BORA INSTITUTE OF ALLIED HEALTH

SCIENCES,
LUCKNOW

OBSTETRIC AND GYNECOLOGY

NURSING CARE PLAN
ON
“ECTOPIC PREGNANCY”

SUBMITTED TO- SUBMITTED BY-

Mrs. SANDHYA VERMA BABLEE BHARTI
HOD OF OBG M.Sc. (N) 2nd year
BORA Institute of Nursing BORA Institute of Nursing

SUBMITTED ON

04/07/2023
PATIENT PROFILE
1)-IDENTIFICATION DATA-
 Name- Mrs. Kajal Devi
 Age- 30year
 Sex- Female
 Address- Barabanki
 IP Number- 1270932
 Ward- ANC Word
 Education- B.A. Pass
 Occupation- housewife
 Religion- Hindu
 Nationality- Indian
 Marital status- Married
 Date of admission- 18/07/2023
 Diagnosis- Ectopic pregnancy
 Duration of marriage- 4 year
 Gravida- 2
 Para- 2
 Abortion- 0
 Living- 1
 Blood group- A+ve
 Husband name- Mr. Ajay kumar
Age- 33year
Education - B.E.D. pass
Occupation- private job

2) - Chief complaints -Mrs. Kajal Devi is admitted in Queen marry hospital in PNC word
on 20/07/2023 with the complaint of she having heavy vaginal bleeding with the bright red
in color, fever, and general weakness.
3) History of illness- Patient having heavy vaginal bleeding.
4) Menstrual History-
 Age of menarche- 14year
 Duration of menstrual cycle- 28-30 days
 Duration of cycle in day- 3-4 days
 Regularity- Regular
 Amount of flow- Aedqucate
 LMP- 06/11/2022
 EDD- 20/07/2023
  Associated complaint- Backache, headache, bleeding.
 Contraceptive History- No any contraceptive History
 Antenatal attendance-
Date – 15/01/2023
Weight- 50kg
Pallor- Normal
Edema- present
Blood Pressures- 130/80mmHg
Height- 156cm
Presentation/ position- Logitudinal / cephalic
FHS- 130b/m
HB- 10.3gm/dl
Urine- Normal
Albumin- Nil g/dl
Sugar- 240mg/dl
Treatment- Iron, folic acid

5)Obstetric History-
 History of previous pregnancy- Present
 Period of pregnancy- 39 weeks
 Type of labour- Normal
 PNC condition- Normal
 Birth weight - 70kg

6)Present pregnancy-
 Date of booking- 20/7/2022
 Number of visits- 2 visits
 History of minor aliments- Nousea, vomiting.

7)-Medical/Surgical history-
 Past medical history -No significant of past medical history.
 Present Medical history -Mrs. Kajal Devi is admitted in PNC word on 20/07/2023
with the complain of heavy vaginal bleeding, amenorrhoea, general weakness,
under treatment of Dr. S.P. Jaiswal.
 Past surgical history- No significant of past medical history.

8)-Socio-economic history-
 Bread winner of Family-Mr. Sanjay.
 Socio-economic status-Satisfactory
 Type of house-Pakka
 Market Facility-Available
 Drainage System-Close
  Defecation System-Own Toilet
 Method Of refuse Disposal-Dumping

9) - Family History-
 Family Tree-
Type of family-Nuclear
Head of family-Mrs. Susheela Devi

 Family Composition-

Sr.no. Name of Relationship Age Sex Education Occupation Health

family with patient status
Member
1 Mr. Sanjay Father in law 56 M Graduation Teacher Healthy
years
2 Mrs. Mother in law 54 F 10th House wife Healthy
Susheela years
Devi
3 Mr. Ajay Husband 33ye M Graduation Teacher Healthy
kumar ars
4 Mrs. Kajal Patient 30ye F B.A. Pass House wife Unhealthy
Devi ars
5 Miss. Arti Doughter 4 F Healthy
year

 Family Medical History- No significant

6)- Personal History-

 Nutrition- She is Non-Vegetarian

 Sleep-Normal
 Habits-She is having no any bad habits like smoking and tobacco chewing.
 History of known allergy-No allergy
 Elimination Pattern-Normal elimination pattern.
PHYSICAL EXAMINATION
GENERAL APPEARANCE-
 Body built- Moderate
 Posture- Normal Posture
 Level of consciousness-consciousness
 Orientation- oriented to time, place, person
 Activity- Active
 Behaviour- Co oprative
 Attitude-Co-operative
 Speech-Slow
 Cleanliness-Clean
VITAL SIGN-
 Temperaure-98.6 F
 Pulse-102beats / min
 Blood Pressure- 92/57 mmHg
 Respiratory Rate-30 breaths / min

ANTHROPOMETRIC MEASUREMENT-
 Height-156 cm
 Weight-76 kg
 Abdominal Grith-90 cm
SKIN-
 Color-Fair
 Turgor-Normal
 Texture-Smooth
 Pigmentation-Present
 Temperature-Warm
 Sensitivity-sensitive
 Lesion-Present
 Scar-absent
HEAD-
 Shape-Normal
 Symmetry- Symmetrical
 Scalp-clean
 Dandruff-Absent
 Pediculi-Absent
 Lesions-Absent
 Hair-present
  Color- Black
 Texture-Normal
 Distribution-Evenly Distributed
FACE-
 Symmetry-Symmetrical
 Facial Movement- Symmetrical
 Facial Puffiness-present
 Sinuses-Normal
EYES-
 Eye Brows-Present
 Symmetry-Symmetrical
 Distribution of hair-Equally Distributed
 Lesion-Absent
 Dandruff-Absent
EYELIDES-
 Movement-Completely
 Position-Normal
 Puffiness-Absent
 Lesion-Absent
 Style-Absent
EYE LASHES-
 Distribution –Normal
 Dandruff-Absent
EYE BALL-
 Position-Normal
 Movement-Normal
 Conjunctiva-Normal
 Sclera-Normal
 Cornea-Transparent
 Visual Acuity-normal
 Use of Spectacles or contact lenses—No
EARS-
 Position-Normal
 Symmetry-Symmetrical
 Size and Shape-Normal
 Lesion and Lump of Pinna-Absent
 External Auditory Canal-Normal and Visible
 Mastoid Process- Normal
 Use Of hearing Aids-No
  Pain-Absent
NOSE-
 Nasal Septum-Normal
 Polyps-Present
 Mucus Membrane-Dry
 Discharge-No
MOUTH-
LIPS
 Color-pick
 Hydration-Dry
 Symmetry-Symmetrical
 Lesion-Present
 Mucus Membrane
 Color-Normal
 Hydration-Poor

TEETH-
 No. of Teeth- 32
 Color-Stained
 Alignment-Normal
 Use of Denture-
NO GUMS- Healthy
Tongue-
 Color-coated
 Hydration-dry
 Lesions-Absent
 Thickness-Normal
 Frenulum- Toungue Tie
PALATE- Normal
UVULA-Midline
TONSIL-Normal
DYSPHASIA-Present
ODOR OF MOUTH- Normal

NECK-
 Range of Motion-Possible
 Thyroid Gland-Normal
 Trachea-midline
 Lymph Node-Palpable
 Jugular vein-distented
CHEST-
INSPECTION-
 Shape-Normal
 Movement-Symmetrical
 Retraction-Present
 Respiratory Rate-22 Breaths / Min
 Location of sternum-Midline
BREAST-
 Shape-Symmetrical
 Position-Normal
 Nipple-Cracked
PALPATION-
 Axillary Lymph Node-palpable
 Respiratory movement-symmetrical
 Fremitus-Normal
AUSCULATATION-
 Lung Sound-Clear & equal
 Heart Beat-92 Beats/min
 Heart sound-Normal
ABDOMEN-
INSPECTION-
 Shape-Rounded
 Skin-Thick
 Distension-Present
 Peristalsis-Not visible
 Distended-Absent
 Umbilicus-Normal
PALPATION-
 Hepatomegaly-Absent
 Spleenomegaly-Absent
 Tenderness-Present
 Mass-Absent
AUSCULTATION-
 Bowel Sound -Increased
 Character-Gurgring sound
PERCUSSION-
 Ascitis-Absent
 Fluid Thrill-Absent
BACK-
 Tenderness-Absent
 Mass-Absent
GENITALIA –
 Anal opening- Clear
 Perineal fissure-Absent
 External heamorrhoids-Absent
FEMALE
 Urethral opening-clear
 Lesion-Absent
 Discharge-Present
EXTRIMITIES-
 Position-Symmetrical
 Gait-Normal
 Range of Motion-Normal
 Congenital deformity-Absent
 Digits- normal(5+5,5+5)
NAIL-
 Shape- Normal
 Color- pink
 Capillary refill time- <2 sec
REFLEX-
 Biceps Reflex-Normal
 Triceps Reflex-Normal
 Patellar Reflex-Normal
VITAL SIGN.

VITAL SIGN PATIENT NORMAL REMARK

VALUE VALUE

Temperature 98.6 F 98.6 F Normal

Pulse Rate 85 Beats / min 70-80 beats/min Normal

Blood Pressure 130/80mmHg 120/90 mmHg Normal

Respiratory Rate 22Breaths / Min 16-20 breaths/min Normal

INVESTIGATION CHART
INVESTIGATION PATIENT NORMAL REMARK
VALUE VALUE
 Hemoglobin 10.1gm/dl 12.5gm/dl Decrease
 TLC 9900cells/mm3 4000- Normal
11000cells/mm3

 Differential %
Leukocytes count-

 Neutrophills 70% 40-80 Normal

 Lymphocyte 26% 20-40 Normal
 Eosinophills 02% 1-6 Normal
 Monocyte 02%
 Basophill 00%
 Platelet count 2.81Lac million 1.5-4.5 Normal
cells/ul

 MPV 9.4fl
 Total RBc 3.29milliocells/ul 3.8-4.8 Normal
27-32 Decrease
 MCH 25.8pg
26.1% 36-46 Decrease
 HCT(Hemocrit)
0-6 Normal
 C- reactive protein 1.22 mg/l
Thyroid profile-
 Serum T3
 Serum T4 0.98ng/ml
0.58-1.59ng/ml Normal
4.87-11.72ug/dl Normal
 Serum TSH 6.65ug/dl
0.35-4.94ul/ml Normal
2.32ug/ml
MEDICATION CHART

DRUG DOSE ROUTE FREQUENCY MECHANISM

OF ACTION
OD Stop cell growth
Inj. 60mg/ml Oral
methotrexate

OD Mineral
Tab. Iron 60mg Oral supplement

OD Ca Supplement
Tab. Calcium 50mg Oral

OD Folic acid
Tab. BNC 15mg Oral supplements
NURSING DIAGNOSIS

 Acute pain secondary ectopic pregnancy as evidenced by abdominal pain.

 Risk for shock related to excessive blood loss secondary to ectopic pregnancy as
evidenced by vaginal bleeding fatigue and nausea.

 Infection as a risk related to ectopic pregnancy, as evidenced by the chief complaint

of heavy prolonged menstruation, abdominal cramping, and vaginal bleeding.

 Nausea as a symptom related to ectopic pregnancy, as evidenced by the chief complaint

of heavy prolonged menstruation, abdominal cramping, and vaginal bleeding.

 Deficient fluid volume related to active blood loss secondary ectopic pregnancy as
evidenced by chief complaint of heavy prolonged menstruation vaginal bleeding
abdominal cramping fatigue.

 Anxiety related to knowledge deficit regarding procedures, management and

disease condition as evidenced by patient asks many questions about the disease.
 NURSING CARE PLAN

ASSESSMENT DIAGNOSIS GOAL PLANNING IMPLEMENTATION EVALUATION

SUBJECTIVE Deficient fluid To -Monitor vital -Monitored vital sign, After nursing
DATA- Patient volume improv sign capillary capillary refill, skin intervention
is complaining related to e the refill, skin color& mucus improved the
of that she is active blood fluid color& mucus membranes. condition of
feeling fluid loss secondary volume membranes. patient.
loss. ectopic .
pregnancy as -Examine and -Examined and
evidenced by document the document the presence
chief presence of of color, odor and
complaint of color, odor amount of bleeding by
and amount of used of the no. of pad.
heavy
prolonged bleeding.
-Observed of a delay
menstruation
-Observation of output and input chart
vaginal
a delay output every 15 min.
bleeding
and input
abdominal Input Output
chart.
OBJECTIVE cramping 100 150
DATA- On fatigue. 200 250
observation of
patient- -Adviced to patient
-Advice to
Pallor
patient to intake Nutrient
Respiratory rate- supplement, green lefy
intake Nutrient
30breaths/ min vegetable, protein rich
supplement
diet.
-with feet higher will
-advice patient increase the venous
to sleep with return and allowing
feet higher, the blood to the brain
while the and other organs.
body
remained
supine.
ASSESSMENT DIAGNOSIS GOAL PLANNING IMPLEMENTATION EVALUATION

SUBJECTIVE Infection as a To -Assess the -Assessed the general After nursing

DATA- Patient risk related to improve general condition of the intervention
is complaining ectopic the HgB condition of patient. improved the
of that she is pregnancy, as level of the patient. tissue perfusion
have fever. evidenced by the of the patient.
the chief patient. -Monitor
complaint of vital sign of -Monitored vital sign of
heavy the patient. the patient.
prolonged Temp.-98.6F
menstruation, Pulse-103b/m
abdominal Resp.-30b/m
cramping, and -Check the
vaginal weight of -Checked the weight
bleeding. the patient of the patient.
Weight-68kg
-Provide the -Provided the fluid
OBJECTIVE fluid to the to the patient
DATA- On patient.
observation of
patient- dryness, -Provide the -provided the quiet
Respiratory rate- quiet and and restful
22breaths/ min restful environment.
environment.

-monitor -changes in blood

blood gas gases and pH levels
levels and pH are a sign of tissue
hypoxia.
ASSESSMENT DIAGNOSIS GOAL PLANNING IMPLEMENTATION EVALUATION

SUBJECTIVE Anxiety To -Assess the -Assessed the After nursing

DATA- Patient related to improv knowledge about knowledge about intervention
is say she is not knowledge e the disease disease condition. improve the
have knowledge deficit knowle condition. patient
about disease. regarding dge of -Clearified the all knowledge
procedures, the -Clearify the doubts of the level.
management patient. all doubts of patients regarding
and disease the patients. disease and
condition as investigation.
evidenced by -Provide the
patient asks knowledge about -Provided the some
many the personal knowledge about the
questions hygiene. personal hygiene.
about the
disease. -Treat the
patient calm, -Provided the emotional
OBJECTIVE
empathetic and support of the patient.
DATA-On
supportive
observation-
attitude.
patient not
have
-provide
knowledge -accurate information
information
about disease. can reduce the
about care
and anxiety and fear of
treatment. the unknown.

-help clients -The expression

identify a sense can reduce feeling
of anxiety. of anxiety.
HEALTH -EDUCATION
1. Diet- Educate the patient to take proper and healthy diet. Advice the patient to

take balance diet. And advice the patient to take Iron rich and green vegetables.

2. Hygiene- Educate the patient to maintain her personal hygiene and to avoid

other infection. And take proper bath daily.

3. Medication- To teach the patient to take medication daily in the time and do not

skip any medicine.

4. Exercise- Educate the patient about active and passive exercise. Educate the patient

for bed rest.

5. Follow-up- educate the patient about regular follow-up care.

 BIBLIOGRAPHY

 Dutta DC ‘A Textbook of obstetric’, 6th Edition, Jaypee publisher’s page no. 844-848.

 Sanju Sera ‘A Textbook of obstetrics and Gynecology’, 4th Edition, lotus publishers,
page no.830-832.