Ectopic Pregnancy Nursing Care Plans

NURSING CARE PLANS

Name: Client J.V. Medical Diagnosis: Ectopic Pregnancy (Post EXLAP)

Age: 27 years old Attending Physician: Dr. Morales

Sex: Female

Date Cues Needs Nursing

Diagnosis

Plan of Care Nursing Interventions Evaluation

September

25, 2010

@

4:00 PM

3-11

SUBJECTIVE:

“Pagkahuman

sa opera kay

medyo

malipong ko”

“Malipong pud

ko usahay

karon tapos

A

C

T

I

V

I

T

Y

-

Ineffective

peripheral

tissue

perfusion

related to

impaired

transport of

oxygen to

capillary and

At the end of 2 hours

of nursing care, the

patient will be able

to:

Verbalize un-

derstanding of

the condition;

and

Demonstrate

1. Determine factors re-

lated to individual sit-

uation.

® To assess causative

factor of the condition

2. Note customary base-

line data.

® To provide compar-

ison with current find-

GOAL

PARTIALLY

MET

September

25,2010 @

6:00pm

3-11

medyo luya

akong lawas”

OBJECTIVE:

Hemoglo-

bin (115-

175 g/Dl)=

79

RBC (4.20-

6.10)= 2.85

Hematocrit

(0.36-

0.52)= 0.25

Weak pe-

ripheral

pulse

Operation

E

X

E

R

C

I

S

E

P

A

T

T

E

R

N

alveolar

membranes

secondary to

bleeding

® Due to

bleeding and

surgical

procedure

performed,

there is a

decrease in

oxygen

resulting in the

failure to

nourish the

tissues at the

increased per-

fusion as indi-

vidually ap-

propriate.

ings

3. Review laboratory

studies.

® To serve as a scien-

tific basis for the

problem.

4. Encourage for a quiet

and restful atmos-

phere.

® To conserve energy

and lowers tissue oxy-

gen demands

5. Perform assistive

range of motion exer-

cise.

® To promote circula-

At the end of 2

hours of nursing

care, the patient

was able to:

Verbalized

understanding

of the condi-

tion “ Mao

diay malipong

ko usahay,

gkan cguro ni

sa akong op-

erasyon”

She

wasn’t able to

show in-

performed:

Salpingec-

tomy

Blood loss

during

surgery:

450 cc

capillary level.

NANDA 11th

edition

(Doenges)

tion.

6. Encourage early am-

bulation as much as

possible.

® To enhance venous

return.

7. Promote position

changes and discour-

age staying at the

same position for a

long period of time.

® To maximize tissue

Perfusion.

8. Elevate head of bed or

add pillow when pa-

tient is lying on bed.

creased per-

fusion as evi-

denced by

weak periph-

eral pulses

and CRT of 3

seconds. Vi-

tal signs were

stable though.

especially at night.

® To increase gravita-

tional blood flow.

9. Encourage the use of

antiembolitic stock-

ings.

® To prevent venous

stasis

10. Administer medica-

tions with precautions.

® Drug response,

half-life and toxicity

levels may be affected

by altered tissue per-

fusion.

11. Demonstrate and en-

courage the use of re-

laxation techniques

such as deep breathing

exercise.

® To decrease tension

levels.

12. Review specific diet

changes with the

client.

® To promote well-

ness.


Diagnosis


September 2, SUBJECTIVE: C Acute pain At the end of 4 hours 1. Perform an assessment GOAL MET

2010

@

4:00 PM

3-11

“Nagasakit-

sakit ang samd

kay bag-o pa

man gud”

“Lisod moubo

ug mokatawa

kay pag mag-

ubo ug

mokatawa ko

kay musakit

man pud siya”

OBJECTIVE:

Pain scale

of 4 on a

scale of 1-

O

G

N

T

I

V

E

-

P

E

R

C

E

P

T

U

A

related to

release of

prostaglandins

secondary to

surgical wound

® Damage in

tissue due to

surgical

incision

contributes to

the release of

prostaglandins

thus making

the patient

experience

pain. This pain



to:

Report pain re-

lief/control;

Verbalized

method that pro-

vide relief; and

Demonstrate re-

laxation tech-

niques and diver-

sional activities.

.Report pain

scale of 1 from

the scale of 1 to

10

of pain that includes lo-

cation, characteristic, fre-

quency and severity.

® To assess factors that

precipitates and contrib-

utes to pain sensation

2. Note the location of sur-

gical procedure

® This can influence the

amount of postoperative

pain experience. Compli-

cations in the area may

make the pain more se-

vere

3. Acknowledge client’s

description of pain.

® Pain is a subjective ex-

September 25,

2010 @ 8:00pm

3-11

At the end of 4

hours of

nursing care,

the patient was

able to:

Report pain

relief/control

Verbalized

method that

provide re-

10

Seeking out

other peo-

ple

Irritability

Diaphoresis

L

P

A

T

T

E

R

N

is experience

by the patient

in a duration of

less than 6

months since

the damage

tissues will be

repaired by the

body followed

by nutritional

and

pharmacologic

al

management.

Maternal and

Child Health

perience and cannot be

felt by others.

4. Observe for nonverbal

cues.

® Observations may not

be congruent with verbal

reports.

5. Encourage verbalization

of feelings about pain.

® Verbalization of feel-

ings help in choosing

more appropriate inter-

ventions in relation to

pain sensation.

6. Provide quiet and calm

environment.

® To promote a con-

lief; and

Demon-

strate relax-

ation tech-

niques and

diversional

activities.

Report pain

scale of 1

from a scale

of 1 to 10

Nursing Care

6th edition by

Adela Pilliteri

ducive place that will help

in alleviating pain sensa-

tion.

7. Encourage the use of re-

laxation exercises such as

deep breathing exercises.

® This helps in reducing

pain sensation.

8. Encourage diversional ac-

tivities such as reading

newspaper and chatting

with others.

® To assist client in

methods that alleviates

pain.

9. Encourage adequate rest

periods

® To prevent fatigue.

10. Administer analgesic as

ordered.

® To provide pharmaco-

logical effect that may re-

duce or eliminate pain.


Diagnosis


September

25, 2010

@

8:00 PM

3/11

SUBJECTIVE:

“Medyo lipong

ko gamay

karon kay

kulang man

gud akong

tulog"

“Nag lisod pud

ko ug tulog

kay saba tapos

medyo init

pud”

"Dili kaayo ko

S

L

E

E

P

-

R

E

S

T

P

A

T

Disturbed

sleeping

pattern related

to

psychological

and

environmental

factors

® Due to

psychological

(personal loss)

and

environmental

(noisy and




to

Verbalize un-

derstanding of

sleep distur-

bance;

identify individ-

ually appropri-

ate interventions

to promote

sleep; and

report improve-

ment in rest and

1. Identify the presence of

factors that contributes

to disturbed sleeping

pattern.

® To identify

causative and con-

tributing factors

2. Determine recent trau-

matic event in pa-

tient’s life.

® This may present an

additional factor that

causes the problem

3. Observe and obtain

feedback from client

GOAL

PARTIALLY

MET

September 25,

2010 @ 11:00

P.M.

3-11

At the end of 3

hours of

nursing care,

the patient:

Verbalized

understand-

katulog pag

gabii sukad

naoperahan

ko.”

“Maayo gani

makauli na mi

karon para

makatulog ko

ug tarong sa

balay.”

OBJECTIVE:

Frequent

yawning

Humid and

noisy envi-

T

E

R

N

humid) factors,

there is a

disruption of

the patient’s

normal

sleeping

pattern

affecting both

amount and

quality of

sleep.

-NANDA 11th

edition

(Doenges)

sleep pattern regarding usual bed-

time, sleeping habits,

and environmental

needs when sleeping

® To determine usual

sleep pattern and pro-

vide comparative

baseline

4. Determine client’s ex-

pectation of adequate

sleep.

® This provides op-

portunity to address

misconception and un-

realistic expectations

5. Listen to subjective

reports of sleep qual-

ing of sleep

distur-

bance“Na-

galisod

gyud ko ug

tulog diria”;

Identified

ways to pro-

mote sleep

such as mak-

ing the bed

comfortable

and provid-

ing adequate

ventilation;

Even

though she

ronment

Less than age-

normed total

sleep

Personal loss

Deep thinking

Restless

Diaphoresis

ity.

® To determine the

degree of sleep distur-

bance patient feels.

6. Arrange care with the

help of the SO to pro-

vide for uninterrupted

period of rest to allow

long periods of sleep

at night when possi-

ble.

® To help client

achieve optimal sleep

and rest.

7. Provide quiet environ-

ment.

® A quiet environ-

was able to

verbalized

ways to im-

prove sleep

and rest, the

patient was

unable to re-

port improve-

ment in sleep

pattern since

she was al-

ready dis-

charged.

ment promotes restful

atmosphere.

8. Recommend limiting

intake of chocolates

and caffeine espe-

cially prior to bed-

time.

® Chocolates and caf-

feine may alter the pa-

tient’s sleeping time.

9. Assist the client to de-

velop individual pro-

gram of relaxation

such as visualization

and muscle relaxation

and demonstrate these

to the patient.

® To promote well-

ness.

10. Assist client emotion-

ally when loss has oc-

curred.

® To help the client

properly deal with the

situation.


Diagnosis


October 2,

2010

@

6:00 PM

SUBJECTIVE:

“Wala naman

koy mahimo

ana, mao mana

ang pag buot

S

E

L

F

Powerlessness

related to

emotional

response

secondary to




to:

Express sense of

1. Identify situational circum-

stances that made her feel

powerless

® To assess causative factor

that leads and affects the

GOAL MET

October 2, 2010

@ 10:00pm

3/11

sa Ginoo”

“Gusto na

namo sundan

ang among tulo

ka anak pero

dili man jud mi

hatagan” as

verbalized by

the patient.

OBJECTIVE:

Dependency

to husband

regarding

decisions

Seen to be al-

ways in

-

P

E

R

C

E

P

T

I

O

N

-

S

E

L

F

personal loss

® A woman

who has had an

ectopic

pregnancy not

only has grief

stages to work

through but

also may have

a sense of

powerlessness

in her current

situation.

Maternal and

Child Health

Nursing Care

control over the

present situation

and future out-

come;

Acknowledge re-

ality that some

areas are beyond

individual’s con-

trol; and

problem

2. Encourage patient to rest

® To promote adequate rest

and sleep

3. Determine client’s perception

and knowledge of condition

®Perception and knowledge

of the condition serves as the

basis for appropriate nursing

interventions

4. Listen to verbalization of

feelings and note for negative

expressions like “giving up”

and “I’m tired”.

® To determine degree of

powerlessness

5. Note nonverbal behavioral re-

3/11

At the end of 4

hours span of

nursing care,

the patient was

able to:

Express

sense of

control over

the present

situation and

future as she

was able to

verbalize

“ Maski ani

deep

thought

-

C

O

N

C

E

P

T

P

A

T

T

E

R

N

6th edition by

Adela Pilliteri

sponses

® Gestures and nonverbal

cues are significant in looking

deeper into what a person

feels. It is one important way

of expressing one’s feelings

6. Show concern for client as

a person.

® To make the client feel that

she is not alone and gives in-

creases her self-esteem

7. Express hope for the client

®There is always hope in ev-

erything

8. Identify the area that she can

do and areas beyond her con-

trol.

ang nahitabo

sa amoa, naa

lang man jud

na sa amoa

kung gusto

pa mi magka

anak pa o

dili“

Acknowl-

edge reality

that some ar-

eas are be-

yond indi-

vidual’s con-

trol

“Kaning ing

ani na

® This helps the client recog-

nize her own ability.

9. Encourage client to maintain

a sense of perspective about

the situation.

® To promote optimism and

positive outlook towards life.

10. Encourage use of anxiety

and stress-reduction tech-

niques such as thinking of

happy thoughts and positive

self-recitation

® To promote wellness.

sitwasyon

wala na jud

mi mahimo”

as the

patient

verbalized.

Date Cues Needs Nursing Diagnosis Plan of Care Nursing Interventions Evaluation

October 2 ,

2010

@

4:00 PM

3/11

SUBJECTIVE:

“Katol ang

samad gikan sa

operasyon”

“Gitanggalan ko

ug fallopian

tube”

OBJECTIVE:

Surgical wound

due to ex-

ploratory la-

parotomy

done

WBC (5-10) =

H

E

A

L

T

H

P

E

R

C

E

P

T

Risk for infection related

to inadequate primary and

secondary defenses

secondary to exploratory

laparotomy

® Impaired primary

defense and inadequate

secondary defense that

resulted from the

operation contributes to

the patient’s wound being

invaded by pathogenic

microorganisms

At the end of 4

hours of nursing

care, the patient

will be able to:

Verbalize

understand-

ing on

causative/

risk factors;

identify in-

terventions

to prevent or

reduce risk

of infection;

1. Note risk fac-

tors for occur-

rence of infec-

tion including

skin integrity,

environmental

exposure and

laboratory re-

sults.

® To serve as

basis in pro-

viding preven-

tive actions.

2. Observe for

localized signs

GOAL MET

October 2,2010

@ 8:00pm

3/11

At the end of 4

hour span of

care, the patient

was able to:

Verbalize

understand-

ing on

12.6

Hemoglobin

(115-175) =

86

Unhealthy envi-

ronment for

postoperative

patient

Dry and intact

surgical

wound

I

O

N

-

H

E

A

L

T

H

M

A

N

A

G

NANDA 11th edition

(Doenges)

and

Achieve

timely

wound heal-

ing and be

afebrile.

of infection at

the surgical

wound

® To assess

physical signs

that manifest

infection

3. Stress proper

hand hygiene

by all care-

givers be-

tween thera-

pies/clients.

® Hand

washing is a

first line of de-

fense against

causative/

risk factors.

identify in-

terventions

to prevent

or reduce

risk of in-

fection; and

Achieve

timely

wound heal-

ing since the

wound was

already dry

and intact

and be

E

M

E

N

T

P

A

T

T

E

R

N

health care as-

sociated infec-

tions.

4. Encourage the

use of protec-

tive gears like

mask and

gloves.

® To reduce

the risk of

contamination

when handling

the patient.

5. Maintain clean

technique

when doing

wound dress-

afebrile.

ing.

® To prevent

bacterial colo-

nization.

6. Cleanse inci-

sion sites daily

and as needed

with appropri-

ate cleaning

solution.

® To maintain

a clean surgi-

cal wound and

reduce the risk

of infection

7. Change dress-

ings daily and

as needed us-

ing clean

dressing.

® To maintain

adequate pro-

tection and

prevent con-

tamination of

the wound.

8. Encourage the

client take nu-

tritious foods

and increase

fluid intake

® To

strengthen the

patient’s im-

mune system

thus decreas-

ing the pa-

tient’s suscep-

tibility to in-

fection.

9. Maintain a

clean and

healthy envi-

ronment.

® To promote

an environ-

ment for faster

wound heal-

ing.

10. Instruct client

and significant

others in tech-

niques to pro-

tect the in-

tegrity of skin,

surgical

wound care

and prevention

of spread in-

fection

® To provide

the client and

significant

others with ap-

propriate

knowledge

and skills in

order to pro-

mote continu-

ity of care.

11. Administer

antibiotics as

ordered.

® To prevent

infection.

12. Provide multi-

vitamins as or-

dered.

® To enhance

the immune

system of the

patient.

Documents

Ectopic Pregnancy Nursing Care Plans