Ms. Martinez is a 26 year old Hispanic female who arrived at the county jail a week ago. The Intake Screening was conducted within 2 hours of her arrival. At that time, she disclosed a history of Gastro-Esophageal Reflux. She denied substance use, except for an occasional alcoholic drink (tequila). She reported that she has had no surgeries or other chronic illnesses. Her last period was approximately three months ago: when questioned further, she stated that she “guessed” that she could be pregnant, but wasn’t really thinking about that prior to getting arrested. A urine pregnancy test was done and was positive, and she was scheduled for the provider’s next clinic day. She was placed on prenatal vitamins, a pregnancy diet, and given a profile for a low bunk per the Nursing Assessment Protocols at the facility. This is her first pregnancy, and told the Intake nurse that she would need some time to “process it all.”
Three Days Ago
Three days ago, Ms. Martinez was seen by the provider, who obtained a more detailed sexual history, to include multiple sexually transmitted infections over the last five years. She has always gotten treated at the Health Department when she experienced symptoms. Her periods are regular, about every 26 days and she has had no “female” problems. Once she was told that she needed a test where the nurse practitioner was going to take “skin from inside of her vagina” because she had something called HPV, but never went to get the test because “nothing was bothering her.” When she saw the provider, Ms. Martinez verbalized excitement about having a baby. Her estimated date of confinement (edc) was calculated based upon her last period, and indicated that she was roughly 10 weeks pregnant. The physical assessment by the provider was unremarkable, and Ms. Martinez was referred to the OB-Gyn group used by the jail for routine pre-natal care. Ms. Martinez was also scheduled for a nursing appointment for pregnancy patient education.
Yesterday Ms. Martinez as seen in Nursing Clinic for her pregnancy patient education. During that encounter, Ms. Martinez stated that she was feeling nauseous and had a few painful “twinges” to her left lower abdominal area. The nurse informed Ms. Martinez that these are both common symptoms in early pregnancy, and are no cause for concern unless they intensify. Ms. Martinez completed her first pregnancy patient education session and returns to her unit, even more excited about her pregnancy.
Later Yesterday Evening
Later that evening, Ms. Martinez complained to the deputy that her nausea was worse, and the pain that was described as intermittent twinges earlier was now constant, and she was concerned about the baby. The deputy called to the clinic, and the nurse on duty instructed the officer to send Ms. Martinez down. Ms. Martinez was seen by the nurse, who documented the following vital signs: blood pressure 128/82; pulse 98 beats per minute; respirations of 18 breaths per minute; temperature 99.1℉; and oxygen saturation level 98% on room air. Ms. Martinez’s heart and lungs were unremarkable, and the abdominal evaluation indicated pain (4-6 on a 1-10 scale) with palpation to left lower quadrant, with normo-active bowel sounds auscultated in all four quadrants. What else should the nurse have done?
The nurse evaluating Ms. Martinez informed her that everything was fine, and said that the pain that she was feeling was probably due to ligaments stretching, and the nausea was normal for an approximately 10 week pregnant woman. Ms. Martinez was comforted by these findings, and she returned to her unit. The nurse planned on scheduling a follow-up appointment for Ms. Martinez in Nurse Sick Call the next day, but she became busy with another patient and did not do it.
Today you are the 7 pm to 7 am nurse who is coming back to the facility after a week of vacation. At approximately 2200 hours, you received a call from the officer in Ms. Martinez’s unit stating that Ms. Martinez was complaining of abdominal pain and that she just found out she was pregnant. You tell the officer to send her to the clinic, and a half hour later, Ms. Martinez is brought via wheelchair, crying and doubled-over. Ms. Martinez tells you the history of her pregnancy (finding out just days ago when she was admitted to the facility; last menstrual period approximately 12 weeks ago; and this is her first pregnancy). She also tells you that she has been nauseous and with “intermittent” twinge-type pain that really increased in intensity yesterday, and tonight is probably three times what it was yesterday. She is also complaining of left shoulder pain. She discloses that when she went to the bathroom right before she spoke to the officer, there was blood “spots” on the tissue. She is crying and fears that she is losing the baby. You obtain vital signs that include the following: blood pressure 100/66; pulse of 128 beats per minute; temperature 100.3℉; respirations 22 breaths per minute; and an oxygen saturation level of 98% on room air. On examination, Ms. Martinez has exquisite tenderness in her left lower quadrant and pelvic area.
What Do You Do?
You identify that Ms. Martinez’s condition is deteriorating, and activate emergency services to send Ms. Martinez to the emergency department for the diagnostics and treatment her serious condition requires. You contact the provider on call and initiate the intravenous fluids ordered and continue monitoring her vital signs every 5 minutes until the EMS arrives. You explain to Ms. Martinez that she is going to the emergency department to check her pregnancy, and testing will be done to help her. EMS arrives and Ms. Martinez is seen in the emergency department, where a left tubal pregnancy is diagnosed. She undergoes surgery for its removal immediately.
When Ms. Martinez returns to the facility three days later, you see her as a “return from the hospital encounter.” Her vital signs are the following: blood pressure 128/76; pulse 74 beats per minute; temperature 98.6 ℉; respirations 16 breaths per minute; oxygen saturation of 98% on room air. Ms. Martinez’s physical evaluation was unremarkable except for a stapled incision in the lower left abdominal quadrant. The wound is clean and dry. Ms. Martinez is scheduled for a follow-up tomorrow with the provider and for daily wound care. You also educate her about the mental health services available on-site, and at her request, you schedule her to be seen by the Mental Health counselor at her next clinic.
For more information about Pregnancy, go to CorrectionalNurse.Net where the October monthly posts are about Pregnancy. Also check out The Correctional Nurse Educator accredited class entitled, Abdominal Assessment : Lower Abdominal Pain for the Correctional Nurse for more information about ectopic pregnancy.
Please share the experiences you have had in your practice with patients presenting with Ectopic Pregnancy in our comments section, below.
*As always, your company or facility policies, procedures and Nursing Protocols/Guidelines take precedence over any written recommendations on this website.