NCP- Ectopic Pregnancy

CUES SUBJECTIVE: “Masakit ang aking tiyan” as verbalized by patient. OBJECTIVE: T-36.8 °C, HR-99/minute, RR-25/minute, BP90/60mmHg Pain Scale9/10 Facial GrimaceWincing and in a guarding position NURSING PROBLEM DIAGNOSIS STATEMENT (GOAL) After 1 hour of Acute pain nursing related to interventions distention or the patient will rupture of be relieved or fallopian controlled. tube. NURSING INTERVENTION INDEPENDENT: -Monitor maternal vital signs. -Monitor for presence and amount of vaginal bleeding. -Monitor for increase and pain and abdominal distention and rigidity. -Monitor complete blood count (CBC). -Provide comfort measure like back rubs, deep breathing. RATIONALE EVALUATION/ EXPECTED OUTCOME -To determine presence of hypotension and tachycardia caused by rupture or hemorrhage. After 1 hour of nursing interventions, the patient’s pain has been ease as evidence by 5/10 from 9/10 using pain scale. -To further assess the present situation indicating hemorrhage. -Increased pain and abdominal distention indicates rupture and possible intra-abdominal hemorrhage. -To determine the amount of blood loss. -Promotes relaxation and may enhance COLLABORATIVE: patient’s coping abilities -Administer analgesics by refocusing attention. as indicated. -To maintain acceptable level of pain. CUES SUBJECTIVE: “Palagi akong nahihilo at bigla nalang ako dinugo” as verbalized by the patient. OBJECTIVE: T-36.8 °C, HR-80/minute, RR-25/minute, BP110/90mmHg NURSING PROBLEM DIAGNOSIS STATEMENT (GOAL) Risk for Within our 2deficient day care, the fluid volume patient will related to maintain bleeding adequate fluid from a volume as ruptured evidenced by: ectopic -Vital Signs pregnancy. -Moist mucous membranes -Skin not dry and has good mobility and turgor: can belifted easily and snaps back immediately to its resting position. -Capillary refill less than 3 seconds -Adequate urinary output. NURSING INTERVENTION RATIONALE EVALUATION/ EXPECTED OUTCOME -Assess capillary refill skin turgor, and mucous membranes. -Tachycardia may occur with hypovolemia to maintain an effective cardiac output. Usually the pulse is weak and may be irregular if electrolyte imbalance also occurs. -At the end of our 2- day, the patient maintained adequate fluid volume and normal vital signs, moist mucous membranes, skin is slightly dry, has poor skin turgor, capillary refill is less than 3 seconds and Urinated 3 times. -Assess color and amount of urine. Report urine output for 2 consecutive hours. -To assess the signs of adequacy of hydration or development of dehydration. -Monitor Input and Output balance. -Concentrated urine denotes fluid deficit. polyuria can be present, requiring more fluid replacement. INDEPENDENT: -Monitor Vital Signs. COLLABORATIVE: -Administer parenteral fluid: D5LR 1 L gtts/min. -To ensure accurate picture of fluid status. Intake and output should be approximately equal, dependent on degree of hydration. - Maintenance of bowel rest requires alternative fluid replacement to correct losses. CUES SUBJECTIVE: “Hindi ko talaga naiintindihan ang kundisyon ko, akala ko normal lang lahat ng nararamdaman ko” OBJECTIVE: T-36.8 °C, HR-99/minute, RR-25/minute, BP90/60mmHg Pain Scale9/10 Facial GrimaceWincing and in a guarding position. NURSING PROBLEM DIAGNOSIS STATEMENT (GOAL) After completing the Anxiety nursing related to the interventions, unfamiliarity the patient of the should be able condition and to: the perceived -Appear threat to the relaxed and mother's and report anxiety fetus's reduced to a biologic manageable integrity as a level. result of a pregnancy -Verbalize complication. understanding of condition, prognosis, and potential complications. NURSING INTERVENTION RATIONALE EVALUATION/ EXPECTED OUTCOME 1. Monitor physiological responses like dizziness, headaches, and tingling sensations, as well as behavioral cues like restlessness and irritability. 1. It could be an indicator of the level of fear the client is feeling —the client might feel out of control or panic. Symptoms, on the other hand, may be linked to physical condition or shock. 2. Create a relaxing and calm environment. 2. Removing the client from outside stressors encourages relaxation and may improve coping Client is able to participate in and follow through with her abilities. therapeutic regimen without any 3. Patients and families confusion or fear of the who are informed are procedures and medications that more likely to follow the will be administered. prescribed therapy and participate in the therapeutic regimen. Informing the client about the plan of care reduces unnecessary anxiety about unknowns. 3. Provide accurate, concrete information about the effects of her condition on her pregnancy, delivery, and maternal and fetal well-being, as well as the procedures and medications that will be performed and administered. - Participate in her therapeutic regimen by accurately monitoring and reporting 4. Encourage people to express their weight, blood pressure, urine worries by speaking 4. Creating a Goal met : The client is well-informed about her condition and its actual effects, and she was able to devise coping mechanisms, making her appear calmer. Client was able to use relaxation techniques such as deep breathing exercises to help her relax. protein, edema, fetal activity, signs of improving or worsening preeclampsia, and side effects or effectiveness of medications. them out loud. Actively listen to the client as they express their feelings. 5. Demonstrate and promote relaxation techniques such as visualization, deep breathing, and guided imagery. 6. Continue to check the mother's vital signs every 15 minutes or as the doctor directs. 7. Continue to practice EFM and monitor feral health changes. Maintain emotional support for the client and his or her family; keep them informed about the findings and the ongoing care plan. therapeutic relationship. 5. Assists the client in dealing with their emotions and provides an opportunity to clarify misconceptions, thereby reducing anxiety. 6. Assessments reveal whether hypertension is rising, which could lead to convulsions. Monitoring fetal heart rates can reveal early or late decelerations. Placental abruption can occur if convulsions disrupt placental perfusion. The client's and fetus' well-being will be well-cared for, reducing anxiety. 7. Support and information help clients and families anticipate what might happen next, which can help reduce anxiety and fears.