with limitations.

activities.

Collaborative: • ister analgesics as indicated.

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To maintain acceptable level of pain.