Ectopic Pregnancy
An ectopic pregnancy
develops as the result of the blastocyst implanting somewhere other than in the
endometrium of the uterus.
Sites of an ectopic pregnancy are
Þ1the fallopian tube,
Þ2ovary,
Þ3cervix,
Þ4or abdominal cavity
The majority of ectopic
pregnancies (95%) are located in the fallopian tube, with 1% located on an
ovary, less than 1 % on the cervix, and 3% to 4% in the abdominal cavity,
Of all tubal pregnancies,
more than half are located in the ampulla, or largest portion of the
tube. The next most common site in the isthmus, or the narrow part of the tube
that connects the interstitial to the ampullar portion. Three percent are
located in the interstitial or muscular portion of the tube adjacent to the
uterine cavity. Rarely does the ectopic pregnancy locate in the fimbria or
terminal end of the tube. The outcome and gestational length of the ectopic
pregnancy will be influenced by its location in the fallopian tube.
Incidence
The incidence of ectopic
pregnancy is approximately 1 out of every 60 pregnancies, or 2% with the number
increasing each year worldwide . Women over 35 years old, nonwhites, or those
who have a history of infertility are at a greater risk of experiencing an of
ectopic pregnancy.
Etiology
¨1
Previous Tubal Infections
Previous pelvic infections caused by certain sexually
transmitted diseases, such as chlamydia and gonorrhea, postpartum endometritis
and postabortal uterine infections can predispose to a tubal infection. A tubal
infection can cause damage to the mucosal surface of the fallopian tube, causing intraluminal adhesions that
interfere with the transportation of the fertilized ovum to the uterine cavity.
¨2
Previous Tubal or Pelvic Surgery
During surgery, if blood is
allowed to enter the fallopian tubes, tubal adhesions can result from the
irritation of the mucosal surface. Salpingectomy, for previous ectopic
pregnancy or for treatment of an inflammatory process, and salpingoplasty, for
infertility are the surgeries that most frequently cause tubal adhesions. Occasionally
irritation results from an appendectomy.
¨3
Hormonal Factors
Altered
estrogen/progesterone levels or inappropriate levels of prostaglandines can
interfere with normal tubal motility of the fertilized ovum.
¨4
Contraceptive Failure
Ectopic pregnancies occur
with the use of an intrauterine device (IUD) in approximately 2 per 1000 users
each year. The cause is unknown but may be related to altered tubal motility or
a tubal infection. There is increased risk for an ectopic pregnancy with the
progestin-only oral contraceptive because of the decreased motility - induced
effect of progesterone.
¨5
Stimulation of Ovulation
There is a 3% increased
incidence of an ectopic pregnancy associated with ovulation -stimulating drugs
such as human menopausal gonadotropin and clomiphene citrate. These drugs alter
the estrogen/progesterone level, which can affect tubal motility.
¨6
Infertility Treatment
There is an increased risk
of an ectopic pregnancy with in vitro fertilization (IVF) or gamete
intrafallopian transfer (GIFT) since underlying tubal damage is frequently one
of the causative factors predisposing one to this type of infertility
treatment.
¨7
Environmental Effect
Maternal cigarette smoking
at the time of conception was found in a case-controlled study, to be
associated with an increased risk of an ectopic pregnancy.
¨8
Transmigration of Ovum
Migration of the ovum from
one ovary to the opposite fallopian tube can occur by an extrauterine or
intrauterine route. This can cause a potential delay in transportation of the
fertilized ovum to the uterus. Then trophoblastic tissue is present on the blastocyst
before it reaches the uterine cavity, and therefore the trophoblastic tissue
implants itself on the wall of the fallopian tube.
¨9
Endometriosis
The presence of endometrial
tissue located outside the uterine cavity increases the receptivity of the
fertilized ovum to an ectopic implantation.
Normal Physiology
The fallopian tube is very
muscular and narrow and contains very few ciliated cells at the interstitial
area. In the ampullar area the fallopian tube becomes less muscular, the
luminal size increases, and the ciliated cells are more abundant.
The fimbriated end of the
fallopian tube has the unique function of moving the ovum and sperm in opposite
directions almost simultaneously by peristaltic (muscular contraction) and
ciliated activity. This tubal activity is initiated by two or more adjacent
pacemakers in the ampullar and isthmic areas of the fallopian tube by sending
out myoelectrical activity is in either direction. The net directional movement
in the fallopian tubes will vary during the menstrual cycle. During
menstruation the net directional force is toward the uterus starting from the
ampullar area to prevent menstrual blood reflux into the tube. This is
stimulated primarily by estrogen induced prostglandins. Just before ovulation,
the directional force from the ampullar area is inward in order to pick the
released ovum from the ovary and moved it into the ampullar area of the
fallopian tube. At the same time the directional force from the uterine area is
just the opposite in order to facilitate sperm motility toward the ovum. This
is influenced by estrogen primarily. After fertilization the directional force
varies in the ampullar area, which delays ovum transport. Approximately 5 days
after ovulation, the net directional force from the middle of the ampullar area
is inward through the isthmus in order to transport the ovum to the uterus.
This is influenced by increasing progesterone and prostaglandin E2 (PGE).
Approximately 7 days after ovulation, the myoelectrical activity become
variable again, moving in both directions from each of the pacemakers.
The fertilized ovum should
reach the uterine cavity in 6 to 7 days, just about the time the trophoblast
cells begin to secrete the proteolytic enzyme and start to develop the
threadlike projections called chorionic villi that initiate the
implantation process.
The uterus is normally
prepared by estrogen and progesterone to accept the fertilized ovum, now called
a blastocyst. As the chorionic villi invade the
endometrium, the villi are held in check by a fibrinoid zone. The uterus is
also supplied with an increased blood supply capable of nourishing the products
of conception.
Pathophysiology
Tubal Ectopic Pregnancy
Because most ectopic
pregnancies initially implant in a fallopian tube, the pathophysiology will
focus on tubal ectopic pregnancies. The blastocyst burrows into the epithelium
of the tubal wall, tapping blood vessels, by the same process as normal
implantation into the uterine endometrium. However, the environment of the tube
is quite different because of the following factors:
1.
There is a decreased resistance to the invading trophoblastic tissue by
the fallopian tube.
2.
There is a decreased muscle mass lining the fallopian tubes; therefore
their dispensability
3.
The blood pressure is much higher in the tubal arteries than in the
uterine arteries is greatly
limited.
4.
There is limited decidual reaction; therefore human chorionic
gonadotropin (hCG) is decreased and the signs and symptoms of pregnancy are
limited.
It is because of these
characteristic factors the termination of a tubal pregnancy occurs
gestationally early by an abortion, spontaneous regression, or rupture,
depending on the gestational age and the location of the implantation. If the
embryo dies early in gestation, spontaneous regression often occurs. If
spontaneous regression fails to occur, then usually an ampullar or fimbriated
tubal pregnancy ends in an abortion and an isthmic or interstitial pregnancy
ends in a rupture
A tubal abortion primarily occurs because
of separation of all or part of the placenta. This separation is caused by the
pressure exerted by the tapped blood vessels or tubal contractions.
With complete
separation, The products of conception are expelled into the abdominal
cavity by way of the fimbriated end of the fallopian tube
With an incomplete
separation, bleeding continues until complete separation takes place,
and the blood flows into the abdominal cavity collecting in the rectouterine
cul-de-sac of Douglas.
Tubal rupture results from the
uninterrupted invasion of the trophoblastic tissue or tearing of the extremely
stretched tissue. In either case the products of conception are completely or
incompletely expelled into the abdominal cavity or between the folds of the
broad ligaments by way of the torn tube.
The duration of the tubal
pregnancy depends on the location of the implanted embryo or fetus and the
distensibility of that part of the fallopian tube. For instance, if the
implantation is located in the narrow isthmic portion of the tube, it will
rupture very early, within 6 to 8 weeks; the distensible interstitial portion
may be able to retain the pregnancy up to 14 weeks of gestation.
Abdominal Ectopic Pregnancy
An abdominal pregnancy almost
always results from an implantation secondary to a tubal rupture or abortion
through the fimbriated end of the fallopian tube. In these cases the placental
continues to grow following attachment to some abdominal structure, usually the
surface of the uterus, broad ligaments, or ovaries. However, it can be any
abdominal structure including the liver, spleen, or intestines. Because the
invading trophoblastic tissue is not held in check, it can erode major blood
vessels at any because they are not cushioned by the myometrium.
Cervical Ectopic Pregnancy
In very rare cases the
fertilized ovum bypasses the uterine endometrium and implants itself in the
cervical mucus. Painless bleeding begins shortly after implantation, and
surgical termination is usually required before the fourteenth week of
gestation.
Signs and Symptoms
Before Rupture
¨
Abdominal Pain
Abdominal pain occurs close
to 100% of the time. It is usually first manifested by a dull pain caused by
tubal stretching following by a sharp colicky tubal pain caused by further
tubal stretching and stimulated contractions. It is diffuse and is bilateral or
unilateral.
¨ Amenorrhea
A history of a late period
for approximately 2 weeks or a higher than usual or irregular period is
reported by 75 % to 90 % of the patients
¨
Abnormal Vaginal Bleeding
Mild to intermittent dark
red or brown vaginal discharge occurs in 50 % to *0 % of the cases related to
uterine decidual shedding secondary to decreased hormones.
¨
Absence of Common Signs of pregnancy
Absence of common signs of
pregnancy is secondary to decreased pregnancy hormones and occurs 75 % of the
time.
¨
Abdominal Tenderness
Abdominal Tenderness occurs
in approximately 95 % of the cases.
¨
Palpable Pelvic Mass
Referred Shoulder Pain
approximately 50 % of the cases. It may be in the opposite abdominal quadrant from the ectopic growth
related to a corpus luteum cyst.
Rupture
Exacerbation of the pain
occurs during rupture in an ectopic pregnancy.
After Rupture
¨
Faintness / Dizziness
Faintness and dizziness
occur in the presence of significant bleeding
Generalized, Unilateral, or
Deep Lower Quadrant Acute
¨
Abdominal Pain
Pain is caused by blood
irritating the peritoneum
¨
Referred Shoulder Pain
Referred shoulder pain
is related to diaphragmatic
irritation from blood in the peritoneal cavity
¨
Signs of Shock
Shock is related to the
severity of the bleeding into the abdomen.
Maternal Effects
Þ
Ectopic pregnancies account for approximately 10% of all maternal
deaths.
Þ
They are the fourth leading cause of maternal mortality, but they are
the number one cause of maternal mortality in the first trimester of pregnancy.
Þ
Hemorrhage is the cause of death in 85 % to 89 % of the cases and occurs
more frequently with an interstitial or abdominal ectopic pregnancy.
Þ
The greater risk of mortality related to an ectopic pregnancy is
associated with an abdominal ectopic growth, which has a 7.7 times greater risk
when compared to other types of ectopic pregnancies.
Fetal and Neonatal Effects
Death is almost certain for
the fetus in an ectopic pregnancy. From 5 % to 25 % of abdominal ectopic
pregnancies will reach viability. However, it is not recommended to continue an
abdominal pregnancy if diagnosed early because of the extreme risk of
hemorrhage at any time during the pregnancy. The risk of fetal deformity is
also high; 20 % to 40 % of the fetuses that live beyond 20 weeks of gestation
will have such deformities as facial asymmetry, severe neck webbing, joint
deformities, and hypoplastic limbs These are pressure deformities caused by
oligohydramnios.
Medical Diagnosis
Early diagnosis before
extrauterine rupture or abortion can decrease maternal mortality from
hemorrhage and simplify the management of an ectopic pregnancy.
Pregnancy Tests
·Because of the lower levels
of hCG being secreted by an ectopic implanted placenta related to poor
vascularization, the pregnancy test must be highly sensitive for beta-human
chorionic gonadotropin (beta- hCG) to confirm a if an ectopic pregnancy is suspected.
·The most common urine
pregnancy tests such as the latex agglutination inhibition slide test are only
50 % to 60 % accurate in confirming a pregnancy that is ectopic
·Radioimmunoassay tests are
able to detect minute amounts of hCG (5 to 10 mIU/mI) and have proven to be
almost 100 % accurate in detecting an ectopic pregnancy. However, they take
several hours to run.
·The new monoclonal antibody
pregnancy tests such as
¨
the enzyme-linked immunosorbent assay (ELISA) and
¨
the immunofluorometric assay (IFMA) are specific for the beta-hCG submit
and therefore are 95 % to 99 % accurate. It takes only minutes to run these
tests.
Ultrasound
The usefulness of
ultrasound in the diagnosis of an ectopic pregnancy is improving continuously.
·With the more sophisticated
real-time equipment and an expert technician, characteristic changes of an
ectopic pregnancy can be picked up with pelvic ultrasound.
·With transvaginal
ultrasound, the location of the gestational sac of an early ectopic pregnancy
can be visualized with 82 % to 84 % accuracy
·Therefore transvaginal
ultrasound is becoming an important diagnostic tool in an ectopic pregnancy
before rupture because the probe can be placed closer to the pelvic structures.
Culdocentesis
Culdocentesis can be used
to diagnose intraperitoneal bleeding if a rupture ectopic pregnancy is
suspected.
·The procedure involves
passing a needle through the cul-de-sac of Douglas to aspirate fluid from the
peritoneal cavity.
Laparoscopy
If any question remains, an
endoscope may be inserted through a small abdominal incision to visualize the
peritoneal cavity for an ectopic implanted pregnancy
Medical treatment
Tubal Ectopic Pregnancy
Before Rupture
·
Surgical treatment
The type of surgical
management depends on the location depends on
·
the location and
·
cause of the ectopic pregnancy,
·
the extent of tissue involvement, and the patient’s wishes for future
fertility.
The choice of treatment for
an unruptured ampullar or fimbriated tubal pregnancy is a salpingostomy, in
which a longitudinal incision is made over the pregnancy site and the products
of conception are gently removed, being very careful to prevent or control the
bleeding.
Segmental resection and
subsequent end-to-end anastomosis after the swelling and infection have subside
may be necessary if the ectopic pregnancy was located in the proximal isthmus
portion of the tube.
Nonsurgical Treatment
A methotrexate type of
chemotherapy has been successfully used as an alternative to surgery. Provided
there are no signs of bleeding, a dose of 1 ml/kg can be given intramuscularly
every other day for 4 days. In clinical studies a single dose of 12.5mg has
been proven effective when locally injected into the ectopic site. This
cytotoxic drug causes dissolution of the ectopic mass.
Tubal ectopic pregnancy
After Rupture
Following a ruptured tubal
pregnancy, a salpingectomy (removal of the affected fallopian tube) is the most
common surgical treatment. Occasionally a salpingooophorectomy (removal of the
affected fallopian tube and adjacent ovary) is performed if the blood supply to
the ovary is affected or the ectopic pregnancy involved the ovary. Otherwise,
preservation of the ovary is recommended. If the couple does not wish to have
more children, then a hysterectomy may be done if the woman’s condition is
stable.
Abdominal Ectopic Pregnancy
For an abdominal pregnancy,
hemorrhage is a serious possibility because the placenta can separate from its
attachment site at any time.
Abdominal surgery to remove
the embryo or fetus is usually done as soon as an abdominal pregnancy is
diagnosed. Unless the placenta is attached to abdominal structures that can be
removed, such as the ovary or exterior of the uterus, or the blood vessels that
supply blood the placenta can be ligated, the placenta is left without being
disturbed.
If the placenta is removed,
large blood vessels would be opened and there would not be a constricting
muscle such as the uterus to apply a sealing pressure. If left intact, the
placenta is usually absorbed by the body, but unfortunately it may cause such
complications as infection, abscesses, adhesions, intestinal obstruction,
paralytic ileus, postpartum preeclampsia, and wound dehiscence. These
complications are less threatening than the hemorrhage that could result, if
removed.
Cervical Ectopic Pregnancy
In the case of a cervical
pregnancy, the risk of hemorrhage is great as any other type of ectopic
pregnancy.
A vaginal delivery should
be attempted if the gestational age is less than 12 weeks and the couple
desires to have more children. The cervical branch of the uterine artery is
ligated and the cervix is then packed or a Foley catheter balloon inflated in
an attempt to curtail the bleeding from opened blood vessels after the removal
of the placenta.
If this does not stop the
bleeding, amputation of the cervix or a hysterectomy must be done.
If the couple does not wish
to have any more children, an abdominal hysterectomy is generally the method of
treatment.
Nursing Process
Prevention
Because an ectopic
pregnancy is closely associated with a previous pelvic infection
·education regarding the
importance of treating a vaginal or pelvic infection early would also decrease
the incidence.
·Since there is a
correlation between cigarette smoking and an increased risk of an ectopic
pregnancy, women during their childbearing years should be encouraged to avoid
smoking.
·If an elective abortion is
desired it should always be carried out only by medically prepared
professionals.
These measures can
decreased the chance of tubal defects and thereby decrease the incidence of an
ectopic pregnancy.
Because of the increasing
incidence of ectopic pregnancy, health professionals should consider the
possibility in any woman who presents with any type of abdominal discomfort
during her childbearing years.
Assessment
Because of the high
maternal mortality associated with an undiagnosed ectopic pregnancy until after
rupture or tubal abortion, it is very important for nurses to be alert to signs
and symptoms of this complication of pregnancy.
Therefore any woman during
her childbearing years who experiences irregular vaginal spotting associated
with a dull, aching pelvic pain, with or without signs of pregnancy, should be
evaluated for a possible ectopic pregnancy.
Risk Factors
·A history of any pelvic
inflammatory disease,
·previous ectopic
pregnancies,
·elective abortions,
·or prior infertility
disorders should be determined; they can increase the patient’s risk for a
tubal defect.
Pain
If an ectopic pregnancy is
suspected, a detailed history should include questions regarding the type of
abdominal pain. The pain caused by an unruptured ectopic pregnancy can be a
unilateral, cramplike pain related to tubal distension by the enlarging embryo
or fetus.
At the time of tubal
rupture many patients experience a sudden, sharp, stabbing pain in the lower
abdomen.
Vaginal Bleeding
Assess for the presence of
vaginal bleeding, and obtain a menstrual history. Vaginal bleeding is usually
related to the sloughing of the endometrial lining related to decreasing
progesterone and estrogen levels and can present as continuous or intermittent
vaginal bleeding in small or large quantities. It is usually different from the
patient’s normal period. Pad Counts should be kept to determine the amount and
type of vaginal bleeding.
Syncope
Assess for the presence of
any signs of syncope.
When an ectopic pregnancy
ruptures or aborts, blood is lost into the peritoneal cavity. At this time the
patient can experience a feeling of faintness or weakness related to
hypovolemia. If the bleeding is not continuous, the depleted blood volume is
restored to near normal in 1 or 2 days by hemodilution and the faint or week
feeling subsides. If the bleeding is profuse, the patient can go into should
quickly.
Vital signs
To assess the amount of
intraperitoneal blood loss, the patient’s vital signs should be checked as
frequently as the situation indicates.
Nursing Diagnosis/Collaborative Problems and Interventions
¨ Fear related risk of
mortality and possible treatment alternatives.
Desired Outcome: The patient and her family
will be able to communicate their fears and concerns openly.
Interventions
1.
Assess family’s anxiety over maternal well-being because of 10 times
greater risk of mortality as compared to normal childbirth.
2.
Assess family’s level of guilt such as their feeling as to what they did
to cause this happen.
3.
Assess family’s coping strategies and resources.
4.
Explain all treatment modalities and reasons for each in understandable
terms.
5.
Prepare patient for transvaginal ultrasound, if this diagnostic
procedure is ordered, by having patient empty her bladder before the procedure.
6.
Prepare patient for a culdocentesis, if this diagnostic procedure is
ordered, by explaining the procedure.
(A sterile speculum
is inserted into the vagina, the cervix is steadied with a tenaculum,
and a 16- to 18- gauge needle is inserted into the cul-de-sac so
any fluid that is present can be aspirated for evaluation.)
Position patient in a semi-Fowler’s
position to allow any intraperitoneal blood, if present, to pool in cul-de-sac.
Just before the procedure
prepare the external genitalia with povidone-iodine (Betadine).
7.
Prepare the patient for the medical procedure.
¨
Pain related
to
Þ
stretching of the tube,
Þ
severe abdominal bleeding secondary to tubal rupture,
Þ
or surgical treatment.
Desired Outcome: the patient will verbally
and nonverbally express reasonable comfort.
Interventions
1.
Assess the type and location of pain.
2.
Maintain position of comfort.
3.
Limit movement, and support patient.
4.
Provide reassurance.
5.
Instruct regarding the use of relaxation and breathing techniques to
reduce pain if medication cannot be administered.
6.
Administer pain medication as ordered if needed.
7.
Notify physician regarding any change in the amount or type of pain the
patient experiences.
¨
Potential Complication: Hemorrhage caused by ectopic rupture/abortion or
surgical treatment.
Desired Outcome: The signs and symptoms of
hemorrhage will be minimized/managed as measured by
Þ
stable vital signs,
Þ
urinary output of 30 ml/hr or greater,
Þ
absence of signs of shock, and
Þ
hematocrit maintained between 30 % and 45 %.
Preoperative Interventions
1.
Check vital signs as indicated (depending on severity).
2.
Check amount of vaginal bleeding.
3.
Check for signs of shock such as tachycardia, drop in blood pressure,
and cool clammy skin. (During pregnancy, signs of shock are not manifested
until there has been at least a 40 % blood volume loss.
4.
Check state of mental acuity/level of consciousness.
5.
Keep an accurate record of intake and output.
Þ
Urinary output during pregnancy is the best noninvasive indicator of
circulatory volume.
Þ
Diminished cardiac output causes a shunting of blood away from the skin,
kidneys, and skeletal muscles in order to ensure blood delivery to heart and
brain.
6.
Start an intravenous infusion with an 18-gauge intracatheter and
maintain as ordered.
Þ
Fluid replacement may reverse impending shock by increasing capillary
blood flow and thereby cardiac output increases. (Normal saline or Ringer’
7.
Obtain blood as ordered for
Þ
a complete blood count,
Þ
prothrombin time,
Þ
partial thromboplastin time,
Þ
Rh antibody screen, and
Þ
type and cross match for 2 to 4 units of blood.
8.
Administer oxygen at 8 to 10 L by mask as needed.
9.
Carry out such preoperative protocol as giving the patient
Þ
nothing by mouth,
Þ
giving no enemas or cathartics since they could stimulate a tubal
ectopic pregnancy to rupture,
Þ
being prepared to insert a Foley catheter as ordered, and
Þ
get the permit signed for surgery.
10.
Notify the attending physician of any changes in
Þ
vital signs,
Þ
decreasing urinary output,
Þ
blood pressure that falls 10 mmHg or more, or
Þ
a change in mental acuity.
11.
If the patient presents in shock, be prepared to assist with central
line placement. The internal jugular and subclavian veins are less likely to
collapsed.
12.
Be prepared to administer blood replacement therapy if
Þ
the hemoglobin level is below 7 g/dl or
Þ
the patient is manifested signs of shock.
Postoperative Interventions
1.
Check blood pressure, pulse, and respiration
·
every 15 minutes, eight times;
·
every 30 minutes two times;
·
every hour, two times;
·
every 4 hours, two times; and then routinely.
2.
Assess vaginal bleeding by pad count.
3.
Check dressing
·
every hour four times and then
·
every shift for bleeding
4.
Refer to laboratory work, such as hemoglobin and hematocrit.
5.
Keep an accurate intake and output records.
6.
Assess for cyanosis.
7.
Reinforce or change dressing as needed.
8.
Carefully administer IV fluids as ordered.
9.
Once the gastrointestinal tract resumes normal function, instruct
regarding the importance of
·
a high protein,
·
high-iron diet for body repair and replacement of blood loss.
10.
Notify physician if
·
blood pressure drops to less than 90 systolic,
·
pulse rises to greater than 120 bpm, or
·
anemia develops.
High Risk For Infection related to blood being an
ideal medium for bacterial growth.
Desired Outcome: The patient’s temperature
will remain normal, incision will approximate without redness or drainage,
vaginal discharge will be without odor, and the white blood cell count will
remain less than 16,000/mm3.
Interventions
1.
Check temperature every 4 hours.
2.
Refer to laboratory work, such as white blood cell count.
3.
Check incision for redness, swelling, and drainage every shift.
4.
Administer prophylactic antibiotics as ordered.
5.
Notify the physician if the temperature increases or any signs of
infection develop.
Anticipatory Grieving related to loss of an
anticipated infant and possible threat to fertility.
Desired Outcome: The patient and family members will
verbalize their feelings of grief appropriately and identify any problems as
they work through the grief process.
Interventions
1.
Assess level of loss and desire for future childbearing.
2.
Encourage the patient and family the chances of recurrence (12 % to 18 %
risk and infertility problems 50 %.
3.
Teach the couple the importance of using a contraceptive of choice for
at least three menstrual cycles to allow time for the woman’s body to recover.
Other potential postoperative complications
·
paralytic ileus,
·
urinary tract infection, pneumonia,
·
anemia,
·
pulmonary edema,
·
Rh sensitization,
·
persistent ectopic pregnancy, or
·
adhesions.
Desired Outcome: Postoperative complications
will be minimized/ managed as measured by no burning on urination, hematocrit
maintained between 30% and 45%, breath sounds clear, bowel sounds active,
abdomen soft, and beta-hCG levels drop to zero in 2 weeks postoperatively.
Interventions
1.
Assess for burning on urination.
2.
Auscultate lung fields every shift for rales, and observe for coughing
or dyspnea.
3.
Auscultate bowel sounds every shift.
4.
Assess for passage of flatus.
5.
Palpate abdomen for hardness and boardlikeness.
6.
Have patient turn, cough, and deep breath every 2 hours.
7.
Give patient nothing by mouth until bowel sounds are present. Then
advance to soft or regular diet.
8.
Have patient do leg exercises every hour while awake until ambulating
well.
9.
Have patient do abdominal tightening every hour while awake until normal
gastrointestinal activity returns.
10.
Encourage and assist with ambulation as soon as ordered
11.