Ectopic Pregnancy SKINNY Reasoning UPDATE

Ectopic Pregnancy SKINNY Reasoning Jean Simmons, 22 years old Primary Concept Perfusion Interrelated Concepts (In order of emphasis) • Reproduction • Pain • Clinical Judgment • Patient Education NCLEX Client Need Categories Percentage of Items from Each Category/Subcategory Covered in Case Study Safe and Effective Care Environment • Management of Care 17-23%  • Safety and Infection Control 9-15% Health Promotion and Maintenance 6-12%  Psychosocial Integrity 6-12%  Physiological Integrity • Basic Care and Comfort 6-12%  • Pharmacological and Parenteral Therapies 12-18%  • Reduction of Risk Potential 9-15%  • Physiological Adaptation 11-17%  SKINNY Reasoning Part I: Recognizing RELEVANT Clinical Data 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: RELEVANT Data from Social History: Clinical Significance: Patient Care Begins: Current VS: P-Q-R-S-T Pain Assessment (5th VS): T: 98.4 F (36.9 C) oral Provoking/Palliative: Movement of any kind/Lying still in fetal position P: 98 (regular) Quality: Sharp/stabbing R: 20 (regular) Region/Radiation: RLQ abdomen BP: 102/52 Severity: 9/10 O2 sat: 98% room air Timing: Constant What VS data is RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Assessment Data: Clinical Significance: Current Assessment: GENERAL APPEARANCE: Appears uncomfortable, body tense RESP: Breath sounds clear with equal aeration bilaterally, nonlabored respiratory effort CARDIAC: 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: Diagnostic Results: Complete Blood Count (CBC) WBC % Neuts HGB PLTs Current: 8.8 70 9.9 155 Most Recent: 9.5 68 12.8 225 MISC. Urine Preg Serum HCG Rh Factor Current: Pos 9250 Neg Pelvic Ultrasound: No gestational sac observed. Cannot exclude ectopic pregnancy. What data must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation) RELEVANT Diagnostic Data: Clinical Significance: TREND: Improve/Worsening/Stable: Part II: Put it All Together to THINK Like a Nurse! 1. After interpreting relevant clinical data, what is the primary problem? (Management of Care/Physiologic Adaptation) Problem: Pathophysiology in OWN Words: Ectopic pregnancy Collaborative Care: Medical Management 2. State the rationale and expected outcomes for the medical plan of care. (Pharm. and Parenteral Therapies) Medical Management: Rationale: Expected Outcome: Establish large bore (18 g.) peripheral IV 0.9% NS 1000 mL IV bolus Hydromorphone 0.5-1 mg IV every hour prn Transvaginal ultrasound Collaborative Care: Nursing 3. What nursing priority (ies) will guide your plan of care? (Management of Care) Nursing PRIORITY: • Acute pain • Maintain adequate hemodynamics PRIORITY Nursing Interventions: Rationale: Expected Outcome: 4. What psychosocial/holistic care PRIORITIES need to be addressed for this patient? (Psychosocial Integrity) Psychosocial PRIORITIES: PRIORITY Nursing Interventions: Rationale: Expected Outcome: CARING/COMFORT: How can you engage and show that this pt. matters to you? Physical comfort measures: EMOTIONAL SUPPORT: Principles to develop a therapeutic relationship SPIRITUAL CARE/SUPPORT: CULTURAL CARE/SUPPORT: (If Applicable) 5. What educational/discharge priorities need to be addressed to promote health and wellness for this patient and/or family? (Health Promotion and Maintenance)