Ectopic Pregnancy
Jean Simmons, 22 years old
Primary Concept
Perfusion
Interrelated Concepts (In order of emphasis)
1.
2.
3.
4.
5.
6.
© 2016 Keith Rischer/www.KeithRN.com
Reproduction
Pain
Clinical Judgment
Patient Education
Communication
Collaboration
UNFOLDING Reasoning Case Study: STUDENT
Ectopic Pregnancy
History of Present Problem:
Jean Simmons is a 22-year-old-college student who presents to the emergency department with RLQ abdominal pain and
intermittent vaginal bleeding. Her pain started suddenly two hours ago and has been severe and persistent. She noticed a
small amount of bright red vaginal bleeding in the last hour. Jean has irregular cycles and it has been six weeks since her
last menses, which is not unusual for her. She admits to feeling more fatigued the last couple weeks with intermittent
nausea. Jean is 5’ 8” and weighs 74 kg (163 lbs.).
Personal/Social History:
Jean has been sexually active since the age of 16 and has had three male partners in the last six months. She insists that
they use condoms which she provides. She has a history of an ovarian cyst and was treated for pelvic inflammatory
disease (PID) six months ago.
What data from the histories is RELEVANT and has clinical significance to the nurse?
RELEVANT Data from Present Problem: Clinical Significance:
sudden severe and persistant RLQ
abdominal pain!
Intermittent bright red vaginal bleeding;
small amount
Has a history of irregular menstural
cycles, weight is 163 lbs
6 weeks since last period
Fatigued with nausea
RELEVANT Data from Social History:
Sexually active since age of 16
Has had 3 male partners in the last 6 months with the
use of condoms
Hx of ovarian cyst
Treated for pelvic inflammatory disease 6 months ago
the pregnancy is developing outside of expected area and the
site of attachment has ruptured!
Fluctuating hormone levels caused the vaginal bleeding from
the endometrium
Irregular periods are indicative of abnormal hormone levels.
This can contribute to ectopic pregnancy. Absence of period is
also a symptom of pregnancy
Showing signs of hemorrhage
Clinical Significance:
Provides sexual history. Increases chances of getting pregnant. Condoms are
not 100% effective. Abnormal hormone levels places the pt at risk for ectopic
pregnancy. Pelvic inflammatory disease is a risk for ectopic pregnancy
Patient Care Begins:
Current VS:
T: 98.4 F (36.9 C) oral
P: 98 (regular)
R: 20 (regular)
BP: 102/52
O2 sat: 98% room air
P-Q-R-S-T Pain Assessment (5th VS):
Provoking/Palliative: Movement of any kind/Lying still in fetal position
Sharp/stabbing
Quality:
RLQ abdomen
Region/Radiation:
9/10
Severity:
Constant
Timing:
What VS data is RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Assessment Data:
Clinical Significance:
BP of 102/52 is low
Sharp, stabbing pain
Pain with movement
Cramping, RLQ pain
states 9/10 constant pain
© 2016 Keith Rischer/www.KeithRN.com
The patient is actively bleeding which can be the reasoning for low
blood pressure, this is also a sign of ectopic pregnancy
Uterine ligaments could be pulling which could result in abdominal
pain
Lower abdominal pain is a sign of ectopic pregnancy
High pain rating; abdominal pain, cramping, vaginal bleeding
Current Assessment:
GENERAL
APPEARANCE:
RESP:
CARDIAC:
Appears uncomfortable, body tense
Breath sounds clear with equal aeration bilaterally, nonlabored respiratory effort
Pink, warm and dry, no edema, heart sounds regular with no abnormal beats, pulses strong,
equal with palpation at radial/pedal/post-tibial landmarks
NEURO:
Alert and oriented to person, place, time, and situation (x4)
GI:
Abdomen soft/tender to gentle palpation in RLQ, bowel sounds audible per auscultation in
all four quadrants
GU/REPRODUCTIVE: Voiding without difficulty, urine clear/yellow, small amount of red vaginal bleeding present
on maxi pad. Pad is NOT soaked.
SKIN:
Skin integrity intact
What assessment data are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Assessment Data:
Clinical Significance:
Appears uncomfortable, body is tense
Abdomen is soft and tender to
palpation in RLQ
Small amount of red vaginal bleeding
present on pad
She is in severe pain, bleeding, and is probably stressed
This is a sign that a tube has already ruptured
Ectopic pregnancy can cause spotting and slow leak bleeding.
Lab Results:
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
Complete Blood Count (CBC:)
WBC (4.5–11.0 mm 3)
Hgb (12–16 g/dL)
Platelets (150-450 x103/µl)
Neutrophil % (42–72)
Current:
8.8
9.9
155
70
High/Low/WNL?
WNL
Low
WNL
WNL
Previous:
9.5
12.8
225
68
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Lab(s):
Clinical Significance:
TREND: Improve/Worsening/Stable:
1. WBC 8.8
2. Hgb 9.9
3. Platelets 155
4. Rh factor: negative
5. beta Hcg 9250
6. No gestational sac
observed
Misc. Labs:
Urine pregnancy
Serum HCG quantitative
Rh factor
1. elevated WBC is common during pregnancy
2. low levels can increase risk for having preterm/low birth
weight baby. Can indicate anemia
3. always monitor with pregnancy to reduce risk of
hemorrhaging
4. could cause preterm birth, may need blood
transfusions
5. increase HCG and no sac = ectopic pregnancy
6. + pregnancy test and no visible gestational sac
indicates ectopic pregnancy
Current:
Pos
9250
negative
1. stable
2. worsening
3. worsening but stable
4. N/A
5. N/A
6. N/A
High/Low/WNL?
High
High
WNL
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Lab(s):
Clinical Significance:
TREND: Improve/Worsening/Stable:
All labs are relevant for these specific labs allows us to get a
most labs are stable, Hgb is
this specific situation better understanding of our patient and
worsening
what her current problems are
© 2016 Keith Rischer/www.KeithRN.com
Lab Planning: Creating a Plan of Care with a PRIORITY Lab:
Lab:
Hgb. 9.9
Normal Value:
Clinical Significance:
12-16 g/dL
low hemoglobin values,
may indicate an
increased risk of tubal
rupture
Critical
Value:
< 6.0 or > 22.0
Nursing Assessments/Interventions Required:
Oxygen, oral or intravenous fluids to prevent
complications. Blood transfusions, folic acid
supplements.
Assess for dizziness, headache, body temperature,
weakness, color of skin, difficulty breathing
Radiology Reports: Pelvic Ultrasound
What diagnostic results are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Results: Clinical Significance:
No gestational sac
If there is no gestational sac but the patient’s pregnancy tests are coming back
observed. Cannot
positive, this could indicate an ectopic pregnancy which could lead to a ruptured
tube
exclude ectopic
pregnancy.
Clinical Reasoning Begins…
1. What is the primary problem that your patient is most likely presenting with?
The patient is experiencing an ectopic pregnancy
2. What is the underlying cause/pathophysiology of this primary problem?
The patient is pregnancy and the fertilized egg is implanted in the fallopian tube. She
is experiencing sharp pelvic pain in RLQ, nausea, light vaginal bleeding, positive urine
pregnancy test, and no gestational sac observed in the ultrasound. Risk of ectopic
pregnancy increases in females with PID.
Collaborative Care: Medical Management
Care Provider Orders:
Establish large bore (18 g.)
peripheral IV
Rationale:
1. allows for faster volume and rate of fluid and
medication administration !
2. hydromorphone is a narcotic that can treat
moderate to severe pain, pt pain was 9/10
0.9% NS 1000 mL IV bolus
3. provides fluids, helps with dehydration which
could improve hypotension and tachycardia
Hydromorphone 0.5-1 mg IV 4. helps examine placement/location of her
internal organs in the pelvic region
every hour prn
Transvaginal ultrasound
© 2016 Keith Rischer/www.KeithRN.com
Expected Outcome:
1. pt will receive expected
amounts of fluids/meds to
resolve current complication!
2. pt will have reduced pain
by end of shift
3. vitals should improve to
WNL
4. no abnormalities should
be picked up by ultrasound
PRIORITY Setting: Which Orders Do You Implement First and Why?
Care Provider Orders:
Order of Priority:
Rationale:
Hydromorphone 0.5-1 mg IV 1. establish peripheral IV 1. need to obtain a IV in order to complete the rest
push every hour prn
2. 0.9% NS 1000 mL IV of orders!
Establish peripheral IV
(large bore 18 g.)
0.9% NS 1000 mL IV bolus
bolus
2. Hypovolemia can lead to life-threatening
3. Hydromorphone
conditions
0.5-1mg IV push q1h prn 3. pain can be taken care of after bolus is given to
prevent or treat hypovolemia
Medication Dosage Calculation:
Medication/Dose:
Mechanism of Action:
Hydromorphone opioid agonist that
0.5 mg IV push binds to several opioid
receptors.
Nursing Assessment/Considerations:
Volume/time frame to
Safely Administer:
1 mg/mL
monitor signs of sedation and
respiratory depression
administer very slowly
over 2-3 minutes
IV Push:
Volume every 30 sec?
Collaborative Care: Nursing
3. What nursing priority(ies) will guide your plan of care? (if more than one-list in order of PRIORITY)
pain, maintaining adequate hemodynamics, coping, education
4. What interventions will you initiate based on this priority?
Nursing Interventions:
Rationale:
Assess vital signs
Assess signs of dehydration
Monitor I&Os
Position patient for comfort
Assess for abdominal pain and tenderness
Monitor blood loss and administer blood
products as ordered
Administer medications as ordered and
monitor for adverse reactions
5.
Patient could go into shock if tube ruptures
Blood loss could cause hypovolemia and
dehydration
Pt should be in supine position to help reduce
movement
Stabbing/sharp pain is a sign of ectopic
pregnancy and also could mean ruptured tube
Pain medication could be administered if
ordered or medications to terminate pregnancy
Expected Outcome:
check HR. BP, RR
Pt will have IV which
can aide in rehydration
Help decrease pain
level
Pain meds to help with
abdominal pain
What body system(s) will you most thoroughly assess based on the primary/priority concern?
reproductive system and GI
6. What is the worst possible/most likely complication to anticipate?
Tube ruptured and the patient hemorrhaging
7. What nursing assessments will identify this complication EARLY if it develops?
© 2016 Keith Rischer/www.KeithRN.com
Assess for signs and symptoms of hypovolemic shock;
hypotension, tachycardia, pale, cool skin, near syncope, and
syncope
8. What nursing interventions will you initiate if this complication develops?
Prepare the patient for immediate surgery after informing the physician
9. What psychosocial needs will this patient and/or family likely have that will need to be addressed?
Emotional support, comfort and education
10. How can the nurse address these psychosocial needs?
therapeutic communication
Evaluation:
Evaluate the response of your patient to nursing and medical interventions during your shift. All physician orders have
been implemented that are listed under medical management.
Thirty minutes later…The 1000 mL IV bolus has just completed. You enter her room to
reassess Jean and her response to the hydromorphone. You collect the following data:
Current VS:
T: 98.4 F (36.9 C) oral
P: 84 (regular)
R: 16 (regular)
BP: 110/60
O2 sat: 96% room air
Current Assessment:
GENERAL
APPEARANCE:
RESP:
CARDIAC:
Most Recent:
T: 98.2 F (36.8 C) oral
P: 98 (regular)
R: 20 (regular)
BP: 102/52
O2 sat: 98% room air
Current PQRST:
Provoking/Palliative:
Quality:
Region/Radiation:
Severity:
Timing:
Movement of any kind/Resting
Sharp
RLQ abdomen
5/10
Constant
Appears more comfortable, body less tense, appears in no acute distress
Breath sounds clear with equal aeration bilaterally, non-labored respiratory effort
Pink, warm and dry, no edema, heart sounds regular with no abnormal beats, pulses
strong, equal with palpation at radial/pedal/post-tibial landmarks
NEURO:
Alert and& oriented to person, place, time, and situation (x4)
GI:
Abdomen soft, remains tender bowel sounds audible per auscultation in all four
quadrants
GU/REPRODUCTIVE: Voiding without difficulty, urine clear/yellow
SKIN:
Skin integrity intact
1. What clinical data are RELEVANT and must be recognized as clinically significant?
RELEVANT VS Data:
Clinical Significance:
Heart rate is still a little high but WNL.
Other vital signs are WNL
RELEVANT Assessment Data:
more comfortable, body is less tense,
breath sounds are clear and non-labored,
heart sounds regular, pink/warm skin, A&O
x4, no difficulty voiding, skin integrity intact,
Abd. soft and tender
© 2016 Keith Rischer/www.KeithRN.com
the patient’s pain level is 5/10, although it had decreased, she is still in
pain which causes the heart rate to increase
Clinical Significance:
Everything is within normal limits, except for GI; abdomen is still soft and
tender. Pain has decreased.
2.
Has the status improved or not as expected to this point?
The patient’s status has improved. Vital signs are WNL
and her pain has decreased to 5/10
3. Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment?
Plan care needs to stay the same, patient is still in
pain. Need to add in emotional support
4. Based on your current evaluation, what are your nursing priorities and plan of care?
Comfort/pain level and emotional support
Jean is going to be transferred to the operating room (OR) for an exploratory laparoscopy.
Effective and concise handoffs are essential to excellent care and if not done well, can adversely
impact the care of this patient. You have done an excellent job to this point, now finish strong
and give the following SBAR report to the nurse who will be caring for this patient in the OR:
Situation:
Name/age:
Jean Simmons / 22 years old
RLQ abdominal pain and intermittent vaginal bleeding. Pain started 2 hours ago
BRIEF summary of primary problem: and is severe/persistent. Small amount of vaginal bleeding. Last period 6 weeks
ago
Day of admission/post-op #: 10-13-2021
Background:
Primary problem/diagnosis: severe abdominal pain / ectopic pregnancy
RELEVANT past medical history:
RELEVANT background data:
irregular cycles, sexually active since 16 years old, ovarian
cyst, treated for pelvic inflammatory disease 6 months ago
irregular periods, last period 6 weeks ago, 3 male partners in the last 6
months, states she uses condoms
Assessment:
Most recent vital signs: T: 98.4 F.
P: 98
R: 20. BP: 102/52
O2: 98%
RELEVANT body system nursing assessment data: GI: tender and soft in RLQ
GU: no difficulty voiding, small amount of red vaginal bleeding
RELEVANT lab values:
WBC 8.8. Neutrophils 70. Hgb 9.9. Platelets 155
TREND of any abnormal clinical data (stable-increasing/decreasing):
WBC is worsening. Hgb is stable. Platelets is stable
INTERPRETATION of current clinical status (stable/unstable/worsening): worsening
Recommendation:
Suggestions: continue to monitor and provide information to prevent ectopic pregnancies in the future
© 2016 Keith Rischer/www.KeithRN.com
Education Priorities/Discharge Planning
1. What will be the most important discharge/education priorities you will reinforce with Jean about her medical
condition to prevent future readmission with the same problem?
Go to all follow up appointment, call your doctors if you have any problems. Vaginal bleeding may occur, use pads
and not tampons. Do not have sex until bleeding has stopped. Take all medications are prescribed/ordered. Get
plenty of rest. Avoid lifting until told otherwise. Give yourself time to grieve. Give brochures or a number for a
counselor
2. What are some practical ways you as the nurse can assess the effectiveness of your teaching with this patient?
have the patient restate what you said
Caring and the “Art” of Nursing
1.
What is the patient likely experiencing/feeling right now in this situation?
The patient is probably still in shock and hasn’t fully
grasped what is happening
2. What can you do to engage yourself with this patient’s experience, and show that she matters to you as a person?
always…therapeutic communication! make the patient
comfortable
Use Reflection to THINK Like a Nurse
Reflection-IN-action (Tanner, 2006) is the nurse’s ability to accurately interpret the patient’s response to an intervention
in the moment as the events are unfolding to make a correct clinical judgment.
1. What did I learn from this scenario?
I learned some of the signs and symptoms of an ectopic pregnancy and if untreated
what it could lead to
2. How can I use what has been learned from this scenario to improve patient care in the future?
This scenario will help me understand what I need to look for if I have a patient with the same
symptoms
© 2016 Keith Rischer/www.KeithRN.com