Ectopic Pregnancy Nursing Care Plans
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Transcript of 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.
Date Cues Needs Nursing
Diagnosis
Plan of Care Nursing Interventions Evaluation
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
of nursing care, the
patient will be able
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.
Date Cues Needs Nursing
Diagnosis
Plan of Care Nursing Interventions Evaluation
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
At the end of 3 hours
of nursing care, the
patient will be able
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.
Date Cues Needs Nursing
Diagnosis
Plan of Care Nursing Interventions Evaluation
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
At the end of 4 hours
of nursing care, the
patient will be able
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.