A CASE STUDY ON

HYPEREMESI S GRAVIDARU M
Presented to:

MS. FLERIDA ZOBELLE TADENA, RN,

Clinical Instructor Roxas District Hospital

I. INTRODUCTION
(from Greek hyper and emesis and Latin gravida; meaning "excessive vomiting of pregnant women") is a severe form of morning sickness, with unrelenting, excessive pregnancy-related nausea and/or vomiting that prevents adequate intake of food and fluids. Hyperemesis is considered a rare complication of pregnancy but, because nausea and vomiting during pregnancy exist on a continuum, there is often not a good diagnosis between common morning sickness and hyperemesis. Estimates of the percentage of pregnant women afflicted range from 0.3% to 2%. Causes: The cause of HG is unknown. The leading theories speculate that it is an adverse reaction to the hormonal changes of pregnancy. In particular Hyperemesis may be due to raised levels of beta HCG (Human Chorionic Gonadotrophin) as it is more common in multiple pregnancies and in gestational trophoblastic disease. Additional theories point to high levels of estrogen and progesterone, which may also be to blame for hypersalivation; decreased gastric motility (slowed emptying of the stomach and intestines); immune response to fragments of chorionic villi that enter the maternal bloodstream; or immune response to the "foreign" fetus. There is also evidence that leptin may play a role in HG. Historically, HG was blamed upon a psychological condition of the pregnant women. Medical professionals believed it was a reaction to an unwanted pregnancy or some other emotional or psychological problem. This theory has been disproved, but unfortunately some medical professionals espouse this view and fail to give patients the care they need. S/S:

Hyperemesis Gravidarum

When HG is severe and/or inadequately treated, it may result in: 1. loss of 5% or more of pre-pregnancy body weight 2. dehydration and ketosis 3. nutritional deficiencies 4. metabolic imbalances 5. difficulty with daily activities 6. altered sense of taste 7. sensitivity of the brain to motion 8. food leaving the stomach more slowly 9. rapidly changing hormone levels during pregnancy 10. stomach contents moving back up from the stomach 11. physical and emotional stress of pregnancy on the body Some women with HG lose as much as 20% of their body weight. Many sufferers of HG are extremely sensitive to odors in their environment; certain smells may exacerbate symptoms. This is known as hyperolfaction. Ptyalism, or hypersalivation, is another symptom experienced by some, but not all, women suffering from HG. As compared to morning sickness, HG tends to begin somewhat earlier in the pregnancy and last significantly longer. While most women will experience near-complete relief of morning sickness symptoms near the beginning of their second trimester, some sufferers of HG will experience severe symptoms until they birth their baby, and sometimes after birthing.

II. NURSING HISTORY/ HEALTH ASSESSMENT

Patients Profile

Name: Patient XXX Address: Santiago, Quirino, Isabela. Gender: Female Birth date: 11-30-73 Age: 35 Religion: Roman Catholic Admission: Date: 8-19-09 Time: 5:05am GTPAL: G4P3 Admitting Diagnosis: Hyperemesis Gravidarum

Health History
Present Health History A 2 months pregnant woman was admitted last August 19, 2009 with a chief complaint of nausea and vomiting for three days prior to confinement. Her admitting diagnosis was Hyperemesis Gravidarum Past Health History According to the S.O it is the second time that the patient was admitted to the hospital because of the same reason. Family History According to the S.O no one in her family has a history of hypertension, cancer, heart disease, GIT problems and even Hyperemesis Garavidarum Medical History The patient didnt undergone any surgery/operations Personal and Social History The patient lives in a quite community with warm neighbors. She is a roman catholic according to her she seldom goes to church. She actively participates on their activities in their barangay like fiesta, birthdays and so on. Gordons 11 Functional Pattern HEALTH PATTERN 1. Health PerceptionHealth Management Pattern BEFORE HOSPITALIZATION Believed that she is healthy as long as she can able to perform her activities of daily living and also with the absence of disease. If she is not feeling well, she will just have a rest and take some OTC (over the counter) drugs if her condition is no longer tolerable by her. The patient usually eats three times a day with no snacks in between. She usually eats vegetables, the primary food that is conveniently available to them and fishes as the secondary food available. DURING HOSPITALIZATION Her reaction to admission is bounded by fear and anxiety especially for the possible complications that might suffer from her illness and burdens of financial constraints from the hospital expenses. Despite her condition she is still filled with hope for early recovery and to be cured significantly. The patient cannot eat properly due to anxiety in vomiting.

2. NutritionMetabolic Pattern

3. Sleep-Rest Pattern

Her usual sleeping pattern was 6-7 hours; if there could be any chance, then she is having her naps in the afternoon.

4. Elimination Pattern

5. Activity-Exercise Pattern

6. CognitivePerceptual Pattern

7. Role-Relationship Pattern

8. Self-PerceptionSelf-Concept Pattern

9. SexualityReproductive Pattern

10. Coping Stress Tolerance Management

The patient usually voids 4 times a day with yellow urine output and defecates for 1-2 times a day. The patient can perform Her activities was been her normal daily living altered due to her activities such as hospitalization. household chores (e.g. cooking, washing dishes, do the laundry and etc.) and also in taking good care of her children. GENERAL: The patient can able to read and write with her senses that are functioning well. The decision for the benefit of the patient merely not only depends on her but also she seeks for another decision that might give by her S.O most especially her husband. GENERAL: The patient can able to comprehend and speak Tagalog and Ilokano. She lives with her family in their house. They turn to with their relatives in times of financial needs since that they are not financially stable. In decision making, both of them (she and her husband) decides on the thing regarding to their needs and sometimes asks for assistance from their relatives also. The patient is confident She wants to recover about the possibility easily because she that she will regain wanted to go home as strength in just a matter soon as possible as well of days. as her belief that she can rest more at home aside from the fact that shes also worried about her hospital dues. The patient is two months pregnant and she suffers abdominal pain, nausea and vomiting and her sexual desire was being altered, but then her husband do understand her situation thats why they didnt perceived it negatively on their part. According to her, she doesnt want to face a problem alone thats why in terms of her stress management, she always seeks assistance to her significant others in order to balance her stress. Also, if failed to do so, then she just leave everything to God since she knows that everything that might seem to be challenging for her part is just a mere test for her and also for her family as well.

The patient was able to sleep for about 4-5 hours only, but those hours of sleeping was being interrupted brought by severe pain in her abdominal part that attacks both night and day. The patient voids for at least 2 times a day and defecate once a day.

11. Value-Belief System

She seldom attends Sunday masses.

She prays to God to bless her and her family as well with good health. And for fast recovery for her.

III. Physical Examination

General Appearance: Conscious and Coherent; weak in appearance Vital Signs: Temperature: 37 C
Cardiac Rate: 80 bpm Respiratory Rate: 22 cpm Time and Date: 4:00pm; 8-19-09

ASSESSED AREAS 1.Head -Hair and Scalp

TECHNIQUES -Inspection -Palpation

FINDINGS -Hair equally distributed -Black in color -Symmetry -No nodules -Presence of dandruff

ANALYS ES -Normal -Normal -Normal -Normal -Due to poor hygiene -Due to stress -Due to her condition -Normal

2. Eyes -Conjunctiva -Sclera -Pupil

-Inspection -Inspection -Inspection

-Pale -Yellowish -PERRLA (Pupils are equally rounded and reactive to light and accommodation) -No lesion -No nasal discharge -No mass -Dry and dark -Presence of some dental caries -Yellowish -Dark in color

3. Nose -Inspection -Palpation 4. Mouth -Lips -Teeth -Gums -Normal -Normal -Normal -Due to dehydrati on -Due to poor oral hygiene -Lack of nutrients in the body 5. Ears -Inspection -Palpation -Symmetry -(+) cerumen -No nodules, -Normal -Due to poor hygiene

-Inspection -Inspection -Inspection

mass 6. Neck -Inspection -Palpation 7. Skin -Inspection -Palpation -No lesion -No mass/nodules -dry and rough -Long and dirty (both fingers and toes) -Less than 3 seconds capillary refill -Large chest expansion -No lesion, no mass -22cpm -ABS (Adventitious Breath Sounds) -Flat -Hypoactive bowel sound -Tympanic -No masses, soft -Symmetry, no lesions -No palpable lymph nodes

-Normal -Normal -Normal -Normal -Normal -Due to poor hygiene -Due to poor hygiene -Normal -due to dyspnea -Normal -Due to difficulty in breathing -Normal -1-2 bowel sounds auscultat ed -Normal -Normal -Normal

8. Nails -Inspection -Palpation -Blanch test 9. Chest -Inspection -Palpation 10. Respiratory -Respiratory rate -Breathing 11. Abdomen -Inspection -Auscultation -Inspection -Auscultation -Percussion -Palpation 12.Extremities -Upper extremities -Lower extremities

-Inspection

-No masses, no lesions

IV. Laboratory Procedures

A. URINALYSIS

Examination

and

other

Diagnostic

Name: Rowena Estellore Color: Yellow Albumin: (+) Spec.Grav.: 1.020 WBC: 10-15

Characteristics: Turbid Sugar: (-) Reaction: 6.0 RBC: 15-20 Epithelial Cell: Occasional

B. Hematology
PARAMETERS Hemoglobin Hematocrit NORMAL VALUES 12-16g/dL 0.38-52vol % RESULT 12.9 0.31 ANALYS ES Normal Low Hct

WBC 5-10x10/L Platelet Count 140-400x10/L DIFFERENTIAL COUNT Lymphocytes 25-35

7.1 290 25

Normal Normal Normal

V. Review of System
A. Anatomy and Physiology

Hyperemesis (2) HG is a debilitating and potentially life-threatening pregnancy disease marked by rapid weight loss, malnutrition, and dehydration due to unrelenting nausea and/or vomiting with potential adverse consequences for the newborn(s). OVERVIEW: Hyperemesis gravidarum (HG) is a severe form of nausea and vomiting in pregnancy. It is generally described as unrelenting, excessive pregnancy-related nausea and/or vomiting that prevents adequate intake of food and fluids. If severe and/or inadequately treated, it is typically associated with:

loss of greater than 5% of pre-pregnancy body weight (usually over 10%) dehydration and production of ketones nutritional deficiencies metabolic imbalances difficulty with daily activities

HG usually extends beyond the first trimester and may resolve by 21 weeks; however, it can last the entire pregnancy in less than half of these women. Complications of vomiting (e.g. gastric ulcers, esophageal bleeding, malnutrition, etc.) may also contribute to and worsen ongoing nausea. There are numerous theories regarding the etiology of hyperemesis gravidarum. Unfortunately, HG is not fully understood and conclusive research on its potential cause

is rare. New theories and findings emerge every year, substantiating that it is a complex physiological disease likely caused by multiple factors. Diagnosis is usually made by measuring weight loss, checking for ketones, and assessing the overall condition of the mother. If she meets the standard criteria and is having difficulty performing her daily activities, medications and/or other treatments are typically offered. Treating HG is very challenging and early intervention is critical. HG is a multifaceted disease that should be approached with a broad view of possible etiologies and complications. When treating mothers with HG, preventing and correcting nutritional deficiencies is a high priority to promote a healthy outcome for mother and child. Most studies examining the risks and outcomes for a pregnant woman with nausea and vomiting in pregnancy find no detrimental effects long-term for milder cases. Those with more severe symptoms that lead to complications, severe weight loss, and/or prolonged nausea and vomiting are at greatest risk of adverse outcomes for both mother and child. The risk increases if medical intervention is inadequate or delayed. The list of potential complications due to repeated vomiting or severe nausea is extensive, all of which may worsen symptoms. Common complications from nausea and vomiting include debilitating fatigue, gastric irritation, ketosis, and malnutrition. Aggressive care early in pregnancy is very important to prevent these and more lifethreatening complications such as central pontine myolinolysis or Wernicke's encephalopathy. After pregnancy and in preparation of future ones, it is important to address any resulting physical and psychological complications. Hyperemesis Gravidarum impacts societies, families and individuals. Recent, conservative estimations suggest HG costs nearly $200 million annually just for inpatient hospitalization. Considering many women are treated outside the hospital to save costs, the actual cost is likely many times greater. Beyond financial impact, many family relationships dissolve and future family plans are almost always limited. Women often lose their employment because of HG, and women are frequently undertreated and left feeling stigmatized by a disease erroneously presumed to be psychological.

C. Pathophysiology

Etiology: Unknown

Predisposing Factor: -woman

Precipitating Factor: -pregnancy

Adverse reaction to the hormonal changes of pregnancy

Increased level of beta HCG

Increased level of estrogen and progesterone

Decreased gastric motility

Immune response to fragments of chorionic villi that enter the maternal bloodstream; immune response to the foreign fetus. Loss of 5% or more of pre-pregnancy body weight.

Dehydration

Metabolic imbalances

Difficulty with daily activities

Food leaving the stomach more slowly

Hypersalivation

Nausea and vomiting

Abdominal pain

Difficulty in breathing

VI. Course in the Ward

DOCTORS ORDER 8-19-09 -Please admit. -For management and treatment of the patients condition. -Facilitate transfer from E.R to ROC. RATIONALE NURSING CONSIDERATIONS

-For lawful purposes. -Secure consent. -Serves as a baseline data checking the present health status of the patient. -To prevent aspiration/because of temporary malfunction of digestive system. -To whether there were abnormal findings found.

-Secured consent to S.O. -Monitored and recorded.

-TPR every shift and record. -NPO temporarily.

-Instructed S.O. for strict NPO.

-Labs: CBC with APC, urinalysis, with PT.

-Follow-up laboratory for the result.

-IVF: D5LR 1L x 30gtts/min.

-Metoclopramide amp, 1 amp TIV prn. -Refer

-To provide salts needed to maintain electrolyte balance; To provide glucose (dextrose), the main fuel for metabolism; To provide water-soluble vitamins and medications; and to establish a lifeline for rapidly needed medications. -For nausea and vomiting of the patient as needed. -For immediate report.

-Observed sterile technique in IVF insertion. Regulate well and check its patency.

-Gave meds as needed.

VII. Nursing Care Plan

Assessme nt
Subjective: The patient verbalizes that Dura ako ng dura, nagsusuka pa ko. Objective: -Irritated -(+) nausea and vomiting

Diagnosis
Deficient fluid volume related to hyperemesis gravidarum as manifested by hypersalivatio n, vomiting and dry skin.

Planning
After the shift of nursing interventions, the patient will decreased the possibility in vomiting, hypersalivatio n decreased and skin becomes moisturized. And irritability will diminish.

Intervention
-Established rapport to the patient and to the S.O.

Rational e
-To gather informatio n.

Evaluatio n
Goal met: After the shift of nursing interventio ns the patient was able to perform changes in her status.

-Monitored vital signs and recorded.

-For Baseline data.

-Monitored IVF drip and its patency.

-To prevent overload of the

-(+) hypersalivati on -(+) dry skin -Vital signs taken as follows: BP: 90/70 CR: 80bpm RR: 22cpm T: 37C -Provided comfort measures. -Maintained quiet environment.

fluid. And IVF can help for the hydration of the patient.

-For relaxation of the patient.

-Administered and documented medications (METOCLOPRAMIDE ) given as ordered by the physician.

-To prevent irritation/ discomfort of the patient.

-Encouraged patient to increase oral fluid intake.

-Encouraged patient to eat dry toast foods.

-To provide wellness to the patient. And to prevent patient from vomiting.

-For hydration of the patient.

-Dry toast foods inhibit the urge of vomiting and at the same time the patient will be refilled to prevent gastric ulcer.

Assessme nt
Subjective: The patient verbalizes that Masakit ang tiyan ko. Objective: -9/10 pain scale -Irritable -Grimacing -Guarding behavior -Vital signs taken as follows: BP: 90/70 CR: 80bpm RR: 22cpm T: 37C

Diagnosis
Acute pain related to hyperemesis gravidarum as manifested by verbal report and guarding behavior.

Planning
After 4 hours of nursing intervention, the patient will relieve from pain. The patient can perform activities (sitting, standing, walking and etc.) comfortably. Pain scale will decelerate to 5/10.

Interventio n
-Established rapport to the patient and to the S.O. -Monitored vital signs and recorded. -Monitored IVF drip and its patency.

Rationale
-To gather informatio n.

Evaluation
Goal met: After 4 hours of nursing intervention the patient was relieved from pain, can do things comfortably and report pain scale to 5/10.

-For Baseline data. -To prevent overload of the fluid.

-Maintained quiet environment.

-For relaxation of the patient.

-Provided comfort measures. -Positioned the patient to her comfortable state. -Massage patient.

-To lessen the pain felt by the patient.

-To decreased pain.

-Instructed S.O. not to leave the patient.

- To alleviate suffering from perceived pain. -To prevent from fall.

Assessme nt
Subjective: The patient verbalizes that Hindi ako makahinga. Objective: -Irritated

Diagnosis
Ineffective breathing pattern related to pain as evidenced by orthopnea, alterations in depth of breathing and nasal flaring.

Planning
After 3 hours of nursing intervention the patient will be able to breathe properly.

Interventio n
-Established rapport to the patient and to the S.O. -Monitored vital signs and recorded.

Rationale
-To gather information.

Evaluation
Goal met: After 3 hours of nursing intervention the patient can perform proper breathing pattern and can breathe properly.

-For Baseline data.

-To prevent overload of

-Orthopnea -Alterations in depth of breathing -Nasal flaring -Vital signs taken as follows: BP: 90/70 CR: 80bpm RR: 22cpm T: C

-Monitored IVF drip and its patency.

the fluid.

-Maintained quiet environment. -Provided comfort measures. -Positioned patient to orthopneic position.

-For relaxation of the patient. -To prevent irritation/ discomfort of the patient. -Helps in the breathing pattern of the patient. It helps the patient to breathe properly. -For proper ventilation.

-Provided air to patient. -Instructed S.O. to massage chest and back of the patient.

-It helps the patients breathing pattern.

Assessme nt
Subjective: Parang mamatay na ko. as verbalized by the patient. Objective: -Irritability -Facial tension -Trembling Restlessness -Vital signs taken as follows: BP: 100/80

Diagnosis
Anxiety related to perceived proximity of death as manifested by the verbal report, irritability, facial tension, trembling, and restlessness.

Planning
After 3 hours of nursing intervention the will no longer feel the proximity of death.

Interventio n
-Established rapport to the mother. -Monitored vital signs and recorded. -Monitored IVF drip and its patency.

Rationale
-To gather information.

Evaluation
Goal met: After 3 hours of nursing intervention, the patient was filled with hope.

-For Baseline data. -To prevent overload of the fluid.

-Maintained quiet environment. -Provided comfort measures.

-For relaxation of the patient.

-Provided calm and peaceful

-To prevent irritation/ discomfort of the client.

CR: 89bpm RR: 22cpm T: 37C

setting.

-Encouraged patient to pray to God.

-Promotes relaxation and ability to deal with situations. -For the patient be filled with faith and hope.

-Taught patient and S.O. about the condition of the patient.

-For them to be clarified about the situation of the patient.

VIII. Drug study Metoclopramide

Drug Availability Classificati on Action Indication and Dosages Contrain dication Adverse Effect Nursing Interventio n

GENERIC NAME: Metoclop ramide Hydrochl oride BRAND NAMES: Reglan

Injection: 5mg/ml Syrup: 5mg/5ml, 10mg/ml Tablets: 5mg, 10mg

Metoclopra mide belongs to a class of antiemetic s

Stimulates motility of upper G.I tract, increases lower esophageal sphincter tone, and blocks dopamine receptors at the chemorece ptor trigger zone.

Emesis during pregnancy Adults: 5 to 10mg P.O. or 5 to 20 mg I.V. or I.M. TID.

Contrain dicated to patients hypersen sitive to drug and in those with phechro mocytom a or seizure disorders . Contrain dicated in patients for whom stimulati on of G.I motility might be dangero us (those with hemorrh age, obstructi on, or perforati on). Use cautiousl y in patients with

CNS: restlessne ss, anxiety, drowsines s, fatigue, lassitude, fever, depressio n, akathisia, insomnia, confusion, suicide ideation, seizures, neuroletic malignant syndrome, hallucinati ons, headache, dizziness. CV: transient hypertensi on, hypotensi on, supravent ricular tachycardi a, bradycardi a GI: nausea, bowel

-Monitor bowel sounds. -Safety and effectivene ss of drug havent been established for therapy lasting longer than 12 weeks. -When oral solution is used (10mg/ml) dilute in pudding, applesauce, juice, or water just before using. -Alert: Use diphenhydr amine 25mg I.V. to counteract extrapyram idal adverse effects from high metoclopra mide doses.

history of depressi on, Parkinso ns disease, or hyperten sion.

disorders, diarrhea GU: urinary frequency, incontinen ce Hematolo gic: neutropen ia Skin: rash, urticaria Other: Prolactin secretion, loss of libido.

IX. Discharge Care Plan/ Health Teaching

Medication

Take the entire course of any prescribed medications. Medication must be continued according to the doctors instructions. -Emphasized the importance of taking medication as prescribed.

Exercises

Get plenty of rest. Adequate rest is important to maintain progress toward full recovery and to avoid relapse. -Emphasized the importance of adequate rest and sleep to prevent fatigue and avoid weight loss. -Encouraged patient to take deep breathing exercises to facilitate circulation.

Treatment

Drink lots of fluids, especially water. Liquids will keep patient from becoming dehydrated. -Advised patient and S.O. to continue taking medication as ordered on a regular basis. Provide wellness and comfort. Emphasized to the S.O and patient the importance of bathing and other hygienic procedure such as regular bathing, hand washing before doing necessary activities and oral care. Keep all of follow-up appointments. Even though the patient feels better, its important to have the doctor monitor her progress. -Instructed patient to have soft diet or diet as tolerated. -Encouraged the patient to eat nutritious foods that may best help for her recovery like vegetables, fruits and other foods that may enhance well-being.

Hygiene

OPD follow-up Diet

Sexual/Spiritual

Advised the patient to attend Sunday masses and encourage to pray

everyday for his condition and faster recovery.