Case Study: Ectopic Pregnancy – NCLEX-RN®

00:01 Hi, I'm Jackie. Let's meet Lydia as we work through a case study.

00:05 Lydia is a 24-year-old female client who suspects that she may be pregnant.

00:11 From the nurse's notes, we find out that when Lydia presented to the unit, she said, "I just don't feel well, I'm lightheaded.

00:19 I have an IUD with hormones in it but I'm worried that I might be pregnant." She also reported that her last menstrual period was two months ago.

00:29 She was experiencing pain in the pelvic region and some light spotting every couple of days.

00:34 She also had some breast tenderness.

00:37 Hmm, finally, Lydia also said, "Does it matter that I feel like I need to pee all the time?" I hope some thoughts are coming up for you about what this could mean.

00:49 From her history, we find out that Lydia has been sexually active since she was 17-years-old.

00:55 She had an IUD that was placed about a year ago.

00:58 She had pelvic inflammatory disease or PID about two years ago that was successfully treated with antibiotics.

01:06 She admits to having unprotected sex and reports that she participates in vaginal and anal sex.

01:14 So, let's review Lydia's statements and determine which elements from her history might require follow-up.

01:22 So, Lydia said she didn't feel well but what she also said was she has an IUD with hormones and she's worried that she might be pregnant.

01:32 So, being worried that you might be pregnant when you have an IUD definitely requires follow-up.

01:38 She also reported that her last menstrual period was two months ago.

01:42 Now, she has an IUD with a hormone.

01:45 And when you have an IUD with a hormone, amenorrhea or absence of a period is to be expected.

01:51 But when you have that along with breast tenderness and a concern that you might be pregnant and pain in the pelvic region, then, that's something we need to follow-up on for sure.

02:04 And finally, Lydia says that she's worried that she has to pee all the time.

02:09 Does that matter? Well, if you remember from any discussion about pregnancy symptoms, having a growing uterus puts pressure on the bladder and it makes urinary frequency a possibility. So, that also goes along with pregnancy.

02:24 So, the nurse will definitely need to follow-up on that. Now, let's look at her past medical history.

02:29 Being sexually active since she's 17 is not something we need to deal with today.

02:34 Having an IUD at all, certainly okay. Having pelvic inflammatory disease two years ago, well, that may require some follow-up in terms of understanding her history today but since it's treated, we don't have to do anything right now.

02:50 We also know that Lydia's had unprotected sex. Well, that can lead to pregnancy.

02:56 So, we need to think about that.

02:59 And finally, whether or not she has vaginal or anal sex only matters if we're thinking about checking for sexually transmitted infections.

03:07 Otherwise, it has no relevancy on the case today. Now, let's look at her assessment.

03:14 So, this is what the nurse does after they take the history. What's important here? Let's go through the vital signs. So, Lydia's heartrate is 100 beats per minute.

03:24 Respiratory rate is 24 breaths per minute. Blood pressure is 90 over 64.

03:30 Her temperature is 36.7 degrees Celsius and her O2 saturation is 96.

03:36 From the physical assessment and this is what the nurse is writing down.

03:40 She notes that Lydia's skin and mucous membranes are pale.

03:44 That Lydia's not really sitting still and Lydia actually states, "I'm feeling very nervous." Lydia's experiencing some tenderness in the right lower abdomen when the nurse does her abdominal palpation and when she's doing the palpation, Lydia says to her, "You know, I've been constipated for the last week." Lydia also says, "My chest hurts above my right breast bone." Her lab results note that her hemoglobin is 10.8. Her hematocrit, 27%, white blood cell count is 11, blood type A negative, pregnancy test is positive at 7,000 mIUs.

04:25 The ultrasound shows a right-side tubal pregnancy that there's also a rupture of the right tube and a three centimeter blood clot noted around the rupture. The IUD however is in the appropriate place in the uterus.

04:41 So, now, let's put all the information we've gathered so far together.

04:46 That's information from the history in how the client presented and also from the tabs, all of the assessments.

04:53 We're going to find out which four problems are of the most concern to the nurse.

04:59 This is a select all that apply. We'll go through each one individually.

05:04 So, spotting, well, that's certainly a concern.

05:08 We need to know how long and how much spotting has occurred, especially, since we know that that hemoglobin and hematocrit are a little bit low.

05:17 The fact that Lydia's last menstrual period was two months ago certainly corresponds with possibly being pregnant, definitely needs more of an investigation.

05:27 We have an IUD in place. Well, this could be a problem if we find out that Lydia's pregnant.

05:33 So, we'll keep that one in our back pocket as well. History of PID.

05:38 Well, there's no signs of infection in the current moment, so, we don't need to deal with this right now.

05:44 Her recent history of vaginal and anal sex, well, how she has sex is not an issue for this case, so, we'll skip that one.

05:53 A positive pregnancy test. Absolutely, we're going to follow-up on this.

05:57 She has an IUD in place, so, the plan was not to be pregnant.

06:01 So, the fact that she is along with all of the other symptoms that go along with the pelvic pain and spotting and bleeding, we have something here that we definitely need to follow-up on.

06:12 Pelvic pain, well, mild cramping might occur with implantation.

06:16 Constant pelvic pain, hmm, that might indicate a problem in terms of possibly a tubal pregnancy.

06:24 Anemia, well, this might be a concern when we think about the fact that Lydia's hemoglobin was 10.8 and her hematocrit was 27%.

06:34 So, altogether, which four are the most concerning to the nurse out of everything we've talked about? Spotting, positive pregnancy test, pelvic pain, and anemia.

06:47 Because altogether, these point to a possible ectopic pregnancy which was confirmed by the ultrasound.

06:55 Now, let's use that very same information to answer a different type of next gen question.

07:02 This will be a close or dropdown question. So, the nurse determines the client is at risk for experiencing blank which can be confirmed by blank. So, let's see what those options might be.

07:17 Option one, we can either have a normal pregnancy, an ectopic pregnancy, or a pelvic inflammatory infection.

07:28 So, the nurse determines the client is at risk for experiencing which one of the following? Could it be a normal pregnancy? Well, certainly, constipation happens with normal pregnancies.

07:40 An elevated white count could happen with a normal pregnancy and a positive pregnancy test will certainly go along with a normal pregnancy.

07:50 But let's look at our other options. Ectopic pregnancy.

07:54 Well, for an ectopic pregnancy, let's think about the symptoms.

07:59 Are they consistent with an ectopic pregnancy? Sounds like it.

08:04 Also, when we have a fertilized egg and it implants outside the uterus, does that cause bleeding and pain? Yes, it does. And much of the history, including the past history of a pelvic inflammatory infection, could go along with an ectopic pregnancy. Also, and this is the key, we have an ultrasound.

08:24 That says we have an ectopic pregnancy.

08:27 Finally, for a pelvic inflammatory infection, we have a white count that's slightly elevated but certainly, not elevated in a way that's consistent with a major infection.

08:38 So, that doesn't really fit. The referred shoulder pain that's happening usually is a result of a rupture of an ectopic pregnancy and has nothing to do with the pelvic inflammatory infection. Heart rate is also normal.

08:51 So, we don't really have any other signs that are consistent with a pelvic inflammatory infection.

08:56 So, that one doesn't seem like it fits very well. So, which answer is the best answer for this? An ectopic pregnancy. We have a diagnosis and we also have symptoms that perfectly match with that option.

09:10 Let's look at option two. So, we're trying to figure out the dropdown for the second space.

09:15 How can we confirm an ectopic pregnancy? So, option one, a positive pregnancy test.

09:22 Well, certainly, with an ectopic pregnancy, it is a pregnancy.

09:26 So, the pregnancy test will be positive but is that the best answer? Let's keep looking. The low hemoglobin and hematocrit. Well, that's certainly a concerning confirmation.

09:37 We know that Lydia's hemoglobin and hematocrit are low but is that the best way that we confirm an ectopic pregnancy because that's the question.

09:47 Finally, we have an ultrasound. So, the ultrasound results told us that they saw a tubal pregnancy.

09:55 And also, a ruptured tube. So, that seems pretty positive, a pretty positive way to confirm an ectopic pregnancy. So, that is our final answer.

10:06 The nurse determines the client is at risk for experiencing an ectopic pregnancy which can be confirmed by an ultrasound. Now, let's move forward in the case.

10:18 We find out from the nurse's notes that the healthcare provider has explained the ruptured ectopic to Lydia.

10:25 She responds by beginning to shake and cry and the nurse provides support and tries to help her remain calm.

10:32 Lydia also reports that no one is there to be with her to offer support.

10:38 So, let's think about from the nurse's perspective what she anticipates that is going to happen next.

10:45 This is also going to be a close or dropdown question. We have two options to consider.

10:52 The nurse anticipates that the client will receive blank and the priority outcome for the procedure is to blank.

11:01 Let's look at option one. What are we anticipating that the client is going to receive? The first option is methotrexate. This is a medication used to dissolve an ovum.

11:13 So, would that work in this case? Hmm, I'm not sure. Let's see what else we could choose from.

11:19 A salpingectomy. Salpingectomy is a surgery to remove a fallopian tube.

11:25 Well, we know the tube is ruptured so that sounds like that might be a good option.

11:30 But let's look at the last option. Dilatation and curettage. So, this is where we scrape the lining of the uterus.

11:38 Hmm, this is an ectopic pregnancy that's occurring in the tubes, so, would scraping the lining of the uterus be expected in this particular case? Probably not.

11:50 So, from the three options, methotrexate, salpingectomy and dilatation and curettage, salpingectomy is the best answer.

11:59 So, let's determine the priority outcome for the salpingectomy. Option two, here we go.

12:06 Stop the eggs from meeting the sperm. Well, Lydia's pregnant, so, they've already met.

12:12 Too late for that.

12:14 Stop ovum cellular growth.

12:17 Well, that would work except the tube is ruptured, so, again, we have another issue to consider.

12:23 And finally, stop internal bleeding. We already know that Lydia's hemoglobin and hematocrit are low.

12:31 She's anemic now. That seems pretty important.

12:35 So, when we think about all of our option two's, which one would be the goal of the salpingectomy? Stop the internal bleeding. Exactly. So, altogether, the nurse anticipates the client will receive a salpingectomy and the priority outcome for the procedure is to stop internal bleeding.

12:59 Now, we're ready to move forward with the salpingectomy.

13:02 The healthcare provider has written a long list of orders and prescriptions.

13:06 You can see all of them on the screen.

13:09 We have selected six however, that we want to place in priority, order, action.

13:16 These prescriptions or orders are IV, our Lactated Ringers at 125 milliliters per hour.

13:22 Ampicillin IV, a signed consent form, lorazepam, also given IV, an abdominal scrub, and finally, a vaginal culture with sensitivity. Take just a second.

13:35 Look at this list of the six prescriptions and decide how you would order these orders.

13:47 Here are the actions in priority order. IV LR 125, vaginal culture and sensitivity, ampicillin IV, signed consent form, lorazepam IV, and abdominal scrub.

14:00 Hopefully, you got those all in order. Let's break down the rationale for each one.

14:06 The first one, an IV of LR at 125. Lydia is not hemodynamically stable, so, getting an IV and starting a line of fluid is going to be a priority action.

14:17 This should be done first. Second, before we give any antibiotics or before we do anything else, we want to make sure that we get a vaginal culture. If we get the culture after the antibiotics, then, sometimes, the antibiotics have already started working and we don't know what the bacteria is.

14:35 So, that's going to be done next. Then, we want to give the antibiotic because it gives it the greatest opportunity to work.

14:43 She is likely to have some sort of infectious process going on and definitely will after the surgery.

14:49 So, we want to start the antibiotic as soon as we can.

14:52 Next, before we engage in any sort of surgery, we need a signed consent form and we definitely want to have that consent form signed before we give lorazepam.

15:03 Lorazepam is going to change the level of consciousness of the patient and affect their ability to give consent.

15:10 So, we have to get the consent form signed first. And then, we give the lorazepam.

15:15 And finally, the last option is the abdominal scrub.

15:19 It's certainly important for the surgery but it's the least priority of all the things listed.

15:25 Lydia has had the salpingectomy and is ready to be discharged home.

15:29 Which statement made by Lydia indicates that she understands her diagnosis? Number one, I will make an appointment with the fertility clinic.

15:39 Number two, I will find an OBGYN clinic for my next yearly test.

15:44 Number three, I think I need birth control. I will make an appointment with my doctor.

15:49 And four, since I've had difficulty with urination, I will see a urologist.

15:55 The correct answer is number three. I think I need birth control.

15:59 Lydia has already been pregnant, so, fertility is not an issue.

16:04 So, it wouldn't be number one. Waiting a year to see an OBGYN after such a complicated case would also not be the best answer.

16:13 Option four, the difficulty Lydia was experiencing with urination was related to the enlargement of the uterus pressing on the bladder.

16:21 Since the pregnancy's been removed, the uterus is no longer pressing on the bladder and this is resolve.

16:27 We don't need to see a urologist.

16:29 Finally, option three, the IUD was likely removed during the procedure and therefore, because Lydia is sexually active, she will need birth control. This is the correct answer.