Case Study on Ectopic Pregnancy

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A Case Study on Ectopic Pregnancy Submitted to: Geetha Reddy Mam Submitted by: G.sudeshna (08immn13)

Transcript of Case Study on Ectopic Pregnancy

Page 1: Case Study on Ectopic Pregnancy

A Case Study on Ectopic Pregnancy

Submitted to:Geetha Reddy Mam Submitted by:

G.sudeshna (08immn13) V.Prashanth (08immn12) V.Srikanth (08immn11)

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...................................Index....................................................

I) OBJECTIVES......................................................................................II)INTRODUCTION.......................................................III.PATIENTS HEALTH HISTORY..............................................................a)PERSONAL DATA.......................................................................................b)PRESENT HEALTH STATUS..................................................................c)PAST MEDICAL HISTORY.......................................................................d)FAMILY HEALTH HISTORY……………………………………………………………………..e)PHYSICAL ASSESSMENT...........................................................................IV.ANATOMY AND PHYSIOLOGY...........................................................V. PATHOPHYSIOLOGY.........................................................................VI.DIAGNOSIS............................................................................................a)DEFINITION…………………………………………………………………………………………………b)RISK AND PREDISPOSING FACTORS…………………………………………………c) SIGNS AND SYMPTOMS………………………………………………………………………..d) DIAGNOSTIC EXAMS............................................................................VII. SURGICAL PROCEDURE.....................................................................VIII. MEDICAL MANAGEMENT........................................................................XI. SURGICAL MANAGEMENT......................................................................X. NURSING MANAGEMENT.....................................XI. DRUG STUDY........................................................................XII. CONCLUSION…………………………………………………...……………………XIII.REFERENCE……………………………………………………………………………………………………….

I)INTRODUCTION

We the I.Msc Nursing sciences group was given the opportunity to have an exposure at FERNANDEZ HOSPITAL; Bogulkunta branch – post opt Ward; and on founda commendable case reasonable to be presented for case study.

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Naga Lakshmi, was one of the patients admitted to the Gyne Ward. She was admitted due to diagnosed ruptured ectopic pregnancy. She has undergone Laparoscopy bilateral Salpingectomy.

Ectopic Pregnancy occurs in about 1 in 250 pregnancies amounting to approximately;An ectopic pregnancy is commonly referred to as a tubal pregnancy because 95 percentoccur in a fallopian tube. An ectopic pregnancy needs to be treated immediately to avoid fallopian tube damage or life threatening blood loss. When identified early, ectopic pregnancies are treatable with medication that stops the pregnancy.

The group chose Naga Lakshmi as their subject primarily because her case posed as aVery intricate case requiring due understanding and knowledge. The group recognizes their partial knowledge about ectopic pregnancy and the surgical procedures involved in such condition, thus making this case a good avenue to broaden the proponents knowledge about the disease and the surgical procedures involved.

II)OBJECTIVES

General Objective:The main goal of the group is to be able to present the case study of our chosen clientthat would provide a comprehensive discussion of the pathological mechanism of the disease to yield significant information for the case study.

Specific Objectives:In order to meet the general objective, the group aims to:

establish rapport to the patient and the patient’s significant others,

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interpret the pertinent data gathered from the patient and her significant others,state past and present health history of the patient,define the complete diagnosis of the patient,present the cephalocaudal assessment obtained from the patient,discuss the anatomy and physiology of the organ involved in the patient’s disease,present the etiology and symptomatology of the patient’s disease,trace the pathophysiology of the patient’s disease,interpret the laboratory test results of the patient,discuss the nature of the drugs given to the patient,discuss the surgical procedure performed to the patientpresent a specific, measurable, attainable, realistic and time-bounded nursing care plans for the clientjustify the client’s prognosis according to the different criteria

III)PATIENT HEALTH HISTORY

a)PERSONAL DATAA 31yr old lady ,G3P2L2 (Post Tubectomy) with 6+1 weeks of amenorrhea ,presents on 14-02-11 with complaints of right Iliac fossa pain since 3-4days .TVS SCAN done outside showed uterus measuring 7.6 X 3.7cm,ET-16mm.

There was evidence that of single gestational sac in right tubal region measuring 7mm with decadal reaction, right tubal pregnancy and minimal free fluid in the pelvis. Scan done on 15-02-11 showed echogenic SOL in the right adnexa.measures 32 x31 mm with 4mm gestational sac, measured moderate ascites ,ET measured 23 mm.

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Explained the patient regarding the need of laparoscopy / laprotomy+_bilateral salpingectomy (in view of tubectomy failure)

b) Present illness or present health status

During the 1st week of Jan, the patient experienced on and off vaginal spotting.No other signs and symptoms related to ectopic pregnancy manifested during this time.This condition persisted and on the 2nd week of Feb. The patient noted hypogastric pain and described it like having dysmenorrhea.. The severity of the pain increased, added with another vaginal spotting made her decide to eventually seek for medical help.

C) Past Medical HistoryThe patient was born via normal spontaneous vaginal delivery. There were nocomplications or abnormalities when she was delivered. She does not have anyinformation about her immunization status.

According to her, she had a chicken pox when she was 9 years old. She does notusually get cough or colds but experiences fever at times due to weather conditions.During the first month of her pregnancy of her first child, she had bleeding. Shesought for medical help and was asked to take a rest and avoid strenuous activities to

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avoid complications in her pregnancy. She delivered her first two babies via normalspontaneous vaginal delivery.

d) Family health status

Her father died 5 years ago due to cardiac arrest. On the other hand, her mother is still living and is hypertensive. Among her 3 siblings, one is also hypertensive.

e) PHYSICAL ASSESSMENT

A. SkinThe patient’s skin is dry with good skin turgor. Skin color is brown which isuniform in all areas except for areas that are not usually exposed to sun such as the axillae, the legs and soles of the feet. Skin is warm to touch, which is uniform on both extremities. A surgical wound covered by a sterile dressing is noted on the hypogastric area of the patient’s abdomen. Both the right and left hands have scratches as it served as IV insertion sites.

B. HairHair is evenly distributed over scalp. It is oily and black in color. Dandruffs arepresent. Fine hairs are evenly distributed on both extremities.

C. Nails

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Nails were unclean and not well trimmed with whitish to light pink nail beds, withnormal angle curvature, and with a capillary refill of 3 seconds. Fingernails and toenails were pale. Surrounding tissues were intact; no lesions nor lacerations were observed.

The Head

A. Skull and FaceThe patient’s head is normocephalic and proportional to body size. Presences of nodules or masses are not noted. Facial features and movements are symmetrical. The patient is able to raise her eyebrows, close her eyes, frown, and smile. Her face manifests a feeling of slight tiredness.

B. The EyesThe hair in the patient’s eyebrows is evenly distributed; skin is intact andsymmetrically aligned with equal movement and there was no noted scaling and flakiness of skin. The eyelashes are equally distributed and curled slightly outward. Her eyelids close symmetrically; discharges and discolorations were not noted. Her pupil size in both eyes are equal, with a diameter of 3mm when dilated and 2mm when constricted; with brisk reaction to light accommodation. According to her, when looking straight ahead, she can see objects in periphery. There was no edema or tenderness noted over her lacrimal glands.

C. Nose and SinusesThe external nose is symmetrical, straight and uniform in color. Nasal flaring was not noted. Color is the same with the entire face; there was no tenderness noted upon palpation. Lesions and tenderness were both absent. Nasal mucosa was pinkish. Both left and right nares were patent, with no discharges; air could freely move in and out when the patient breathes. The nasal septum is intact and in the midline without deviations. The frontal and maxillary sinuses were non-tender upon palpation. Sense of smell was good.

D. EarsAuricles are smooth, symmetrical and no discoloration noted. Her external pinna isnormoset; deformities, lesions or inflammations were not present. Pinna recoils after it is being folded; it is firm and non tender. The ears were physically symmetrical in size and normoset since both are located in line with the outer canthus of his eyes. Normal voice tones are audible.

E. Mouth and OropharynxThere were no lesions and masses noted on the lips and they appear moist and

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pinkish. Oral mucosa was pinkish and the tongue was located at the midline, pink in color, slightly dry and furry with whitish coating. She was able to move her tongue freely. The gums was pinkish, with no signs of bleeding. The uvula is in the midline and the mucosa surrounding it is slightly pink. His tonsils were free from inflammation. Dental carries were present

Neck

The muscles in her neck were equal in size. His neck movement was coordinated anddifficulty in moving was not noted. He was able to flex, hyperextend, laterally flex and rotate his neck without distress. He can also turn his head on one side against the resistance of our hand with the similar strength and shrug his shoulders up against the resistance of our hand with equal strength. The trachea is in the midline. No lymph nodes were palpable.

Chest and Lungs

The patient has a regular and normal breathing pattern; quiet and rhythmic respirations,with respiratory rate of 17 cyles in one full minute. No tenderness and masses upon palpation. No adventitious breath sounds on both left and right lung fields were heard during auscultation. Tactile fremitus on both lungs are symmetrical. Posterior chest was not assessed.

Heart

A. Heart and Central VesselsPoint of maximum impulse and beat is auscultated at the 5th intercoastal space leftmidclavicular line. The patient has a cardiacrate of 73 beats per minute. Presence of abnormal heart sounds were not noted upon auscultation.

B. Peripheral pulsesPeripheral pulses have regular rhythm but weak. Her pulse rate is 71 beatsper minute. The skin is warm upon palpation and capillary refill time is 3 seconds.

Abdomen

The patient’s abdomen has same color with his chest. The hypogastric area is coveredwith brace. Beneath it is a surgical wound as a result of surgery. The umbilicus is medially located and shows no signs of inflammation. Bowel sounds are present upon auscultation. There were symmetric movements between the abdomen and respiration.

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Genito-Urinary

The patient reported that there were no lesion, tenderness and masses in her perineum and anus. Musculoskeletal

A. Upper ExtremitiesThe patient’s radial and brachial pulses were regular but weak. Good range of motionwas noted. Palm is able to stay in both prone and supine in a good manner without difficulty. She was able to exhibit strong hand grip on both arms. Client was able to extend both arms. Reflex on the upper extremity was good. No hand tremors noted.

B. Lower ExtremitiesThe patient reported that there were no problems in her lower extremities. However, shehad difficulty ambulation due to the surgical wound in her hypogastric area.

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IV)ANATOMY AND PHYSIOLOGY

The vagina is a thin-walled tube 8 to 10 cm long. It lies between the bladder and rectumand extends from the cervix to the body exterior. Often called the birth canal, the vagina provides a passageway for the delivery of an infant and for the menstrual flow to leave the body.The cervix (from Latin "neck") is the lower, narrow portion of the uterus where it joinswith the top end of the vagina. Where they join together forms an almost 90 degree curve. It is cylindrical or conical in shape and protrudes through the upper anterior vaginal wall.Approximately half its length is visible with appropriate medical equipment; the remainder lies above the vagina beyond view. It is occasionally called "cervix uteri", or "neck of the uterus".

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During menstruation, the cervix stretches open slightly to allow the endometrium to beshed. This stretching is believed to be part of the cramping pain that many women experience.Evidence for this is given by the fact that some women's cramps subside or disappear after their first vaginal birth because the cervical opening has widened.The portion projecting into the vagina is referred to as the portio vaginalis or ectocervix.On average, the ectocervix is three cm long and two and a half cm wide. It has a convex, elliptical surface and is divided into anterior and posterior lips. The ectocervix's opening is called the external os. The size and shape of the external os and the ectocervix varies widely with age, hormonal state, and whether the woman has had a vaginal birth. In women who have not had a vaginal birth the external os appears as a small, circular opening. In women who have had a vaginal birth, the ectocervix appears bulkier and the external os appears wider, more slit-like and gaping.The passageway between the external os and the uterine cavity is referred to as theendocervical canal. It varies widely in length and width, along with the cervix overall. Flattened anterior to posterior, the endocervical canal measures seven to eight mm at its widest in reproductive-aged women. The endocervical canal terminates at the internal os which is the opening of the cervix inside the uterine cavity.During childbirth, contractions of the uterus will dilate the cervix up to 10 cm in diameterto allow the child to pass through. During orgasm, the cervix convulses and the external os dilates.The uterus is shaped like an upside-down pear, with a thick lining and muscular walls.

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Located near the floor of the pelvic cavity, it is hollow to allow a blastocyte, or fertilized egg, to implant and grow. It also allows for the inner lining of the uterus to build up until a fertilized egg is implanted, or it is sloughed off during menses.The uterus contains some of the strongest muscles in the female body. These muscles are able to expand and contract to accommodate a growing fetus and then help push the baby out during labor. These muscles also contract rhythmically during an orgasm in a wave like action. It is thought that this is to help push or guide the sperm up the uterus to the fallopian tubes where fertilization may be possible.The uterus is only about three inches long and two inches wide, but during pregnancy itchanges rapidly and dramatically. The top rim of the uterus is called the fundus and is alandmark for many doctors to track the progress of a pregnancy. The uterine cavity refers to the fundus of the uterus and the body of the uterus.Helping support the uterus are ligaments that attach from the body of the uterus to thepelvic wall and abdominal wall. During pregnancy the ligaments prolapse due to the growing uterus, but retract after childbirth. In some cases after menopause, they may lose elasticity and uterine prolapse may occur. This can be fixed with surgery.Some problems of the uterus include uterine fibroids, pelvic pain (includingendometriosis, adenomyosis), pelvic relaxation (or prolapse), heavy or abnormal menstrual bleeding, and cancer. It is only after all alternative options have been considered that surgery is recommended in these cases. This surgery is called hysterectomy. Hysterectomy is the removal of the uterus, and may include the removal of one or both of the ovaries. Once performed it is irreversible. After a hysterectomy, many women begin a form

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of alternate hormone therapy due to the lack of ovaries and hormone production.The Fallopian tubes are paired, tubular, seromuscular organs whose course runs medially from the cornua of the uterus toward the ovary laterally. The tubes are situated in the upper margins of the broad ligaments between the round and utero ovarian ligaments. Each tube is about 10 cm long with variations in length from 7 to 14 cm. The abdominal ostium is situated at the base of a funnel-shaped expansion of the tube, the infundibulum, the circumference of which is enhanced by irregular processes called fimbriae. The ovarian fimbria is longer and more deeply grooved than the others and is closely applied to the tubal pole of the ovary. Passing medially, the infundibulum opens into the thin-walled ampulla forming more than half the length of the tube and 1 or 2 cm in outer diameter; it is succeeded by the isthmus, a round and cord-likestructure constituting the medial one-third of the tube and 0.5-1 cm in outer diameter. The interstitial or conual portion of the tube continues from the isthmus through the uterine wall to empty into the uterine cavity. This segment of the tube is about 1 cm in length and 1 mm in inner diameter.The tubal wall consists of three layers: the internal mucosa (endosalpinx), theintermediate muscular layer (myosalpinx), and the outer serosa, which is continuous with the peritoneum of the broad ligament and uterus, the upper margin of which is the mesosalpinx. The endosalpinx is thrown into longitudinal folds, called primary folds, increasing in number toward the fimbria and lined by columnar epithelium of three types: ciliated, secretory, and peg cells. In the ampullary and infundibular sections, secondary folds of the tubal mucosa also exist, markedly increasing the surface areas of these segments of the tube. The myosalpinx actually consists of an inner circular and an outer longitudinal layer to which a third layer is added in the interstitial portion of the tube.Peristaltic contraction of the smooth muscle fibers in the tubal wall allows the gametes(the sperm and egg) to be brought together, thus allowing fertilization and subsequent transport of the fertilized ovum from the normal site of fertilization in the ampulla to the normal site of implantation in the uterus.There are fewer ciliated cells in the isthmus than in the ampullary portion of the tube,whereas they are most prominent in the fimbriated infundibulum. Ciliation and deciliation is a continuous process throughout the menstrual cycle. Ciliation is maximum in the periovulatory period, particularly in the fimbria. Estrogen enhances the process of ciliation, whereas progesterone inhibits it, so significant deciliation occurs in atrophic postmenopausal tube.

Ciliary activity is responsible for the pickup of ova by, the fimbrial ostium and movement

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through the ampulla, as well as the distribution of the tubal fluid which supports gametematuration and fertilization and facilitates gamete and embryo transport. The closeapproximation between the ovary and fimbria is likely to be important for ovum pickup,although, transperitoneal migration has been reported.The paired ovaries are pretty much the size and shape of almonds. An internal view of an ovary reveals many tiny saclike structures called ovarian follicles. Each follicle consists of an immature egg called an oocyte, surrounded by one or more layers of very different cells called follicle cells.The ovaries are for oogenesis-the production of eggs (female sex cells) and for hormone production (estrogen and progesterone). As the developing egg begins to ripen or mature, follicle enlarges and develops a fluid filled central region. When the egg is matured, it is called a graafian follicle, and is ready to be ejected from the ovary.The process of ovulation is controlled by the hypothalamus of the brain and through therelease of hormones secreted in the anterior lobe of the pituitary gland, (Luteinizing hormone (LH) and Follicle-stimulating hormone (FSH)). In the follicular (pre-ovulatory) phase of the menstrual cycle, the ovarian follicle will undergo a series of transformations called cumulus expansion, this is stimulated by the secretion of FSH. After this is done, a hole called the stigma will form in the follicle, and the ovum will leave the follicle through this hole. Ovulation is triggered by a spike in the amount of FSH and LH released from the pituitary gland. During the luteal (post-ovulatory) phase, the ovum will travel through the fallopian tubes toward the uterus.If fertilized by a sperm, it may perform implantation there 6–12 days later.In humans, the few days near ovulation constitute the fertile phase. The average time ofovulation is the fourteenth day of an average length (twenty-eight day) menstrual cycle. It is normal for the day of ovulation to vary from the average, with ovulation anywhere between the tenth and nineteenth day being common.Cycle length alone is not a reliable indicator of the day of ovulation. While in general anearlier ovulation will result in a shorter menstrual cycle, and vice versa, the luteal (postovulatory) phase of the menstrual cycle may vary by up to a week between women.Fertilization occurs when a single sperm cell has penetrated the oocyte. After spermentry, changes occur in the fertilized egg to prevent other sperm from gaining entry. Infertilization, the genetic material of a sperm combines with the ovum to form a zygote.

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After fertilization, the zygote travels to the uterus through peristalsis and cilia. The zygote generally gets implanted at the top of the uterus, beginning between 5 and 8 days after fertilization. This process is completed by 9 or 10 days. At this time, the outer layer of this cell mass or trophoblast attaches itself by secreting the required enzymes, which actually erode the uterine wall cells.

Ectopic pregnancy results from a delay in the passage of the fertilized ovum throughfallopian tube. This delay can result from anatomical abnormalities of the tubes, such asconstriction and false passage formation (e.g. diverticulum), or from tubal dysfunction as altered contractility or abnormal ciliary activity.

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V)PATHOPHISIOLOGY

Egg develops normally, arising from the union of a sperm and an egg. As itreaches implantation stage, certain etiological factors affect normal implantation. Age,congenital anomalies of the tube, dysfunctions of the tube, previous surgical procedures and pelvic infections usually contribute to the discontinuity of the integrity of the fallopian tubes and their function, thus making it hard for the fertilized egg to anchor itself to the uterine cavity. So, instead, the blastocyst burrows into the epithelium of the tubal wall, tapping blood vessels by the same process as in normal implantation into the uterine endometrium. Implantation on the tubal mucosa arises.The erosive action of villous trophoblast causes penetration of the tubal wall which mayextend to the peritoneal coat, invading blood vessels and causing bleeding into the lumen, tubal wall or the peritoneal cavity. From this phenomenon, sudden abdominal pain is felt by the patient. Ultrasound findings in this event would show absence of an intrauterine gestational sac and B-hCG levels of greater than 6500mIU per mL. The treatment for this early diagnosis of ectopic pregnancy is salphingostomy which would remove the fetus from the tube; administration of methotrexate tomake sure no ectopic tissue is left and the administration of broad spectrum antibiotics for prophylaxis to address infection and swelling.This sudden abdominal pain experienced by most patients, indicative of early stageectopic pregnancy, if not promptly addressed, would lead onto further formation of an embryo extrauterinally. However, due to the environment of the fallopian tube, which is not ideal for the

VI)DIAGNOSIS

a)DEFINITION

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Ectopic pregnancy is pregnancy implantation outside the uterus, usually in the fallopiantube. If discovered before the tube ruptures, this can be treated with methotrexate ormifepristone. If not discovered early, it produces sharp lower quadrant pain at about 6 to weeks as the tube ruptures. Surgery is done to remove the conceptus and repair the tube to halt bleeding.

It occurs when a fertilized ovum (a blastocyst) becomes implanted on any tissue otherthan the uterine lining (eg.the fallopian tube, ovary, abdomen, or cervix) the most common site of ectopic implantation is the fallopian tube.

b) RISKS AND PREDISPOSING FACTORS

Age : Increased age predisposes an individual to ectopic pregnancy due to basicwear and tear.The patient is 36 years old, considering her age and one normal spontaneous vaginaldelivery, discontinuities to the tubes can be present and thus precedentsectopic pregnancy.Sex Present Ectopic pregnancy is a condition which is only applicable to a femaleindividual considering the structure of the reproductive system.The patient is female. Congenital abnormalities of the tube absent Abnormalities in the tubal structure or functions puts an individual at risk ofectopic pregnancy.

Infertility absent Usually, problems related to infertility has underlying factors whichare similar to the factors predisposing on to ectopic pregnancy .

c)SIGNS AND SYMPTOMS

Abnormal vaginal bleeding Present Mild to intermittent dark red or brownvaginal discharge occurs in 50% of the cases related to uterine decidualshedding.The patient claims to have experienced episodes of vaginal spotting and bleeding,

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which is primarily why she opted to seek medical attention. Bleeding was saidto be slightly profuse.Abnormal pain Present Usually first manifested by dull pain caused by tubalstretching followed by sharp colicky tubal pain caused by further stretchingand stimulated contractions.Patient reports abdominal pain which as time progressesbecomes unbearable.Shoulder pain absent Referred shoulder pain may occur as a result of diaphragmaticThis was not present in the patient. in the peritoneal cavityWeakness, dizziness present Occurs in the presence of bleeding.Patient experiences some series of orthostatic hypotension, body malaiseand dizziness.Decreased blood pressure present Related to bleeding. This was present in thepatient.

d)DIAGNOSTIC EXAMS

A. Laboratory Tests and Diagnostic Examinations

DIAGNOSTIC AND LABORATORY RESULTS:

HEMATOLOGY RESULT NORMAL VALUES INTERPRETATION

       

HEMOGLOBIN 86 120 - 170 g/L Decrease protein production causing anemia

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HEMATOCRIT 0.25 0.37 - 0.54 Decreased because the patient has

      Significant with hemorrhage

RED BLOOD CELL 2.87 4.0 - 6.0 x 1012 L Decrease O2 production due to

      Vaginal bleeding that cause anemia

WHITE BLOOD CELL 11.2 4.5 - 10 x 109 L Slightly increased because infection started

       

DIFFERENTIAL COUNT:      

NEUTROPHILS 0.75 0.38 - 0.68 Increased because of WBC elevation

LYMPHOCYTES 0.15 0.22 - 0.53 Decreased because immune system is affected

EOSINOPHILS 0.08 0.01 - 0.07 Increased due to parasitic infection

MONOCYTES NOT DONE 0.05 - 0.12 NOT DONE

BASOPHILS NOT DONE 0.002 - 0.01 NOT DONE

STABS NOT DONE 0.0 - 0.05 NOT DONE

LABORATORY EXAMINATION

1.) COMPLETE BLOOD COUNT:

2.) PLATELETS COUNT = Adequate

3.) RED CELL MORPHOLOGY

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MCV (MEAN CORPUSCULAR VOL.) = 90 L F1 IV.U (80 – 96 f1)

4.) PERIPHERAL SMEAR

MCH (MEAN CORPUSCULAR HEMOGLOBIN)

= 30.0 pg IV.U (27 – 33 pg)

MCHC (CORPUSCULAR HEMOGLOBIN CONCENTRATION)

= 33 L 9/L IV.U (320 – 360 9/L)

DEFINITION OF TERMS INDICATED IN THE LABORATORY EXAMINATION

COMPLETE BLOOD COUNT (CBC)

- A complete blood count (CBC), also known as full blood count (FBC) or full blood exam

(FBE) or blood panel, is a test requested by a doctor or other medical professional that gives

information about the cells in a patient's blood. A Medical technologist performs the requested

testing and provides the requesting Medical Professional with the results of the CBC. A CBC is

also known as a "hemogram".

- The cells that circulate in the bloodstream are generally divided into three types: white

blood cells (leukocytes), red blood cells (erythrocytes), and platelets or thrombocytes.

Abnormally high or low counts may indicate the presence of many forms of disease, and hence

blood counts are amongst the most commonly performed blood tests in medicine.

RED BLOOD CELLS (ERYTHROCYTES)

- Are the most common type of blood cells and the vertebrate body’s principal means of

delivering oxygen from the lungs or grills to body tissue via blood.

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- The number of red cells is given as an absolute number per litre.

HEMOGLOBIN

- Is a protein that is carried by the red cells. It picks up oxygen in the lungs and delivers it

to the peripheral tissues to maintain the viabilty of the cells.

- The amount of hemoglobin in the blood, expressed in grams per litre. (Low hemoglobin

is called anemia.)

HEMATOCRIT OR PACKED CELL VOL. (PCV)

- This is the fraction of whole blood volume that consists of red blood cells.

MEAN CORPUSCULAR VOL. (MCV)

- the average volume of the red cells, measured in femtolitres. Anemia is classified as

microcytic or macrocytic based on whether this value is above or below the expected normal

range. Other conditions that can affect MCV include thalassemia and reticulocytosis.

MEAN CORPUSCULAR HEMOGLOBIN (MCH)

- the average amount of hemoglobin per red blood cell, in picograms.

- It is diminished in microcytic anemias, and increased in macroanemias.

- It is calculated by dividing the total mass of hemoglobin by the RBC count.

MEAN CORPUSCULAR HEMOGLOBIN CONCENTRATION (MCHC)

- the average concentration of hemoglobin in the cells.

- It is diminished (“hypochromic”) in microcytic anemias, and normal (“normochromic”) in

macro anemias (due to large cell size, though the hemoglobim amount or MCH is high, the

concentration remains normal).

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WHITE BLOOD CELLS (LEUKOCYTES)

- Are cells of the immune system which defend the body against both infectious disease

and foreign materials.

- All the white cell types are given as a percentage and as an absolute number per litre.

A complete blood count with differential will also include:

NEUTROPHILS

- This is the main defender of the body against infection and antigens. High levels may

indicate an active infection.

- May indicate bacterial infection. May also be raised in acute viral infections.

LYMPHOCYTES

- Is a type of blood cell in the vertebrate immune system.

- Elevated levels may indicate an active viral infections.

- Higher with some viral infections such as glandular fever and. Also raised in lymphocytic

leukaemia CLL.

MONOCYTES

- May be raised in bacterial infection

- Is a leukocyte, part of the immune system that protects against bloodborne pathogens

and moves quickly to sites of infections in the tissue.

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- Elevated levels may indicate an allergic reactions or parasites.

EOSINOPHILS

- Are white blood cells of the immune system that are responsible for combating infection

by parasites in vertebrates. They are granulocytes that develop in the bone marrow before

migrating into blood.

- Increased in parasitic infections.

- High levels are found in allergic reactions.

BASOPHILS

- Circulates vhite blood cells.

- Basophils degranulate to release histamine, proteoglycans (e.g. heparin and

chondroitin), and proteolytic enzymes (e.g. elastase and lysophospholipase). They also secrete

lipid mediators like leukotrienes, and several cytokines.

PLATELET COUNT

- Platelets or thrombocytes are the cell fragments circulating in the blood that are involved

in the cellular mechanisms of primary hemostasis leading to the formation of blood clots.

Dysfunction or low levels of platelets predisposes to bleeding, while high levels, although

usually asymptomatic, may increase the risk of thrombosis.

- Functions of Platelets can be generalised into a number of categories: Adhesion,

Aggregation, Clot retraction, Pro-Coagulation, Cytokine signalling, Phagocytosis.

- A normal platelet count in a healthy person is between 150,000 and 400,000 per mm³ of

blood (150–400 x 109/L). 95% of healthy people will have platelet counts in this range. Some

will have statistically abnormal platelet counts while having no abnormality, although the

likelihood increases if the platelet count is either very low or very high.

- Low platelet counts are generally not corrected by transfusion unless the patient is

bleeding or the count has fallen below 5 x 109/L; it is contraindicated in thrombotic

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thrombocytopenic purpura (TTP) as it fuels the coagulopathy. In patients having surgery, a level

below 50 x 109/L) is associated with abnormal surgical bleeding, and regional anaesthetic

procedures such as epidurals are avoided for levels below 80-100.

RED BLOOD CELL MORPHOLOGY

- Also known as Blood Smear, and Manual differential.

- Was once prepared on nearly everyone who had a complete blood count (CBC)

performed. With the automated blood cell counting instruments currently used, an automated

differential is also provided. However, if the presence of abnormal WBCs, RBCs, or platelets is

suspected, a blood smear examined by a trained eye is still the best method for definitively

evaluating and identifying immature and abnormal cells.

- Findings from the blood smear evaluation are not always diagnostic in themselves and

more often indicate the presence of an underlying condition and its severity and suggest the

need for further diagnostic testing. Blood smear findings may include: RBC, WBC and

differential count.

PERIPHERAL SMEAR

- A Peripheral smear is a blood test that gives information about the number and shape of

blood cells.

DIAGNOSTIC EXAMINATION

GYNECOLOGY = “PELVIC ULTRASOUND” is the examination done to the patient

I. UTERUS

ABNORMALITIES

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The uterus is enlarged with a dilated endometrial cavity as measured containing complex

structure with multiple cystic spaces of varied sizes interspersed within suggestive of a molar

gestation.

II. ENDOMETRIUM

Thick – 7.96 CM Hyper-echoic

VII)SURGICAL PROCEDURE

A fallopian tube segment is removed. The remaining healthy fallopian tube maybe reconnected. Salpingectomy is needed when the fallopian tube is being stretched bythe pregnancy and may rupture or when it has already ruptured or is very damaged.If the ectopic pregnancy has ruptured or bleeding persists, salpingectomy is anoption. This procedure involves excision of segment of the fallopian tube involved inthe ectopic pregnancy. The tubal segment to be removed is coagulated and cut off withbipolar forceps . The mesovarium is also coagulated and cut off in the same manner.

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VIII)MEDICAL/SURGICAL NURSING CARE MANAGEMENT:

Medical Management

If the hCG level is below a certain limit and there is no risk of imminent rupture, the doctor mprescribe a drug called methotrexate to treat the ectopic pregnancy. Methotrexate is also used in chemotherapy and works to stop rapidly growing cells from multiplying. The drug is administered as an injection.

Research has found methotrexate to be an effective treatment for early ectopic pregnancies, preventing the need for surgery about 90% of the time when the woman is a candidate for the treatment. When using methotrexate to treat ectopic pregnancy, doctors usually continue to monitor a woman's hCG levels also in order to make sure that the ectopic pregnancy is not continuing to develop.

VIII)SURGICAL MANAGEMENT:

Salpingectomy has traditionally been done via a laparotomy; more recently however, laparoscopic salpingectomies have become more common as part of minimally invasive surgery. The tube is severed at the point where it enters the uterus and along its mesenteric edge with hemostatic control.

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NURSING CARE MANAGEMENT

Nursing Responsibilitiesa. Pre-Operative Phase

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Nursing Responsibilities:

Secure the informed consent for legal purposes and take theresponsibility to remember the things that follow:

1. The surgeon must be the one to provide a clear and simple explanation regarding the surgical procedure.2. The nurse may witness the patient signing the consent.3. If the patient needs additional information about the procedure or did not understand the instruction, the nurse should notify the surgeon.4. If the patient is a minor, unconscious or incompetent, permission must be obtained from a family member or guardian of legal age.5. An emancipated minor (married or independently living or earning on his own) may sign his/her own consent form without permission from a guardian.6. No patient should be forced, urged or coerced to sign the consent.Tell the woman (and significant others) what is going to be done, listen to her, respond attentively to her questions and concerns.Assess the woman’s nutritional status. Good nutrition is an essential factor in promoting healing and resisting infection.Assess for the woman’s previous medication use. A medication history is obtained from each patient because of the possibility of drug interactions.Teach deep-breathing, coughing exercises to help in aiding the patient after surgery.Teach cognitive coping techniques such as imagery, distraction and optimistic self-recitation to reduce fear and anxiety.Obtain and document patient’s vital signs for baseline data and maintain the preoperative record.Infuse IV fluids, catheterize the woman’s bladder, and have anesthetist give anesthesia and prophylactic antibiotics.

a . Intra-Operative PhaseNursing Responsibilties:

Preparing the woman:○ Place the woman in the supine position on the operating table.○ Ensure that the anesthesia has taken full effect.Skin Preparation:○ Apply antiseptic solution to the abdomen using a gentle circular motion and place a drape over the woman.Circulating nurse:○ Manages the operating room.○ Protects patient’s safety and health by monitoring the activities of the surgical team.

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○ Monitors safe functioning of the equipments.○ Coordinates with the surgical/ perioperative team and monitors aseptic practices.○ Count all sponges, instruments, and needles together with the scrub nurse.Scrub nurse:○ Sets up sterile field.○ Assists the surgeon and assistant surgeon, and takes care of specimens.○ Counts all sponges, instruments, and needles together with the circulating nurse.○ Cuts and dissects needles that should be kept separately from other instruments and demands careful handling at all times.

Type of Anesthesia:

The woman, together with her family, will have a pre-operative interview with an anesthesiologist, who will ask questions regarding her medical history. The anesthesiologist will determine what type of anesthesia is most suitable. The most common forms are general and local anesthesia. With a general anesthetic, patient will be asleep during your surgery. With a local anesthetic, patient will be alert during the surgery, and only the incision location will be anesthetized. In this case, the woman received sub-arachnoid block.

a . Post-Operative Phase

Nursing Responsibilities:

In admitting patient to the PACU:○ Avoid rough handling.○ Avoid hurried movement & rapid changes in position.○ Do not leave the woman unattended until the effects of the anesthesia have worn off.The patient’s breathing is observed, blood pressure and vital signs are monitored, and documentation of all pertinent information are documented. Observations of the patient and documentation of nursing interventions are vital for patient safety regarding continuity of care.Perform safety checks like good body alignment, side rails & restraints.Encourage deep breathing.

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Allow family member to visit the Post-Anesthesia Care Unit.Explain to the woman what was found at surgery and what procedures have been done.

Medication

Instruct the client to comply with the medication as ordered by thephysician, even if feeling better.Provide information for the client understands regarding therapeutictreatment.Encourage reporting of any unusuality observed when taking the drugsEmphasize the right timing or taking or the right time intervals of thesedrugs to maximize its effects and avoid further complications.Inform the client about the possible side effects of the medication.

Exercise:

Encourage early ambulation.Explain to client that exercises are important to avoid tighteningmuscles.Instruct the client to take a warm shower before the exercise to helploosen stiff muscles.

Treatment:

Instruct the client and her family to comply to the physician’s orders.Inform the client as well as the family the dangers of non complianceto treatment regimen.Encourage the patient to have followed up visitations to the physicianafter discharge.

Health Teaching:

Inform the patient about the importance of complying with the prescribed medication.Emphasize the proper dosage of the medications taken.Educate the client about the importance of proper nutrition.Encourage the client to have the prescribed diet for his condition.Provide counseling on prognosis for fertility and, if appropriate, provide family planning.

Outpatient:

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Regular check up to see new changes and assess the development ofclient.Instruct the client and her family to report to the physician if there is arecurrence or if unusualities are observed.Ensure the woman has written postoperative instructions, necessarymedications before discharge and instructions regarding a followupvisit.

Diet:

Instruct patient to have a healthy diet and not to become constipated.Instruct patient to have a high-fiber diet such as fruits and vegetablesthis will help soften the stool.Encourage patient to adhere to a diet prescribed by the physician or thedietician.

DRUG STUDY

Generic Name :Tramadol hydrochlorideBrand Name Dolcet, Dolotral, Milador, Siverol, TramalClassification Pharmacologic class: opioid agonistTherapeutic class: analgesicDosage Adults:

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-Patients who require rapid analgesic effect: 50–100 mg PO q 4–6 hr; do not exceed 400 mg/day.-Patients with moderate to moderately severe chronic pain: Initiate at 25 mg/day in the morning and titrate in 25-mg increments q 3 days to reach 100 mg/day. Then, increase in 50 mg-increments q 3 days to reach 200 mg/day. After titration, 50–100 mg q 4–6 hr; do not exceed 400 mg/day.-Patients with cirrhosis: 50 mg q 12 hr.-Patients with creatinine clearance < 30 ml/min: 50–100 mg PO q 12 hr. Maximum 200 mg/day.

Pediatric Patients:-Safety and efficacy not established.

Geriatric patients or patients with renal or hepatic impairment75yr: Do not exceed 300 mg/day.

Mode of Action Chemical Effect:Binds to mu-opioid receptors and inhibits the reuptake of norepinephrine and serotonin; causes many effects similar to the opioids—dizziness, somnolence, nausea, constipation—but does not have the respiratory depressant effects.

Therapeutic Effect: Relieves pain.Indication Relief of moderate to moderately severe pain when non-opioid analgesics are not active enough Renal impairment Hepatic impairmentContraindication : Contraindicated with allergy to tramadol or opioids or acuteintoxication with alcohol, opioids, or psychoactive drugs.○ Opioid-dependent patients.○ Severe hepatic impairment.○ Patients on obstetric preoperative medication.○ Abrupt discontinuation.○ Children <16 years old.○ Use cautiously with pregnancy, lactation, seizures, concomitant use of CNS depressants or MAOIs, renal dysfunction, or hepatic impairment.

Drug Interactions:Drug – Drug✔ Carbamazepine. Significantly decreases tramadol levels(may need up to twice usual dose).✔ MAO Inhibitors. Tramadol may increase adverse effects.✔ Tricyclic Antidepressants, Cyclobenzaprine,Phenothiazines, Selective Serotonin Reuptake Inhibitors(SSRI), MAO Inhibitors. May enhance seizure risk withtramadol.

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✔ Other CNS Depressants. May increase CNS adverse effectsof tramadol.✔ Herbal: St. John's Wort. May increase sedation.

Side Effects ➢ CNS: sedation, dizziness or vertigo, headache, confusion, dreaming, sweating, anxiety,➢ CV: hypotension, tachycardia, bradycardia➢ Skin: sweating, pruritus, rash, pallor, urticaria➢ GI: nausea, vomiting, dry mouth, constipation, flatulence➢ GU: urinary retention / frequency, menopausal symptoms,dysuria, menstrual disorder➢ Other: potential for abuseAdverse Effects: CNS: seizuresOther: anaphylactoid reactions

Nursing Responsibilities1. Assess for level of pain relief and administer prn dose as needed but

not to exceed the recommended total daily dose. 2. Monitor vital signs and assess for orthostatic hypotension or signs of CNS depression.3. Explain the drug action, purpose of drug and side effects. Allows the patient to know the benefits that may be gained from the drug, what would be happening to him and the expected effects.4. Advise the patient to avoid activities that require mental alertness.® The drug may cause drowsiness and impair mental or physical performance.5. Assess for history of drug addiction, allergy to opiates or codeineor seizures.® The drug may increase the risk of convulsions.6. Assess the patient’s skin color, texture, lesions; orientation, reflexes, bilateral grip strength, affect; P, auscultation, BP; bowel sounds, normal output; LFTs, renal function tests.® To note any signs of unusualities and have a basis for future comparison.7. Instruct the patient to lye down for a while after taking the drug.® To relieve nausea and vomiting and some other side effects.8. Report severe nausea, dizziness, severe constipation.® To prevent accidents or injuries to occur.9. Monitor input and output ratio. Check for decreasing output.®It may indicate urinary retention.10. Instruct the patient to make position changes slowly.® Orthostatic hypotension may occur.11. Tell the patient and watcher to report symptoms of CNS changes,allergic reactions.® To prevent complications or problems.12. Provide safety measures: side rails, night light, call bell withineasy reach.

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® To ensure safety and to report any emergencies.

Generic Name: Ketorolac

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Brand Name: Toradol, Acular, Kortezor, Remopain, RolacClassification: Nonsteroidal anti-inflammatory agents, Nonopioid analgesicsDosage Oral therapy is indicated only as a continuation of parenteral therapy; parenteral therapy should not exceed 20 doses/ 5 days. Total duration of therapy by all routes should not exceed 5 days.PO (Adults < 65 yr): 20 mg initially, followed by 10 mg q 4-6 hours as needed (not to exceed 40 mg/day).PO (Adults ≥ 65 yr, < 50 kg, or with renal impairment): 10 mg q 4-6 hours as needed (not to exceed 40 mg/day).IM (Adults < 65 yr): Single dose – 60 mg. Multiple dosing – 30 mg q 6 hours (not to exceed 120mg/day).IM (Adults ≥ 65 yr, < 50 kg, or with renal impairment):Single dose – 30 mg. Multiple dosing – 15 mg q 6 hours (not to exceed 60 mg/day).IV (Adults < 65 yr): Single dose – 30 mg. Multiple dosing – 30 mg q 6 hours (not to exceed 120 mg/day).IV (Adults ≥ 65 yr, < 50 kg, or with renal impairment): Single dose – 15 mg. Multiple dosing – 15 mg q 6 hours (not to exceed 60 mg/day).Mode of Action Inhibits prostaglandin synthesis, producing peripherally mediatedanalgesia. Also have anti-pyretic and anti-inflammatory properties and it has a therapeutic effects that it can decrease pain.

Indication : Short-term management of moderately severe, acute pain for single-dose treatment.○ Short-term management of moderately severe, acute pain for multiple-dose treatment.○ Short-term management of moderately severe, acute pain when switching from parenteral to oral administration (oral therapy is indicated only as continuation of parenterally administered drug and should never be given without patient first having received parenteral therapy.Contraindication: ✔ Hypersensitivity to drug✔ Cross-sensitivity with other NSAIDs✔ Labor, Delivery or Lactation✔ Pre- or perioperative use✔ Known alcohol intolerance✔ Per-operative pain from coronary artery bypass graft surgeryDrug InteractionsDrug-Drug: ACE inhibitors – may increase risk of renal impairment, particularly in volume depleted patients. Anti-coagulant, salicylates – Ketorolac may increase levels of free (unbound) salicylates or anticoagulants in the blood.

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Antihypertensives, diuretics – decreased effectiveness. Monitor patient closely. Lithium – increased lithium levels. Methotrexate – decreased methotrexate clearance and increased toxicity. Don’t use together.

Side Effects : Drowsiness Nausea Dyspepsia GI painAdverse Effects ➢ Arrhythmias➢ Peptic ulceration➢ GI bleeding➢ Exfoliative dermatitis➢ Stevens-Johnson Syndrome➢ Toxic Epidermal Necrolysis

Nursing Responsibilities1. Patients who have asthma, aspirin-induced allergy, and nasalpolyps are at increased risk for developing hypersensitivityreactions. Assess for rhinitis, asthma and urticaria.2. Assess pain (note type, location and intensity) prior to and 1 – 2hours following administration.3. Evaluate liver function tests, especially AST and ALT,periodically in patients receiving prolonged therapy since it may increase its levels.4. Warn patient that IM administration may cause pain at the injection site. Holding pressure over the site for 15 to 30 seconds after the injection will minimize local effects. Give it deep IM.5. Observe patients with coagulopathies and those taking with anticoagulants. Ketorolac inhibits platelet aggregation and can prolong bleeding time. This effect will disappear within 48 hours of discontinuing drug.6. Instruct patient on how and when to ask for pain medication.7. Instruct patient to take medication exactly as directed. Take missed doses as soon as remembered if not almost time for the next dose, do not double the doses.8. May cause drowsiness or dizziness. Advice to avoid driving or other activities requiring alertness until response to the medication is known.9. Instruct patient that co administration with opioid analgesic may have additive effect and may permit lower opioid doses.10. Always remember that ketorolac therapy should always be given initially by the IM or IV route. Use oral therapy only as a continuation of parenteral therapy.

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11. Alert that patient that the maximum combined duration of therapy (parenteral and oral) must be limited to 5 days.

Generic Name : Celecoxib

Brand Name :Celebrex, FlamarClassification: Nonsteroidal anti-inflammatory agents, Nonopioid analgesics,Specific COX-2 enzyme blockerDosage Adults:Initially, 100 mg PO bid; may increase to 200mg/day PO bid as needed.

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Acute pain, dysmenorrheal: 400 mg, then 200 mg PO bid. FAP: 400 mg PO bid.Ankylosing spondylitis: 200mg/day PO; after 6 weeks, a trial of 400 mg/day may be tried for 6 weeks; if no effect is seen, suggest another therapy.

Pediatric patients ≥ 2 years:10 kg or ≤ 25 kg: 50 mg capsule PO bid.Patients with hepatic impairment:Reduce dosage by 50%. Mode of Action

Therapeutic actions:

Analgesics and anti inflammatory activities related to inhibition of the COX-2 enzyme, which is activated in inflammation to cause the signs and symptoms associated with inflammation; does not affect the COX-1 enzyme, which protects the lining of the GI tract and has blood clotting and renal functions.

Indication : Acute and long-term treatment of signs and symptoms of rheumatoid arthritis and osteoarthritis.○ Reduction of the number of colorectal polyps in familial adenomatous polyposis (FAP)○ Management of acute pain○ Treatment of primary dysmenorrheal○ Relief of signs and symptoms of ankylosing spondylitis○ Relief of signs and symptoms of juvenile rheumatoid arthritisContraindication: ✔ With allergies to sulfonamides, celecoxib, NSAIDS, or aspirin✔ Significant renal impairment✔ 3rd trimester pregnancy✔ Lactation✔ Use cautiously with impaired hearing, hepatic and CV conditions.

Drug Interactions Drug-Drug: Increased risk of bleeding if taken concurrently with warfarin.Monitor patient closely and reduce warfarin dose as appropriate. Increased lithium levels and toxicity. Increased risk of GI bleeding with long-term alcohol use and smoking.

Side Effects : Headache Dizziness Somnolence Insomnia Rash DyspepsiaAdverse Effects ➢ Anaphylactoid reactions to anaphylactic shock.

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Nursing Responsibilities1. Administer drug with foods or after meals if GI upset occurs.2. Establish safety measures if CNS or visual disturbances occur.3. Arrange for periodic ophthalmologic examination during long-term therapy.4. If overdose occurs, institute emergency procedures – gastric lavage, induction of emesis, supportive therapy.5. Provide further comfort measures to reduce pain (eg, positioning, environmental control) and to reduce inflammation (eg, warmth, positioning, and rest).6. Take only the prescribed dosage; do not increase dosage.7. Report if client feels sore throat, fever, rash, itching, weight gain, swelling in ankles or fingers; changes in vision.8. Be aware that patient may be at increased risk for CV events, GI bleeding and monitor accordingly.9. Educate patient that she/he may feel side effects: dizziness and drowsiness.10. Advice patient to avoid driving or the use of dangerous machinery while using this drug.

Generic Name: Ranitidine

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Brand Name: Zantac, Ramadine, Aceptin, Ceranid, RaxideClassification: Antiulcer agents Histamine H2 antagonistsDosage Duodenal and gastric ulcer (short-term treatment); pathologic hypersecretory conditions such as Zollinger-Ellison syndrome.

Adults: 150 mg PO b.i.d. or 300 mg daily h.s. Or, 50 mg IV or IM q 6-8 hours. Patients with Zollinger-Ellison syndrome may need doses up to 6 g PO daily.Maintenance therapy for duodenal or gastric ulcer Adults: 150 mg PO h.s.Gastroesophageal reflux disease Adults: 150 mg PO b.i.d.Erosive esophagitis Adult: 150 mg PO q.i.d. Maintenance dose is 150 mg PO Heartburn

Adult: 75 mg PO as symptoms occur, not to exceed 150 mg daily. Mode of Action Inhibits the action of histamine at the H2 receptor site located primarily in gastric parietal cells, resulting in inhibition of gastric acid secretion. Therapeutic effects: Healing and prevention of ulcers. Decreased symptoms of gastroesophageal reflux. It decreasessecretion of gastric acid.

Indication Duodenal and gastric ulcer (short-term treatment); pathologic hypersecretory conditions such as Zollinger-Ellison syndromeMaintenance therapy for duodenal or gastric ulcerGastroesophageal reflux diseaseErosive esophagitisHeartburn

Contraindication :HypersensitivityCross sensitivity may occurSome products that contain alcohol should be avoided with patients with known intolerance.

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Drug Interactions: Drug-Drug:Warfarin – possible interference with warfarin clearanceClazithromycin - increases ranitidine levelsAntacids - decreased ranitidine absorption.Diazepam – decreased absorption of diazepamGlipizide – possible increased hypoglycemic effectProcainamide – possible decreased renal clearance of procainamideSide Effects: ConfusionMalaiseDrowsinessHeadacheNauseaConstipationPain at IM site

Adverse Effects: LeukopeniaAnaphylaxisArrhythmiasAgranulocytosisAplastic anemia

Nursing Responsibilities:1. Assess patients with suspected ulcers; epigastric and abdominal pain, hematemesis, occult blood in stools, blood in gastric aspirate before and throughout treatment, monitor gastric pH (5 should be maintained).2. Assess the IV site for phlebitis.3. Monitor heart rate after administering the drug.4. Give by intermittent infusion over 15 min after diluting 50mg/100ml of D5W , NaCl over 5 min or more.5. May cause dizziness and drowsiness. Make patient aware not to engage in activities requiring alertness.6. Advice patient to avoid foods that can cause GI irritation such as salty foods, alcohol even product containing aspirin or NSAIDs.7. Inform patient that increased fluid and fiber intake may minimize constipation.8. Advise patient to report signs of superinfection such as black furry tongue fever, and malaise.9. Advise patient to report bruising, fatigue, malaise; blood dyscrasias may occur.10. Tell patient to avoid OTC preparations such as aspirin, cough, and cold preparations because condition may worsen.11. Instruct patient to take medication as directed for the full course of the therapy, even if feeling better. Take missed doses as soon as remembered if not almost time for the next dose, do not double the doses.

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12. Inform patient that smoking interferes with the action of histamine antagonists. Encourage patient to quit smoking or at least not to smoke after last doe of the day.

Generic Name: Paracetamol

Brand Name: Tempra, BiogesicClassification: Non-narcotic analgesic, AntipyreticDosage: 1 tsp q6h and for pain Mode of Action Decreases fever by hypothalamic effect leading to sweating and vasodilation. Also inhibits the effect of pyrogens on thehypothalamic heat-regulating centers. May cause analgesia by inhibiting CNS prostaglandin synthesis; however, due to minimal effects on peripheral prostaglandin synthesis, it has no anti-inflammatory or uricosuric effects. Antipyretic and analgesic effects are comparable to those of aspirin.

Indication : Control of pain due to headache, earache, dysmenorrheal, arthralgia,myalgia, musculoskeletal pain, arthritis, immunizations, teething, tonsillectomy; to reduce fever in bacterial or viral infections; as a substitute for aspirin in upper GI disease, aspirin allergy, bleeding disorders, clients on anticoagulant therapy, and gouty arthritis.

Contraindication : Contraindicated in patients hypersensitive to drug; renal insufficiency, anemia; clients with cardiac or pulmonary disease.

Drug Interactions:Activated charcoal, cholestyramine and colestipol: Decreased absorptionBarbiturates, carbamezepine, diflunisal, hydantoins, isoniazid, rifabutim, rifampin, sulfinpyrazone: Increased risk of hepatotoxicity.

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Hormonal contraceptives: Decreased efficacy Oral anticoagulants: Increased anticoagulant effect.Phenothiazines: Severe hypothermiaZidovudine: Increased risk of granulocytopeniaSide/ Adverse Effects:Hematologic: hemolytic anemia, neutropenia, leucopenia, pancytopeniaHepatic: jaundiceMetabolic: hypoglycemiaSkin: rash urticaria

Nursing Responsibilities

Assess vital signsIdentify indications for therapy and expected outcomes.Document presence of fever. Rate pain, noting type, onset, location, duration and intensity.Do not exceed a dose of 75/mg/kg/day in children.\Do not take for more than 5 days for pain in children or for more than 3 days for fever without consulting the doctor.In children, don’t exceed five doses in 24 hours.Report pallor, weakness and palpitations.Advise client to take only as directed and with food or milk to minimize GI upsetMany OTC and prescription products contain paracetamol; be aware of this when calculating total daily dose.Review with parents the difference between the concentrated dropper dose formulation and teaspoon dose formulation.Any unexplained pain or fever that persists longer than 3-5 days requires medical evaluation.

CONCLUSION:

In the two weeks of being exposed in Post opt Ward, the group had the chance to interact with various women and families, and also got to know them. Those two weeks gave the group a chance to apply the knowledge and skills they have learned from the school especially from the clinical instructors. It was a chance to practice the skills we learned as nurses to the patients in the Post opt ward. The group has understood that each woman is unique and should receive individualized approaches to adapt to their needs. These women are different from each other, and have varying views about health. The group has given their effort to practice health promotion and disease prevention. The group believes that these activities are of great help to thewomen, in terms of reinforcing their knowledge and modifying their beliefs. Through thegroup’s abilities, effort and skills, the group has given what they got to accomplish their tasks and duties.

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The student nurses have assessed the needs of the women by conducting observations and interview. Through observation, the group was given the chance to enhance their senses, and be critical with their work. Through interviews, the group has developed their skills in communicating effectively, and establishing rapport with them.The group also took part with implementing different interventions for different women. As student nurses, we acquired knowledge in Maternal and Child Nursing and reached out with women and families and gave health teachings. In socializing with the women and families, the group has gotten out of their comfort zones to extend their helping hands. Though the group and the women of Post opt ward have different beliefs, both parties have learned to be open and change for the better. On the other hand, Health teaching has become part of the group’s exposure to Post opt ward and to every women and families in the ward. Through health teaching, the student nurses can provide information related to their condition and situation.To evaluate what the group has done, the student nurses utilized the skills they have earned from socializing and taking care of the women. They, once again, used inspection and observation, and conducted interviews to them to reassess if the implementation has been effective. To end this, Maternal and Child Nursing is indeed for the women and babies. It is a selfless advocacy to restore and strengthen the worth and dignity of a woman.

REFERENCESKozier and Erb’s Fundmentals of Nursing 8th Edition.Text Book of Obstetrics ,D.C.Dutta,Edition 6th,pg no 179 -183

WEBSITES:

http://nongae.gsnu.ac.kr/~bkkim/won/won_117.htmlhttp://emedicine.medscape.com/http://www.medterms.com/script/main/art.asp?articlekey=9809http://www.medcompare.com/jump/750/ectopic_pregnancy.htmlhttp://en.wikipedia.org/wiki/Ectopic_pregnancyhttp://www.ectopicpregnancy.net/resources_physicians.htmlhttp://www.pregnancy.com.ph/ectopic_pregnancy.htmhttp://pregnancy.nci.nih.gov/pregnancytopics/types/ectopic_pregnancy/http://emedicine.medscape.com/article/1222849-overviewhttp://www.pregnancy.org/docroot/CRI/content/CRI

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