Ectopic pregnancy was any pregnancy implanted outside the uterine cavity In the UK the incidence is approximately 11/1,000 pregnancies, with approximately 11,000 ectopic pregnancies diagnosed each year1. Ectopic pregnancy was a high-risk of gynecological emergency and complicated to manage. If the fallopian tube ruptures, it will cause of shock from intra-abdominal hemorrhage, which can be life-threatened. Therefore, there must be closed and continuous care and observation by nurses in caring when there discharge according to nursing standards [2].

In Thailand, an incidence of 1-2 percent of pregnancies is found, with 95-98 percent occurring in the fallopian tubes, which are mostly located in the fallopian tubes. The ampulla is 12-13% located in the isthmic and fimbria, while the interstitial is 2-4%. In addition, it is located in the ovaries, cervix or in the abdominal cavity. (Less than 1 percent) [3] Ectopic pregnancy is considered a gynecological emergency. In general, treatment is divided into Supportive follow-up treatment with drugs and surgery, although nowadays there is a trend of increasing the use of drugs to treat ectopic pregnancy. And new drugs have been developed and used to treat ectopic pregnancies, but surgical treatment is still a popular method. Got good results there is a low recurrence rate And has high safety [4].

In patients (Pt.) with ectopic pregnancy who require surgical treatment, close supervision is required from the beginning and continuous monitoring because ectopic pregnancy is considered a gynecological emergency. Which is extremely difficult and complicated to care for especially patients who require urgent surgery under the Fast Tract Ectopic Pregnancy surgery system, which is still new in Thailand. Public health personnel or the team providing care therefore need to have very high knowledge, abilities, skills, and expertise. In particular, nurses, who are the closest caregivers to patients, need to develop necessary competencies in all four areas. Therefore, educators have a need to study the roles of advanced nurses and appropriate nursing care in patient care. Ectopic pregnancy that was surgically treated in the fast-track system this will lead to the determination of policies, guidelines, or models of care at both the hospital level and the national level [5].

Ultrasound is the gold standard for diagnosis of ectopic pregnancy with a specificity and sensitivity previously described as 94% and 87% respectively. The abdominal-pelvic nuclear magnetic resonance imaging (MRI) may help guide the involvement of adjacent organs [5].

Fast Track Surgery: FTS or Enhanced Recovery after Surgery: ERAS explain by Kehlet, H. (1990) main point of program was early rehabilitation of patients under collaboration of multidisciplinary with many model or multiple or multiple of techniques. Committed for decrease of abnormality and mobility after surgery. However, the treatment in ectopic pregnancy brought up to Fast Track Surgery: FTS or Enhanced Recovery after Surgery: ERAS for utilization get to safety in patients [6].

Objective

Comparative 2 case studied in nursing care for patients with ectopic pregnancy undergoing surgery in fast-track surgery according to nursing standards.

Purpose

• Get to fast tract surgery in ectopic pregnancy nursing care guideline in organization
• Explain and utilizations in organization and outside to international

Importance of study

Ectopic pregnancy was a crisis in gynecology, many complicated of care in individual and family care all of mental, emotional and social especially who undergo on surgery there want to closeup of care when first visit until discharge and continue to home care.  Management depends on maternal symptoms and fetal status. In many cases, emergency laparotomy is the chosen technique, as the patient may present acute, severe intra-abdominal hemorrhage due to placental separation of the implantation bed. Due to the extreme risk of complications and associated maternal mortality of up to 5 per 1000 cases, some experts recommend surgical intervention as soon as the diagnosis has been made. Cases of conservative management are usually isolated and fetal mortality can reach more than 50%. Abdominal pregnancy has also been associated with congenital malformations in about 20% of neonates [5].

This comparative case studies use for descriptive research methodology design to compare nursing process in fast tract surgery in ectopic pregnancy. Select case with purposive sampling there arrive to visit in Kalasin hospital from April to July 2022 get to 2 sample sites. Data collective with personal data collective form, observative form, in-dept interview form, Gordon's functional health patterns, medical record, a satisfaction questionnaire. Data analysis with descriptive, nursing diagnosis, nursing care and outcome. The comparison of nursing diagnosis by evaluate health status using patient assessment concepts. According to Gordon's 11 health pattern to find problems and health needs bring to analyze problems and respond to needs in nursing practice to have quality that covers promotion, prevention, treatment, rehabilitation of health and use nursing process as key success for nursing practice. Since for the time first visit until discharge during the study period significant nursing problem where into 3 phases: preoperative postoperative and discharge planning.

Personal History

Case study 1: Thai female 26 years old 1st visit present with chief complaint abdominal pain 1 week. Pass History of Illness (PHI) 1 week Pre Time-Admit (PTA) abdominal pain at middle line paroxysm. The last of menstruation was 2 weeks ago abnormally present with 2 days and present of blood clot but a normally was 5 days no blood clot glavida3 Para 2 abortion 1 (ectopic pregnancy) Labor 2 last 7 years. Refer to Kalasin hospital on 9 April 2022 1.36 p.m. At ER good conscious mild pale conjunctival, right lower quadrant and left lower quadrant tenderness, no guading v/s was show   BP 114/80 mmHg. PR 68 bpm. RR 20 bpm. BT 37.0 C. UPT positive beta HCG result 53,621 Hematocrit (Hct.) 26.1% U/S was seen empty uterus, rupture left tubal pregnancy free fluid estimate 500 ml. Shock was identified get to manage shock sign then set operation for exploratory laparotomy with left salpingectomy under general anesthesia. In operation room was found left tubal pregnancy with rupture site at fimbria estimate of hemoperitoneum about 300 ml. normal looked of right ovary and fallopian tube, normal looked of left ovary. V/s BP 120/80 mmHg, PR 90 bpm, RR 18 bpm. (On ventilator) and BT 37.0 C. Post operation good conscious no bleeding per surgical wound no complications and sign of shock not found transfer to Gynecology ward for observe. At ward Pt. good conscious V/S was show BT 36.6-37.7 C., PR. 80-92 bpm. RR 20 bpm. BP 104/70-126/72 mmHg., no constipation plan for discharge on 12 April 2022 rang of stay 4 day and appointment 4 weeks at OPD Gynecology.

Case study 2: Thai female 22 years old 1st visit present with abdominal pain 1 day. PHI 1 day PTA abdominal pain generalize with vaginal bleeding no nausea and vomiting not diarrhea normal urine. Gravida 3 Para 1 Abort 1 (ectopic pregnancy) Labor 1 last 2 years. Refer to emergency room (ER) Kalasin hospital on 17 April 2022 12.02 p.m. At ER Pt. alert, abdominal pain with guading generalized tenderness observe vital sign(v/s) was show blood pressure 120/68 mmHg, pulse 86 beat per minute(bpm), respiratory rate (RR) 20 bpm and body temperature (BT) was 36.9, urine preg test (UPT) was positive, urine amphetamine was positive, Hct. was 28.4 % ultrasound was found rupture right tubal pregnancy free fluid in abdomen was positive estimate 500 ml. Shock was identified get to manage shock and set operation exploratory laparotomy with right salpingectomy with removal tubal pregnancy stat. In operation room finding uterus mild enlarged, adhesion between bladder and anterior lower part of uterus, normal both ovaries status post left salpingectomy and right tubal pregnancy estimate size 2x2 cm. with rupture hemoperitoneum (blood clot) estimate 500 ml., in operation vital sign was show BT 36.6  PR. 98-100 bpm. RR 20-22 bpm. (On ventilator) BP. 100/60 mmHg. Post operation good conscious no bleeding per surgical wound no complications sign of shock not found transfer to Gynecology ward for observe. At ward Pt. good conscious V/S BT 36.6-37.3 C PR. 90-102 bpm. RR 18-20 bpm BP100/58-111/62 mmHg, no constipation plan for discharge on 19 April 2022 rang of stay 3 day and follow up 4 weeks at OPD Gynecology.

In other health status was comparative via Gordon's functional health patterns between case study 1 and case study 2 was show on the (Table 1).

Table 1: Comparative Gordon's functional health patterns between case study 1 and case study 2.

The comparative in case study all with normal standard of ectopic pregnancy sign and management was show on table 2.

Table 2: Data comparative and analysis in ectopic pregnancy of 2 case study.

Case studied 1 was a married Thai woman 26 years old G2P0A1L0 last 3 years visit at Kalasin hospital present with abdominal pain Rt. lower quadrant investigate by ultrasound found ectopic pregnancy with rupture Rt. fallopian tube with shock go on fast tract surgery. In case studied 2 was Thai women 25 years old G3P2A0L2 post sterilize visit at Kalasin hospital present with lower abdominal pain left side with vaginal bleeding, urine pregnancy test was positive, ultrasound found ectopic pregnancy in left fallopian tube no rupture go on fast tract surgery on time. Nursing diagnosis obtained from evaluating the patients about the disease via evaluating the physical, spiritual and social aspects, it was found that there were problems that needed to be taken care, so a nursing care plan for both patients was developed and comparative as follows on table 3.

Table 3: Comparative nursing diagnosis, data support and nursing intervention of 2 case study.

In summary from table 3 found that health problem all of 2 cases was similar 1) Hypovolemic shock related to abdominal bleeding evidenced by ultrasound found ectopic pregnancy with rupture Rt. fallopian tube with blood loss 2) Acute pain related to tissue injury from rupture ectopic pregnancy evidenced by grimacing, expression of pain and abdominal guarding. 3. Uncomfortable due to abdominal distension secondary to the operation received. 4. Risk to complication after surgery evidence by post-operative salpingectomy and 5. Risk for Infection related to tissue injury from surgery. In addiction differentiate nursing diagnosis between case study 1 and case study 2 was 1. Anxiety related to stress as evidenced by increased tension, apprehension, and expression of concern regarding upcoming surgery 2. Grieving and loss due to loss of pregnancy evidenced by ectopic pregnancy and rupture fallopian tube that problem was found in case study 1 but case study 2 was none

The nursing outcome found that nursing care had been closely provided via expert nurses based on patient’s conditions to correct the shock. Finally, patient was safe from shock and other mentioned health problems. In addiction differentiate of nursing diagnosis between 1^st and 2^nd case were anxiety case studied 1 was done related illness and operative but case studied 2 none because her experience in two time of caesarians section and own sterilized. Nursing care had been closely provided via expert nurses based on patient’s conditions to correct the shock. Finally, patient was safe from shock and other mentioned health problems.

 Case study 1

 A married Thai woman 26 years old with a report of absence of 2-month period of menstrual visit at Kalasin hospital with lower abdominal pain, faint, good conscious. At Kalasin hospital, shock was worsening progressive treatment was on 0.9% Normal Saline Solution intravenous drip rate 120 ml/hrs. after that a patient’s clinical improved enough to tolerate the fast tract surgery for right partial salpingectomy was performed and found hemoperitoneal 1,000 ml. with ultimately, a patient’s conditions were dramatically recovered.  In summary, the patient’s health problems was 1^st stage pre operated 1) actual hypovolemic shock (deficient fluid volume) due to massive blood loss in the abdomen secondary to ectopic pregnancy, 2) actual ineffective tissue perfusion related to progression of shock with decreased red blood cell to transport oxygen to tissues, 3) risk for fluid and electrolyte imbalance, 4) actual anxiety related to feelings that illness was worsening and is potentially life threatening (patient and significant others), 5) actual pain secondary to tissue injury, 6) actual anemia due to massive blood loss, and 7) actual alter in comfort due to abdominal distension secondary to the operation received. Nursing care had been closely provided based on patient’s conditions to correct the shock. Finally, Patient was safe from shock and those mentioned health problems.

Restrictions

1. It have to short time for study due to limited of case in timing
2. Because fast tract surgery it’s new innovation for surgery so it not clears for some process of system

Suggestions

In Nursing

Just to base on of development of clinical nursing practice guideline in ectopic pregnancy who undergo on fast tract surgery

To developmental

Result expands to other complex disease

To research study

Result expands for any research design

For Utilization

Result expands for setting policy in service in many divisions all of in Thailand and global

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