7/28/2019 Ecto

1/11

Ectopic Pregnancy

An ectopic pregnancy develops as the result of the blastocyst implanting somewhere otherthan in the endometrium of the uterus.

Sites of an ectopic pregnancy are

the fallopian tube,ovary,

cervix,

or abdominal cavityThe majority of ectopic pregnancies (95%) are located in the fallopian tube, with 1% located

on an ovary, less than 1 % on the cervix, and 3% to 4% in the abdominal cavity,

Of all tubal pregnancies, more than half are located in the ampulla, or largest portion of the

tube. The next most common site in the isthmus, or the narrow part of the tube that connects the

interstitial to the ampullar portion. Three percent are located in the interstitial or muscular

portion of the tube adjacent to the uterine cavity. Rarely does the ectopic pregnancy locate in thefimbria or terminal end of the tube. The outcome and gestational length of the ectopic pregnancy

will be influenced by its location in the fallopian tube. Incidence

The incidence of ectopic pregnancy is approximately 1 out of every 60 pregnancies, or 2%

with the number increasing each year worldwide . Women over 35 years old, nonwhites, or those

who have a history of infertility are at a greater risk of experiencing an of ectopic pregnancy.

Etiology

Previous Tubal InfectionsPrevious pelvic infectionscaused by certain sexually transmitted diseases, such as chlamydia

and gonorrhea, postpartum endometritis and postabortal uterine infections can predispose to a

tubal infection. A tubal infection can cause damage to the mucosal surface of the fallopian tube,

causing intraluminal adhesions that interfere with the transportation of the fertilized ovum to theuterine cavity.

Previous Tubal or Pelvic Surgery

During surgery, if blood is allowed to enter the fallopian tubes, tubal adhesions can resultfrom the irritation of the mucosal surface. Salpingectomy, for previous ectopic pregnancy or for

treatment of an inflammatory process, and salpingoplasty, for infertility are the surgeries that

most frequently cause tubal adhesions. Occasionally irritation results from an appendectomy.

Hormonal FactorsAltered estrogen/progesterone levels or inappropriate levels of prostaglandines can interfere

with normal tubal motility of the fertilized ovum.

Contraceptive Failure

Ectopic pregnancies occur with the use of an intrauterine device (IUD) in approximately 2 per1000 users each year. The cause is unknown but may be related to altered tubal motility or a

tubal infection. There is increased risk for an ectopic pregnancy with the progestin-only oral

contraceptive because of the decreased motility - induced effect of progesterone.

Stimulation of OvulationThere is a 3% increased incidence of an ectopic pregnancy associated with ovulation -

stimulating drugs such as human menopausal gonadotropin and clomiphene citrate. These drugs

alter the estrogen/progesterone level, which can affect tubal motility.

7/28/2019 Ecto

2/11

Infertility Treatment

There is an increased risk of an ectopic pregnancy with in vitro fertilization (IVF) or gameteintrafallopian transfer (GIFT) since underlying tubal damage is frequently one of the causativefactors predisposing one to this type of infertility treatment.

Environmental EffectMaternal cigarette smoking at the time of conception was found in a case-controlled study, to

be associated with an increased risk of an ectopic pregnancy.

Transmigration of OvumMigration of the ovum from one ovary to the opposite fallopian tube can occur by an

extrauterine or intrauterine route. This can cause a potential delay in transportation of thefertilized ovum to the uterus. Then trophoblastic tissue is present on the blastocyst before it

reaches the uterine cavity, and therefore the trophoblastic tissue implants itself on the wall of the

fallopian tube.

Endometriosis

The presence of endometrial tissue located outside the uterine cavity increases the receptivity

of the fertilized ovum to an ectopic implantation.Normal Physiology

The fallopian tube is very muscular and narrow and contains very few ciliated cells at theinterstitial area. In the ampullar area the fallopian tube becomes less muscular, the luminal size

increases, and the ciliated cells are more abundant.

The fimbriated end of the fallopian tube has the unique function of moving the ovum andsperm in opposite directions almost simultaneously by peristaltic (muscular contraction) and

ciliated activity. This tubal activity is initiated by two or more adjacent pacemakers in the

ampullar and isthmic areas of the fallopian tube by sending out myoelectrical activity is in either

direction. The net directional movement in the fallopian tubes will vary during the menstrualcycle. During menstruation the net directional force is toward the uterus starting from the

ampullar area to prevent menstrual blood reflux into the tube. This is stimulated primarily byestrogen induced prostglandins. Just before ovulation, the directional force from the ampullararea is inward in order to pick the released ovum from the ovary and moved it into the ampullar

area of the fallopian tube. At the same time the directional force from the uterine area is just the

opposite in order to facilitate sperm motility toward the ovum. This is influenced by estrogen

primarily. After fertilization the directional force varies in the ampullar area, which delays ovumtransport. Approximately 5 days after ovulation, the net directional force from the middle of the

ampullar area is inward through the isthmus in order to transport the ovum to the uterus. This is

influenced by increasing progesterone and prostaglandin E2 (PGE).Approximately 7 days afterovulation, the myoelectrical activity become variable again, moving in both directions from each

of the pacemakers.

The fertilized ovum should reach the uterine cavity in 6 to 7 days, just about the time thetrophoblast cells begin to secrete the proteolytic enzyme and start to develop the threadlikeprojections calledchorionic villi that initiate the implantation process.

The uterus is normally prepared by estrogen and progesterone to accept the fertilized ovum,

now called a blastocyst. As the chorionic vill iinvade the endometrium, the villi are held incheck by a fibrinoid zone. The uterus is also supplied with an increased blood supply capable of

nourishing the products of conception.

7/28/2019 Ecto

3/11

PathophysiologyTubal Ectopic Pregnancy

Because most ectopic pregnancies initially implant in a fallopian tube, the pathophysiologywill focus on tubal ectopic pregnancies. The blastocyst burrows into the epithelium of the tubal

wall, tapping blood vessels, by the same process as normal implantation into the uterine

endometrium. However, the environment of the tube is quite different because of the followingfactors:

1. There is a decreased resistance to the invading trophoblastic tissue by the fallopian tube.

2. There is a decreased muscle mass lining the fallopian tubes; therefore their dispensability

3. The blood pressure is much higher in the tubal arteries than in the uterine arteries is

greatly limited.

4. There is limited decidual reaction; therefore human chorionic gonadotropin (hCG) is

decreased and the signs and symptoms of pregnancy are limited.

It is because of these characteristic factors the termination of a tubal pregnancy occurs

gestationally early by an abortion, spontaneous regression, or rupture, depending on the

gestational age and the location of the implantation. If the embryo dies early in gestation,

spontaneous regression often occurs. If spontaneous regression fails to occur, then usually anampullar or fimbriated tubal pregnancy ends in an abortion and an isthmic or interstitial

pregnancy ends in a rupture

A tubal abortionprimarily occurs because of separation of all or part of the placenta. Thisseparation is caused by the pressure exerted by the tapped blood vessels or tubal contractions.

With complete separation, The products of conception are expelled into the abdominal cavity

by way of the fimbriated end of the fallopian tube

With an incomplete separation, bleeding continues until complete separation takes place, and

the blood flows into the abdominal cavity collecting in the rectouterine cul-de-sac of Douglas.

Tubal ruptureresults from the uninterrupted invasion of the trophoblastic tissue or tearing of

the extremely stretched tissue. In either case the products of conception are completely or

incompletely expelled into the abdominal cavity or between the folds of the broad ligaments byway of the torn tube.

The duration of the tubal pregnancy depends on the location of the implanted embryo or fetusand the distensibility of that part of the fallopian tube. For instance, if the implantation is located

in the narrow isthmic portion of the tube, it will rupture very early, within 6 to 8 weeks; the

distensible interstitial portion may be able to retain the pregnancy up to 14 weeks of gestation.

Abdominal Ectopic PregnancyAn abdominal pregnancy almost always results from an implantation secondary to a tubal

rupture or abortion through the fimbriated end of the fallopian tube. In these cases the placental

continues to grow following attachment to some abdominal structure, usually the surface of the

uterus, broad ligaments, or ovaries. However, it can be any abdominal structure including the

liver, spleen, or intestines. Because the invading trophoblastic tissue is not held in check, it canerode major blood vessels at any because they are not cushioned by the myometrium.

Cervical Ectopic Pregnancy

In very rare cases the fertilized ovum bypasses the uterine endometrium and implants itself inthe cervical mucus. Painless bleeding begins shortly after implantation, and surgical termination

is usually required before the fourteenth week of gestation.

7/28/2019 Ecto

4/11

Signs and Symptoms

Before Rupture Abdominal Pain

Abdominal pain occurs close to 100% of the time. It is usually first manifested by a dull pain

caused by tubal stretching following by a sharp colicky tubal pain caused by further tubalstretching and stimulated contractions. It is diffuse and is bilateral or unilateral.

Amenorrhea

A history of a late period for approximately 2 weeks or a higher than usual or irregular period

is reported by 75 % to 90 % of the patients

Abnormal Vaginal Bleeding

Mild to intermittent dark red or brown vaginal discharge occurs in 50 % to *0 % of the cases

related to uterine decidual shedding secondary to decreased hormones.

Absence of Common Signs of pregnancy

Absence of common signs of pregnancy is secondary to decreased pregnancy hormones andoccurs 75 % of the time.

Abdominal TendernessAbdominal Tenderness occurs in approximately 95 % of the cases.

Palpable Pelvi c Mass

Referred Shoulder Pain approximately 50 % of the cases. It may be in the opposite abdominal

quadrant from the ectopic growth related to a corpus luteum cyst.

RuptureExacerbation of the pain occurs during rupture in an ectopic pregnancy.

After Rupture

Fain tness / Dizziness

Faintness and dizziness occur in the presence of significant bleeding

Generalized, Unilateral, or Deep Lower Quadrant Acute

Abdominal Pain

Pain is caused by blood irritating the peritoneum

Referred Shoulder Pain

Referred shoulder pain

is related to diaphragmatic irritation from blood in the peritoneal cavity

Signs of Shock

Shock is related to the severity of the bleeding into the abdomen.

Maternal Effects Ectopic pregnancies account for approximately 10% of all maternal deaths.

They are the fourth leading cause of maternal mortality, but they are the number onecause of maternal mortality in the first trimester of pregnancy.

Hemorrhage is the cause of death in 85 % to 89 % of the cases and occurs more frequently

with an interstitial or abdominal ectopic pregnancy.

The greater risk of mortality related to an ectopic pregnancy is associated with anabdominal ectopic growth, which has a 7.7 times greater risk when compared to other

types of ectopic pregnancies.

7/28/2019 Ecto

5/11

Fetal and Neonatal EffectsDeath is almost certain for the fetus in an ectopic pregnancy. From 5 % to 25 % of abdominal

ectopic pregnancies will reach viability. However, it is not recommended to continue anabdominal pregnancy if diagnosed early because of the extreme risk of hemorrhage at any time

during the pregnancy. The risk of fetal deformity is also high; 20 % to 40 % of the fetuses that

live beyond 20 weeks of gestation will have such deformities as facial asymmetry, severe neckwebbing, joint deformities, and hypoplastic limbs These are pressure deformities caused by

oligohydramnios.

Medical DiagnosisEarly diagnosis before extrauterine rupture or abortion can decrease maternal mortality from

hemorrhage and simplify the management of an ectopic pregnancy.

Pregnancy TestsBecause of the lower levels of hCG being secreted by an ectopic implanted placenta related

to poor vascularization, the pregnancy test must be highly sensitive for beta-human chorionic

gonadotropin (beta- hCG) to confirm a if an ectopic pregnancy is suspected.

The most common urine pregnancy tests such as the latex agglutination inhibition slide testare only 50 % to 60 % accurate in confirming a pregnancy that is ectopic

Radioimmunoassay tests are able to detect minute amounts of hCG (5 to 10 mIU/mI) and

have proven to be almost 100 % accurate in detecting an ectopic pregnancy. However, they take

several hours to run.

The new monoclonal antibody pregnancy tests such as

the enzyme-linked immunosorbent assay (ELISA) and

the immunofluorometric assay (IFMA) are specific for the beta-hCG submit andtherefore are 95 % to 99 % accurate. It takes only minutes to run these tests.

UltrasoundThe usefulness of ultrasound in the diagnosis of an ectopic pregnancy is improving

continuously.

With the more sophisticated real-time equipment and an expert technician, characteristicchanges of an ectopic pregnancy can be picked up with pelvic ultrasound.

With transvaginal ultrasound, the location of the gestational sac of an early ectopicpregnancy can be visualized with 82 % to 84 % accuracy

Therefore transvaginal ultrasound is becoming an important diagnostic tool in an ectopicpregnancy before rupture because the probe can be placed closer to the pelvic structures.

CuldocentesisCuldocentesis can be used to diagnose intraperitoneal bleeding if a rupture ectopic pregnancy

is suspected.

The procedure involves passing a needle through the cul-de-sac of Douglas to aspirate fluidfrom the peritoneal cavity.

LaparoscopyIf any question remains, an endoscope may be inserted through a small abdominal incision to

visualize the peritoneal cavity for an ectopic implanted pregnancy

7/28/2019 Ecto

6/11

Medical treatment

Tubal Ectopic Pregnancy Before Rupture

Surgical treatment

The type of surgical management depends on the location depends on the location and

cause of the ectopic pregnancy,

the extent of tissue involvement, and the patients wishes for future fertility.

The choice of treatment for an unruptured ampullar or fimbriated tubal pregnancy is a

salpingostomy, in which a longitudinal incision is made over the pregnancy site and the productsof conception are gently removed, being very careful to prevent or control the bleeding.

Segmental resection and subsequent end-to-end anastomosis after the swelling and infection

have subside may be necessary if the ectopic pregnancy was located in the proximal isthmus

portion of the tube.

Nonsurgical TreatmentA methotrexate type of chemotherapy has been successfully used as an alternative to surgery.

Provided there are no signs of bleeding, a dose of 1 ml/kg can be given intramuscularly everyother day for 4 days. In clinical studies a single dose of 12.5mg has been proven effective when

locally injected into the ectopic site. This cytotoxic drug causes dissolution of the ectopic mass.

Tubal ectopic pregnancy After RuptureFollowing a ruptured tubal pregnancy, a salpingectomy (removal of the affected fallopian

tube) is the most common surgical treatment. Occasionally a salpingooophorectomy (removal of

the affected fallopian tube and adjacent ovary) is performed if the blood supply to the ovary isaffected or the ectopic pregnancy involved the ovary. Otherwise, preservation of the ovary is

recommended. If the couple does not wish to have more children, then a hysterectomy may bedone if the womans condition is stable.

Abdominal Ectopic PregnancyFor an abdominal pregnancy, hemorrhage is a serious possibility because the placenta can

separate from its attachment site at any time.

Abdominal surgery to remove the embryo or fetus is usually done as soon as an abdominalpregnancy is diagnosed. Unless the placenta is attached to abdominal structures that can be

removed, such as the ovary or exterior of the uterus, or the blood vessels that supply blood the

placenta can be ligated, the placenta is left without being disturbed.

If the placenta is removed, large blood vessels would be opened and there would not be aconstricting muscle such as the uterus to apply a sealing pressure. If left intact, the placenta is

usually absorbed by the body, but unfortunately it may cause such complications as infection,

abscesses, adhesions, intestinal obstruction, paralytic ileus, postpartum preeclampsia, and wounddehiscence. These complications are less threatening than the hemorrhage that could result, if

removed.

Cervical Ectopic PregnancyIn the case of a cervical pregnancy, the risk of hemorrhage is great as any other type of

ectopic pregnancy.

7/28/2019 Ecto

7/11

A vaginal delivery should be attempted if the gestational age is less than 12 weeks and the

couple desires to have more children. The cervical branch of the uterine artery is ligated and the

cervix is then packed or a Foley catheter balloon inflated in an attempt to curtail the bleedingfrom opened blood vessels after the removal of the placenta.

If this does not stop the bleeding, amputation of the cervix or a hysterectomy must be done.

If the couple does not wish to have any more children, an abdominal hysterectomy isgenerally the method of treatment.

Nursing Process

PreventionBecause an ectopic pregnancy is closely associated with a previous pelvic infection

education regarding the importance of treating a vaginal or pelvic infection early would also

decrease the incidence.

Since there is a correlation between cigarette smoking and an increased risk of an ectopicpregnancy, women during their childbearing years should be encouraged to avoid smoking.

If an elective abortion is desired it should always be carried out only by medically prepared

professionals.These measures can decreased the chance of tubal defects and thereby decrease the incidence

of an ectopic pregnancy.

Because of the increasing incidence of ectopic pregnancy, health professionals should

consider the possibility in any woman who presents with any type of abdominal discomfortduring her childbearing years.

AssessmentBecause of the high maternal mortality associated with an undiagnosed ectopic pregnancy

until after rupture or tubal abortion, it is very important for nurses to be alert to signs and

symptoms of this complication of pregnancy.

Therefore any woman during her childbearing years who experiences irregular vaginal

spotting associated with a dull, aching pelvic pain, with or without signs of pregnancy, should beevaluated for a possible ectopic pregnancy.

Risk FactorsA history of any pelvic inflammatory disease,

previous ectopic pregnancies,

elective abortions,

or prior infertility disorders should be determined; they can increase the patients risk for atubal defect.

PainIf an ectopic pregnancy is suspected, a detailed history should include questions regarding the

type of abdominal pain. The pain caused by an unruptured ectopic pregnancy can be a unilateral,cramplike pain related to tubal distension by the enlarging embryo or fetus.

At the time of tubal rupture many patients experience a sudden, sharp, stabbing pain in the

lower abdomen.

Vaginal Bleeding

Assess for the presence of vaginal bleeding, and obtain a menstrual history. Vaginal bleeding

is usually related to the sloughing of the endometrial lining related to decreasing progesterone

and estrogen levels and can present as continuous or intermittent vaginal bleeding in small or

7/28/2019 Ecto

8/11

large quantities. It is usually different from the patients normal period. Pad Counts should be

kept to determine the amount and type of vaginal bleeding.

SyncopeAssess for the presence of any signs of syncope.

When an ectopic pregnancy ruptures or aborts, blood is lost into the peritoneal cavity. At this

time the patient can experience a feeling of faintness or weakness related to hypovolemia. If thebleeding is not continuous, the depleted blood volume is restored to near normal in 1 or 2 days

by hemodilution and the faint or week feeling subsides. If the bleeding is profuse, the patient can

go into should quickly.

Vital signs

To assess the amount of intraperitoneal blood loss, the patients vital signs should b e checked

as frequently as the situation indicates.

Nursing Diagnosis/Collaborative Problems and Interventions

Fear related risk of mortality and possible treatment alternatives.

Desired Outcome: The patient and her family will be able to communicate their fears and

concerns openly.Interventions1. Assess familys anxiety over maternal well-being because of 10 times greater risk of

mortality as compared to normal childbirth.

2. Assess familys level of guilt such as their feeling as to what they did to cause this happen.

3. Assess familys coping strategies and resources.

4. Explain all treatment modalities and reasons for each in understandable terms.

5. Prepare patient for transvaginal ultrasound, if this diagnostic procedure is ordered, by having

patient empty her bladder before the procedure.

6. Prepare patient for a culdocentesis, if this diagnostic procedure is ordered, by explaining the

procedure.

(A sterile speculum is inserted into the vagina, the cervix is steadied with a tenaculum, anda 16- to 18- gauge needle is inserted into the cul-de-sac so any fluid that is present can be

aspirated for evaluation.)

Position patient in a semi-Fowlers position to allow any intraperitoneal blood, if present, to

pool in cul-de-sac.

Just before the procedure prepare the external genitalia with povidone-iodine (Betadine).

7. Prepare the patient for the medical procedure.

Pain related to

stretching of the tube,

severe abdominal bleeding secondary to tubal rupture,

or surgical treatment.

Desired Outcome: the patient will verbally and nonverbally express reasonable comfort.

Interventions1. Assess the type and location of pain.

2. Maintain position of comfort.

3. Limit movement, and support patient.

4. Provide reassurance.

7/28/2019 Ecto

9/11

5. Instruct regarding the use of relaxation and breathing techniques to reduce pain if medication

cannot be administered.

6. Administer pain medication as ordered if needed.

7. Notify physician regarding any change in the amount or type of pain the patient experiences.

Potential Complication: Hemorrhage caused by ectopic rupture/abortion or surgical

treatment.Desired Outcome: The signs and symptoms of hemorrhage will be minimized/managed asmeasured by

stable vital signs,

urinary output of 30 ml/hr or greater,

absence of signs of shock, and

hematocrit maintained between 30 % and 45 %.

Preoperative Interventions1. Check vital signs as indicated (depending on severity).

2. Check amount of vaginal bleeding.

3. Check for signs of shock such as tachycardia, drop in blood pressure, and cool clammy skin.

(During pregnancy, signs of shock are not manifested until there has been at least a 40 %blood volume loss.

4. Check state of mental acuity/level of consciousness.

5. Keep an accurate record of intake and output.

Urinary output during pregnancy is the best noninvasive indicator of circulatory volume.

Diminished cardiac output causes a shunting of blood away from the skin, kidneys, and

skeletal muscles in order to ensure blood delivery to heart and brain.

6. Start an intravenous infusion with an 18-gauge intracatheter and maintain as ordered.

Fluid replacement may reverse impending shock by increasing capillary blood flow andthereby cardiac output increases. (Normal saline or Ringer

7. Obtain blood as ordered for

a complete blood count,

prothrombin time,

partial thromboplastin time,

Rh antibody screen, and

type and cross match for 2 to 4 units of blood.

8. Administer oxygen at 8 to 10 L by mask as needed.

9. Carry out such preoperative protocol as giving the patient

nothing by mouth,

giving no enemas or cathartics since they could stimulate a tubal ectopic pregnancy to

rupture,

being prepared to insert a Foley catheter as ordered, and

get the permit signed for surgery.

10.Notify the attending physician of any changes in

vital signs,

decreasing urinary output,

blood pressure that falls 10 mmHg or more, or

a change in mental acuity.

7/28/2019 Ecto

10/11

11. If the patient presents in shock, be prepared to assist with central line placement. The internal

jugular and subclavian veins are less likely to collapsed.

12. Be prepared to administer blood replacement therapy if

the hemoglobin level is below 7 g/dl or

the patient is manifested signs of shock.

Postoperative Interventions1. Check blood pressure, pulse, and respiration

every 15 minutes, eight times;

every 30 minutes two times;

every hour, two times;

every 4 hours, two times; and then routinely.

2. Assess vaginal bleeding by pad count.

3. Check dressing

every hour four times and then

every shift for bleeding4. Refer to laboratory work, such as hemoglobin and hematocrit.

5. Keep an accurate intake and output records.

6. Assess for cyanosis.

7. Reinforce or change dressing as needed.

8. Carefully administer IV fluids as ordered.

9. Once the gastrointestinal tract resumes normal function, instruct regarding the importance of

a high protein,

high-iron diet for body repair and replacement of blood loss.

10.Notify physician if

blood pressure drops to less than 90 systolic,

pulse rises to greater than 120 bpm, or

anemia develops.

High Risk For Infection related to blood being an ideal medium for bacterial growth.Desired Outcome:The patients temperature will remain normal, incision will approximatewithout redness or drainage, vaginal discharge will be without odor, and the white blood cell

count will remain less than 16,000/mm3.

I nterventions

1. Check temperature every 4 hours.

2. Refer to laboratory work, such as white blood cell count.

3. Check incision for redness, swelling, and drainage every shift.

4. Administer prophylactic antibiotics as ordered.

5. Notify the physician if the temperature increases or any signs of infection develop.

Anticipatory Grieving related to loss of an anticipated infant and possible threat to fertility.Desired Outcome: The patient and family members will verbalize their feelings of griefappropriately and identify any problems as they work through the grief process.

Interventions

1. Assess level of loss and desire for future childbearing.

2. Encourage the patient and family the chances of recurrence (12 % to 18 % risk and infertility

problems 50 %.

7/28/2019 Ecto

11/11

3. Teach the couple the importance of using a contraceptive of choice for at least three

menstrual cycles to allow time for the womans body to recover.

Other potential postoperative complications paralytic ileus,

urinary tract infection, pneumonia,

anemia, pulmonary edema,

Rh sensitization,

persistent ectopic pregnancy, or

adhesions.

Desired Outcome: Postoperative complications will be minimized/ managed as measured byno burning on urination, hematocrit maintained between 30% and 45%, breath sounds clear,bowel sounds active, abdomen soft, and beta-hCG levels drop to zero in 2 weeks postoperatively.

Interventions1. Assess for burning on urination.

2. Auscultate lung fields every shift for rales, and observe for coughing or dyspnea.

3. Auscultate bowel sounds every shift.

4. Assess for passage of flatus.

5. Palpate abdomen for hardness and boardlikeness.

6. Have patient turn, cough, and deep breath every 2 hours.

7. Give patient nothing by mouth until bowel sounds are present. Then advance to soft orregular diet.

8. Have patient do leg exercises every hour while awake until ambulating well.

9. Have patient do abdominal tightening every hour while awake until normal gastrointestinal

activity returns.

10. Encourage and assist with ambulation as soon as ordered

11.