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Hyperemesis Gravidarum Case Study, Assessment and Nursing Care Plan

Sunday, 21 September 2014

Hyperemesis gravidarum is severe and unremitting nausea or vomiting associated with pregnancy that can persist past the first trimester. In contrast, morning sickness is transient nausea or vomiting that generally occurs during only the first trimester. Women with multiple gestations, family history of the disorder, transient hyperthyroidism, or abnormally elevated human chorionic gonadotropin levels are at increased risk for hyperemesis gravidarum. The prognosis for mother and fetus is usually good when treatment is initiated before significant complications develop and the woman can gain more than 7 lb (3.2 kg) throughout the pregnancy.

Hyperemesis Gravidarum Case Study, Assessment and Nursing Care Plan
Pathophysiology

The exact cause of hyperemesis gravidarum is unknown, but it's linked to trophoblastic activity and gonadotropin production, which may indicate multiple gestation or molar pregnancy. It can be prolonged or exacerbated by vitamin B1 or B6 deficiencies.

Complications


■ Dehydration
■ Wernicke's encephalopathy from vitamin B1 deficiency
■ Mallory-Weiss tears (esophageal tears and bleeding)
■ Esophageal bleeding
■ Pneumothorax
■ Acute tubular necrosis
■ Electrolyte and acid‑base imbalances

Assessment
Nursing History by functional health pattern


Nutrition and metabolism
■ Sour taste in mouth
■ Sensation of thirst
■ Anorexia
■ Severe, persistent nausea and vomiting despite nonmedicinal treatments

Physical Examination

Integumentary
■ Pale, dry skin with decreased turgor
■ Dry mucous membranes and lips
■ Sunken eyes
■ Jaundice

Cardiovascular
■ Tachycardia
■ Hypotension
■ Vertigo
■ Syncope

Gastrointestinal
■ Fruity breath
■ Severe nausea
■ Marked emesis
■ Mucosal bleeding
■ Ptyalism (drooling associated with excess saliva production)
■ Weight aberration (failure to gain weight or actual weight loss)

Neurologic
■ Low‑grade fever
■ Lethargy
■ Confusion
■ Somnolence
■ Polyneuritis or peripheral neuropathy

Renal and urinary
■ Oliguria
■ Ketonuria

Diagnostic studies

■ Potassium, sodium, chloride, and protein levels are decreased due to losses from vomiting.
■ Blood urea nitrogen, nonprotein nitrogen, and uric acid levels are increased due to renal compromise and hemoconcentration.
■ Hemoglobin (Hb) level and hematocrit (HCT) are increased due to hemoconcentration.
■ Urinalysis reveals ketones and, possibly, protein; urine specific gravity increases.
■ Vitamin B1 and B6 levels are decreased due to impaired intake.
■ Thyroid-stimulating hormone, thyroxine, and triiodothyronine levels may be mildly increased.

Nursing care plan

Nursing diagnosis
Nursing priorities

Imbalanced nutrition: Less than body requirements related to nausea, emesis, and subsequent inconsistent or insufficient food intake
     Monitor the patient for effects of nausea and vomiting that are unresponsive to nonmedical treatment, and initiate treatment before severe complications can occur.

Deficient fluid volume related to protracted emesis
     Observe for signs of dehydration and provide replacement fluids and electrolytes as needed.

Fear related to hospitalization and pregnancy outcome
     Provide the patient with information to fight fears and offer support.

Acute pain related to repeated episodes of vomiting
     Prevent vomiting when possible, or decrease the frequency and severity of episodes.


Other potential nursing diagnoses: Constipation related to inadequate food intake Impaired home maintenance related to debilitating emesis Disturbed sensory perception (gustatory) related to persistent emesis




Imbalanced nutrition: Less than body requirements related to nausea, emesis, and subsequent inconsistent or insufficient food intake

Expected outcome

The patient will respond to measures to decrease nausea and vomiting and will resume a healthy diet, yielding a positive weight gain.

Suggested NOC Outcomes

Nausea & vomiting severity; Nutritional status: Food & fluid intake; Nutritional status: Nutrient intake; Sensory function: Taste & smell; Symptom control

Nursing interventions

Intervention type
Intervention
Rationale
Independent
Weigh the patient at each prenatal clinic visit; if she's hospitalized, weigh her daily. Use the same scale, weigh her at same time of day, and make sure she's wearing the same type of clothing. Note patterns of weight gain.
Consistency ensures accurate measurements and minimizes diurnal variation. A total gain of 25 to 35 lb (11.3 to 15.9 kg) is optimal for fetal growth and maternal changes. The patient should gain from 2 to 4 lb (1 to 1.8 kg) during the first trimester and about 1 lb (0.5 kg) per week for the remainder of the pregnancy.
Independent
Monitor the patient's intake by asking her to recall her diet over the past 24 hours.
A 24-hour diet recall provides a database for assessment.
Independent
Assess the patient for edema, noting tight or constrictive shoes, reports of feeling bloated, and benign, dependent leg edema.
Edema may mask a true failure to gain weight. Weight gain should reflect maternal and fetal growth, not retained excess fluid.
Collaborative
Assess for ketones in urine.

Ketonuria is a sign that stored reserves are being used for fetal growth and is associated with fetal brain damage.
Independent
Monitor the patient for morning sickness during the first trimester.

Morning sickness may result from hormonal changes, maternal hypoglycemia, and decreased gastric motility as well as from fatigue, emotional factors, and cultural expectations.
Independent
Provide nonmedical methods to minimize symptoms, including a high‑protein bedtime snack; dry carbohydrates 30 minutes before rising; a delay in mealtime until nausea has subsided, but no skipping of meals; no fluids with meals; no greasy, spicy, gas‑forming foods or foods that have a strong aroma; frequent small meals rather than three large ones; no periods of more than 12 hours without eating; and acupuncture or acupressure of point P6.
Palliative treatment focuses on minimizing stressors and maternal hypoglycemia and dehydration or impaired nutritional intake. Traditional Chinese medicine recommends that stimulation of the P6 site via acupuncture or acupressure relieves symptoms. Special bands can be purchased over the counter to provide pressure on the recommended site. This treatment may be used alone or with Western medical treatments.

Collaborative
Teach the patient to use all prescription and over‑the‑counter drugs with caution, not exceeding the practitioner's orders. Inform the patient of medication effects and adverse effects on her fetus and herself.
Certain vitamin deficiencies are associated with nausea and vomiting. The Food and Drug Administration hasn't specifically approved an antiemetic or other regimen for use in pregnancy. Thorough teaching is required so the patient can make informed decisions about recommended drug therapy and know how to safely use prescribed drugs.
Independent
Assess emesis If excessive vomiting occurs and the patient requires hospitalization. Note its onset, frequency, and duration; the time of day it occurs; its relation to intake; and precipitating and alleviating factors. For each occurrence, also note the color, amount, and consistency of the vomitus and the presence of undigested food, mucus, blood, or bile.
Vomiting can result in loss of acidic gastric contents or lower GI alkaline products. Proper assessment is essential to reverse developing acid‑base and electrolyte imbalances.

Independent
Assess the patient's abdomen every 2 hours or as her condition warrants, including size, contour, and bowel sounds, and note pain, tenderness, and guarding. Also assess her vital signs.
Accurate assessment can help diagnose various disorders that cause vomiting, including liver disease, kidney infection, pancreatitis, GI obstruction or lesions, drug toxicity, and intracranial lesions.
Collaborative
Obtain and monitor serum chemistries, complete blood count, and thyroid panel, as ordered.
Abnormalities may reflect the adverse effects of prolonged vomiting such as dehydration.
Collaborative
Administer peripheral parenteral nutrition (PPN) through a peripherally inserted central catheter (PICC), as ordered.

When needed, PPN allows the GI tract to rest while the patient receives adequate nutrition. Inserting a PICC is less invasive than inserting a central line, and administering PPN through a PICC poses less risk of such complications as sepsis and clots. PICCs can also be managed in the home, which may be more comfortable for the patient.
Independent
Weigh the patient daily, if hospitalized, or at each visit. Using the same scale, weigh her at the same time of day, making sure she's wearing the same type of clothing. Note patterns of weight gain.
A consistent weighing protocol ensures adequate measurement and minimizes diurnal variation.


[Additional individualized interventions]


Suggested NIC Interventions
Intravenous therapy; Medication management; Nutritional monitoring; Nutrition management; Nutrition therapy; Teaching: Individual; Total parenteral nutrition administration

Deficient fluid volume related to protracted emesis

Expected outcome

The patient will return to and maintain a normovolemic state, have fewer episodes of vomiting, and maintain optimal nutrition.

Suggested NOC Outcomes

Electrolyte & acid/base balance; Fluid balance; Hydration

Nursing interventions

Intervention type
Intervention
Rationale
Independent
Monitor the patient for signs and symptoms of fluid volume deficit, including dry skin with poor turgor, dry mucous membranes, sunken eyes, concentrated urine and oliguria, malaise, hypotension, vertigo, and syncope.
Deficient fluid volume interferes with homeostatic mechanisms and threatens maternal and fetal well‑being.

Collaborative


Monitor Hb level and HCT, as ordered.

Increased Hb level and HCT may indicate hemoconcentration, or decreases may be seen if GI bleeding occurs due to the trauma of severe vomiting.
Collaborative
Monitor serum electrolytes and renal function tests, as ordered.
Abnormalities may occur with marked dehydration from lack of fluid intake plus losses through vomiting.
Collaborative
Restrict all oral intake for 24 to 48 hours.

Restriction allows the patient's stomach to rest and irritated gastric mucosa to heal.
Collaborative
Administer a balanced I.V. solution that contains electrolytes, glucose, and vitamins.

This solution helps to reverse fluid deficits and corrects acid‑base imbalances, altered electrolyte levels, and hypovitaminosis.
Collaborative
Permit the patient to progress to a normal diet after she hasn't vomited for 24 hours. If she starts vomiting after any of the following steps, revert to the previous step.
Begin with clear fluids (an electrolyte solution, not plain water), not to exceed 100 ml, alternated every 1 to 2 hours with dry toast or crackers. Next, progress to a soft diet. Finally, progress to a regular diet; all portions should be small (six or seven meals per day).
Careful and slow introduction of food is usually effective.

Collaborative
Administer blood products, as ordered.
Blood products are rarely required unless an esophageal rupture or a tear occurs.

[Additional individualized interventions]


Suggested NIC Interventions

Bleeding reduction: Gastrointestinal; Electrolyte monitoring; Fluid & electrolyte management; Surveillance; Vital signs monitoring

Fear related to hospitalization and pregnancy outcome

Expected outcome

The patient will express less fear for her health and that of her baby.

Suggested NOC Outcomes

Anxiety self-control; Fear level; Health beliefs: Perceived threat

Nursing interventions

Intervention type
Intervention
Rationale
Independent
Accept the patient's verbal and nonverbal responses to illness.
Acceptance promotes communication and trust.
Independent
Provide information in a clear, forthright manner, and allow the patient to ask questions. Describe all procedures and nursing care in advance, reinforce the practitioner's explanation of the disorder and its effects on the pregnancy, and teach normal prenatal self care as the patient can respond to it.
Open communication gives the patient a sense of control and helps decrease her fear. The severity and duration of the disorder helps determine the outcome of the pregnancy. When controlled, the disorder usually doesn't recur or cause fetal complications.
Independent
Be supportive and nonjudgmental. Accept the patient's emotional responses, and allow her to cope in the manner she has established for herself.
The patient may need to grieve over the difficult pregnancy, which can result in a low‑birth‑weight neonate.
Independent
Provide information on emotional and spiritual support services available through the hospital, the practitioner's practice, or in the community (including online discussion groups).
Professional and community-based support services can help the patient deal with reactions to stress or any ambivalence she may feel about the pregnancy. Psychogenic causes for the disorder are now discredited, except possibly in the case of a patient with a preexisting serious mental health disorder. The fact that 70% to 85% of pregnant women experience some degree of nausea and vomiting points toward a physiologic factor not yet discovered by research.
Independent
Inform the family and the patient's partner of her condition, especially because visitors are limited in early hospitalization.
Family interaction bolsters the patient's established support systems.


[Additional individualized interventions]


Suggested NIC Interventions
Anxiety reduction; Emotional support; Presence; Support system enhancement

Acute pain related to repeated episodes of vomiting

Expected outcome

The patient will verbalize and demonstrate less pain as evidenced by improved sleep, ability to be diverted, and decreased complaints of GI discomfort and muscle stress.

Suggested NOC Outcomes

Comfort level; Nausea & vomiting severity

Nursing interventions

Intervention type
Intervention
Rationale
Independent
Provide a clean, odor‑free environment. Keep an emesis basin and bedpan out of sight but within reach. Keep the dietary food cart away from the patient's room. Remove the patient's tray as soon as possible after she has finished her meal.
Some odors may trigger vomiting in nauseated patients.

Independent
Provide mouth care before each meal and snack and after each episode of vomiting.
Good oral hygiene contributes to the patient's comfort and sense of well‑being. Mouth care after emesis minimizes acid contact with teeth.
Independent
Provide gentle massage of aching muscles.
Repeated straining to vomit and awkward positioning can cause muscular fatigue and aching that can be ameliorated with gentle massage.
Independent
Teach patient relaxation techniques to utilize between episodes of vomiting or while nauseated as well as encouraging use of distraction by radio, television, reading, word puzzles, planning the baby's room or name, and talking with friends and relatives who visit.
Use of relaxation techniques, such as guided imagery and deep breathing, can help the patient recover from uncomfortable stimuli or thoughts. Distraction is a useful tool for low- to moderate-level nausea without vomiting.
Independent
Place the patient in high Fowler's position or seated upright for 30 minutes after each meal.
This position minimizes gastric reflux and burning pain.

[Additional individualized interventions]


Suggested NIC Interventions

Distraction; Environmental management: Comfort; Pain management; Positioning; Progressive muscle relaxation; Simple guided imagery; Simple massage; Simple relaxation therapy

Teaching checklist

■ Characteristics of usual pregnancy nausea and vomiting
■ Signs and symptoms to report to the practitioner, such as excessive vomiting and dehydration
■ Nonmedicinal measures to relieve nausea and vomiting
■ Measures to maintain food and fluid intake despite nausea and vomiting
■ Measures to medically rest the GI tract while providing supplemental fluids, electrolytes, and nutrients
■ Name, effects, dosage, administration, adverse effects, and drug interactions of medications prescribed to treat nausea, vomiting, and vitamin deficiencies
■ Relaxation techniques, massage, alternative medicine practices, and distraction to alleviate the discomforts of nausea and vomiting or the actual symptoms
■ Risks of prolonged nausea and vomiting to the fetus or patient
 

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