Ectopic pregnancy is a potentially life-threatening condition where a fertilized egg implants outside the uterine cavity, most commonly in the fallopian tubes. This nursing diagnosis focuses on identifying early warning signs, managing symptoms, preventing complications, and providing emotional support to affected patients.
Causes (Related to)
Ectopic pregnancy can develop due to various risk factors and underlying conditions:
- Previous pelvic inflammatory disease (PID)
- History of tubal surgery or previous ectopic pregnancy
- Use of assisted reproductive technology
- Smoking
- Advanced maternal age (>35 years)
- Anatomical factors such as:
- Scarred fallopian tubes
- Congenital tubal abnormalities
- Endometriosis
- Inflammatory conditions including:
- Salpingitis
- Chronic pelvic inflammation
- Previous pelvic infections
Signs and Symptoms (As evidenced by)
Ectopic pregnancy presents with distinctive signs and symptoms that nurses must recognize for prompt intervention.
Subjective: (Patient reports)
- Sharp, unilateral pelvic pain
- Amenorrhea
- Vaginal spotting or bleeding
- Shoulder pain (if rupture occurs)
- Dizziness or lightheadedness
- Nausea and vomiting
- Breast tenderness
- Urinary frequency
Objective: (Nurse assesses)
- Positive pregnancy test
- Abdominal tenderness
- Signs of shock if ruptured
- Decreased hemoglobin and hematocrit
- Vital sign changes
- Pallor
- Diaphoresis
- Enlarged adnexa on examination
Expected Outcomes
The following outcomes indicate successful management of ectopic pregnancy:
- Early recognition and diagnosis
- Hemodynamic stability maintained
- Pain effectively managed
- Emotional support provided
- Prevention of complications
- Understanding of future pregnancy implications
- Recovery from surgical intervention if needed
- Successful grieving process completion
Nursing Assessment
Monitor Vital Signs
- Check blood pressure, pulse, and respiratory rate every 15-30 minutes
- Assess for signs of shock
- Monitor temperature
- Document cardiovascular status
Assess Pain Status
- Location and intensity
- Radiation of pain
- Associated symptoms
- Response to interventions
- Changes in character
Evaluate Bleeding
- Amount and color
- Presence of clots
- Duration
- Associated symptoms
- Changes in status
Monitor Emotional Status
- Assess coping mechanisms
- Evaluate support system
- Document psychological response
- Screen for depression
- Note anxiety levels
Check for Complications
- Monitor for rupture signs
- Assess for hemorrhage
- Watch for infection
- Evaluate shock symptoms
- Document adverse reactions
Nursing Care Plans
Nursing Care Plan 1: Risk for Shock
Nursing Diagnosis Statement:
Risk for Hypovolemic Shock related to potential tubal rupture and internal bleeding as evidenced by tachycardia, hypotension, and pallor.
Related Factors:
- Internal bleeding
- Tubal rupture
- Fluid volume loss
- Cardiovascular compromise
Nursing Interventions and Rationales:
- Monitor vital signs q15min
Rationale: Early detection of shock symptoms - Maintain IV access and fluid resuscitation
Rationale: Ensures immediate access for emergency intervention - Position patient supine with legs elevated
Rationale: Improves venous return and cardiac output - Monitor intake and output strictly
Rationale: Assesses fluid balance status
Desired Outcomes:
- The patient will maintain stable vital signs
- The patient will show no signs of shock
- The patient will maintain adequate tissue perfusion
Nursing Care Plan 2: Acute Pain
Nursing Diagnosis Statement:
Acute Pain related to tissue damage and inflammation as evidenced by verbal reports of sharp, unilateral pelvic pain and guarding behavior.
Related Factors:
- Tissue inflammation
- Fallopian tube distention
- Peritoneal irritation
- Psychological stress
Nursing Interventions and Rationales:
- Assess pain characteristics regularly
Rationale: Determines intervention effectiveness - Administer prescribed analgesics
Rationale: Provides pain relief - Apply comfort measures
Rationale: Enhances pain management
Desired Outcomes:
- The patient will report decreased pain levels
- The patient will demonstrate improved comfort
- The patient will use effective pain management strategies
Nursing Care Plan 3: Anxiety
Nursing Diagnosis Statement:
Anxiety related to pregnancy loss and health crisis as evidenced by expressed concerns, restlessness, and increased tension.
Related Factors:
- Threat to reproductive health
- Loss of pregnancy
- Uncertain prognosis
- Fear of future fertility issues
Nursing Interventions and Rationales:
- Provide emotional support and active listening
Rationale: Helps patient process emotions - Explain procedures and expectations
Rationale: Reduces fear of the unknown - Facilitate support system involvement
Rationale: Enhances coping mechanisms
Desired Outcomes:
- The patient will express decreased anxiety
- The patient will utilize effective coping strategies
- The patient will verbalize understanding of the situation
Nursing Care Plan 4: Risk for Infection
Nursing Diagnosis Statement:
Risk for Infection related to surgical intervention and compromised tissue integrity as evidenced by invasive procedures and tissue trauma.
Related Factors:
- Surgical intervention
- Invasive procedures
- Compromised tissue
- Stress response
Nursing Interventions and Rationales:
- Monitor for infection signs
Rationale: Enables early intervention - Maintain sterile technique
Rationale: Prevents infection - Administer prescribed antibiotics
Rationale: Prevents/treats infection
Desired Outcomes:
- The patient will remain free from infection
- The patient will demonstrate proper wound care
- The patient will maintain a normal temperature
Nursing Care Plan 5: Anticipatory Grieving
Nursing Diagnosis Statement:
Anticipatory Grieving related to loss of pregnancy and reproductive concerns as evidenced by expressed feelings of sadness and loss.
Related Factors:
- Pregnancy loss
- Future fertility concerns
- Emotional trauma
- Role transition interruption
Nursing Interventions and Rationales:
- Acknowledge loss and validate feelings
Rationale: Supports the grieving process - Provide resources for grief counseling
Rationale: Facilitates healthy coping - Discuss future pregnancy planning when appropriate
Rationale: Addresses fertility concerns
Desired Outcomes:
- The patient will progress through the grief stages
- The patient will utilize support resources
- The patient will express hope for the future
References
- Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2023). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.
- Fisch JD, Ortiz BH, Tazuke SI, Chitkara U, Giudice LC. Medical management of interstitial ectopic pregnancy: a case report and literature review. Hum Reprod. 1998 Jul;13(7):1981-6. doi: 10.1093/humrep/13.7.1981. PMID: 9740461.
- Harding, M. M., Kwong, J., & Hagler, D. (2022). Lewis’s Medical-Surgical Nursing: Assessment and Management of Clinical Problems, Single Volume. Elsevier.
- Herdman, T. H., Kamitsuru, S., & Lopes, C. (2024). NANDA International Nursing Diagnoses – Definitions and Classification, 2024-2026.
- Ignatavicius, D. D., Rebar, C., & Heimgartner, N. M. (2023). Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care. Elsevier.
- Mullany K, Minneci M, Monjazeb R, C Coiado O. Overview of ectopic pregnancy diagnosis, management, and innovation. Womens Health (Lond). 2023 Jan-Dec;19:17455057231160349. doi: 10.1177/17455057231160349. PMID: 36999281; PMCID: PMC10071153.
- Sivalingam VN, Duncan WC, Kirk E, Shephard LA, Horne AW. Diagnosis and management of ectopic pregnancy. J Fam Plann Reprod Health Care. 2011 Oct;37(4):231-40. doi: 10.1136/jfprhc-2011-0073. Epub 2011 Jul 4. PMID: 21727242; PMCID: PMC3213855.
- Silvestri, L. A. (2023). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.
