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HYPEREMESIS GRAVIDARUM
Macasaet, Maria Margaret A.
Mam Anita Urbi, RN, Ed D
OB-Gyne Ward [Station I], LCDH
January 18-21 2010
I. Demographic Data
Patient RF, residing at San Carlos, Lipa City, a 42 years old female and a housewife, marriedwith 4 sons and 2 daughters, was confined to the hospital last January 16 with the chiefcomplaint of experiencing frequent vomiting for 2 weeks. The attending doctor, Dr. Apalisok,diagnosed her with Hyperemesis Gravidarum, an unusual excessive vomiting during the firsttrimester of pregnancy.
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II. History
A. History of Present illness
The patient was 8 weeks pregnant to her seventh child.B. Past medical history
The patient had not been hospitalized before due to serious cases other than
her present illness. According to her she only went to hospital for maternal
check ups. Also, the patient has no history of accidents and injuries.
C. Genogram of Family history
According to her, other than the usual mumps, no other disease or disorders
were experienced by her family.
D. Social Data
The patient from Romblon, came from an average family with 10 other
siblings, 5 of which were girls and 4 of which were boys. Being the 4th child,
she was forced to work after graduating in highschool in order to help her
family. After getting married, she lived in her husbands place and became a
fulltime housewife.
E.Lifestyle
Being the housewife, she does all the household chores as well as the role of
taking care of her 6 sons and daughters. The familys only means of living is
her husbands tricycle.
F.Psychological Data
Although her family is supportive, anxiety as well as apprehension can be
seen in the patient.
G. Patterns of Health Care
The patient believes in albularios but often times, she brings her family to
the barangay health center whenever they catch some illness. She also
expressed the practice of self medication.
H. Developmental History
For the psychological data, she is under Psychosocial Developmental Theory
of Erik Erikson, stage 6: Intimacy vs. Isolation. She is developing close and
committed relationship with other people her husband and children.
I. Obstetric and Gynecologic history.
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The patient had 6 pregnancies, all of which reached full term. She had no
aborted or born dead babies.
III. Physical Assessment
GENERAL SURVEY: The patient has an assisted ambulation and seems very weak.
BODY PART METHOD USED FINDINGS INTERPRETATIONSkin - inspection - has fair
complexion
-skin color is
equally distributed
-no lesions
-slightly dry
Skin dryness is due to
frequent vomitting
Hair - inspection - hair is color black
- evenly distributed
and covers the
scalp completely
normal
Head - inspection - symmetrical
normal
Scalp - palpation
- inspection
- no lesions or scars
noted
- free from lice, nits
and dandruff
- no tenderness or
masses noted upon
palpation
- lighter in color
than the
complexion
normal
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Face - inspection - symmetrical
- no involuntary
muscle movements
- can move facial
muscles well
normal
Eyes - inspection -symmetrical
- clear with no
purulent discharge
- pink palpebral
conjunctiva
- cornea is round
and equal
- pupils are dark
- eyebrows are
symmetrical and
black; eyelashes
are black
normal
Ears - inspection - auricles are
symmetrical; align
to the eyes
- same color as
complexion
- no foul discharge
normal
Nose - inspection - patent nostrils
- no discharge normal
Mouth - inspection - red lips
-red gums
-pearly teeth
normal
Neck - palpation
- inspection
- no hard masses
- head moves
easily, up and
down, left and right
normal
Legs and arms - palpation
- inspection
- no hard masses
- no sores and
lesions
Normal
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Nails -inspection -noncyanosis;
pinkish in color
Normal
legs -infection -non edematous
No presensce of
rashes or lesions
normal
genitalia
For privacy
purpose
IV. Normal Anatomy and Physiology
During the course of pregnancy, certain changes in the mothers metabolic andhormonal activity becomes well distinguished. As the fetus and placenta grow and place
increasing demands on the mother, phenomenal alterations in metabolism occur. Themost obvious physical changes are weight gain and altered body shape. Weight gain isdue not only to the uterus and its contents but also to increase breast tissue, blood andwater volume in the form of extravascular and extracellular fluid. Deposition of fat andprotein and increased cellular water are added to the maternal stores. The averageweight gain during pregnancy is 12,5Kg.
During normal pregnancy, approximately 1000g of weight gain is attributable toprotein. Half of this is found in the fetus and the placenta, with the rest being distributeas uterine contractile protein, breast glandular tissue, plasma protein, and hemoglobin.Plasma albumin levels are decreased and fibrinogen levels increased.
Total body fat increases during pregnancy, but the amount varies with totalweight gain. During the second half of pregnancy, plasma lipids increase, buttriglycerides, cholesterol and lipoproteins decrease soon after delivery. The ratio of lowdensity lipoproteins to high density lipoproteins increases during pregnancy.
V. Pathophysiology
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The physiologic basis of hyperemesis gravidarum is controversial. Hyperemesisgravidarum appears to occur as a complex interaction of biological, psychological, andsociocultural factors. The following theories have been proposed:
Hormonal changes
Women with hyperemesis gravidarum often have high hCG levels that causetransient hyperthyroidism. hCG can physiologically stimulate the thyroid glandthyroid-stimulating hormone (TSH) receptor. hCG levels peak in the first trimester.Some women with hyperemesis gravidarum appear to have clinical hyperthyroidism.However, in a larger portion (50-70%), TSH is transiently suppressed and the freethyroxine (T4) index is elevated (40-73%) with no clinical signs of hyperthyroidism,circulating thyroid antibodies, or enlargement of the thyroid. In transienthyperthyroidism of hyperemesis gravidarum, thyroid function normalizes by themiddle of the second trimester without antithyroid treatment. Clinically overthyperthyroidism and thyroid antibodies are usually absent.
A report on a unique family with recurrent gestational hyperthyroidismassociated with hyperemesis gravidarum showed a mutation in the extracellular
domain of the TSH receptor that made it responsive to normal levels of hCG. Thus,cases of hyperemesis gravidarum with a normal hCG may be due to varying hCGisotypes.
A positive correlation between the serum hCG elevation level and free T4levels has been found, and the severity of nausea appears to be related to thedegree of thyroid stimulation. hCG may not be independently involved in the etiologyof hyperemesis gravidarum but may be indirectly involved by its ability to stimulatethe thyroid. For these patients, hCG levels were linked to increased levels ofimmunoglobulin M, complement, and lymphocytes. Thus, an immune process may beresponsible for increased circulating hCG or isoforms of hCG with a higher activity forthe thyroid. Critics of this theory note that (1) nausea and vomiting are not usualsymptoms of hyperthyroidism, (2) signs of biochemical hyperthyroidism are not
universal in cases of hyperemesis gravidarum, and (3) some studies have failed tocorrelate the severity of symptoms with biochemical abnormalities.
Psychological issues
Some cases of hyperemesis gravidarum may represent psychiatric illnesses,including Munchausen syndrome, conversion or somatization disorder, or majordepression. They may occur under situations of stress or ambivalence surroundingthe pregnancy. It appears that psychologic responses can interact and exacerbatethe physiology of nausea and vomiting during pregnancy. Most likely, physiologicalchanges associated with pregnancy interact with each woman's psychologic stateand cultural values. However, hyperemesis gravidarum is usually not the result of apsychologic illness. It is frequently the cause of, as opposed to the result of,psychologic stress.
VI. Laboratory/ Diagnostic Procedure
CBC Reference Values Actual Result Interpretation
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WBC 4.5 10.5 H x 10 3 /uL 11.4 H x 10 3/uL
High infection
LY 20.5 51.1 L % 17.1 L % Low malnutrition
MO 1.7 9.3 3 % 1.9 3 % normal
GR 42.2 75.2 3H % 81 3H % High stress
LY # 1.2 3.4 x 10 3 /uL 1.9 x 10 3 /uL normal
MO # 0.1 0.6 3 x 10 3 /uL 0.2 3 x 10 3 /uL normal
GR # 1.4 6.5 3H x 10 3 /uL 9.2 3H x 10 3 /uL High stress
RBC 4.00 6.00 L x 10 6
/uL
3.75 L x 10 6 /uL normal
HgB 11.0 - -18.0 g/dL 12.4 g/dL normal
Hct 35.0 60.0 % 36.3 % normal
MCV 80.0 99.9 fL 96.9 fL normal
MCH 27.0 31.0 H pg 35.0 H pg High anemia
MCHC 33.0 37.0 g/dL 37.0 g/dL normal
RDW 11.6 13.7 % 13.5 % normal
PLT 150.0 450.0 x 10 3 /uL
441.0 x 10 3 /uL normal
MPV 7.8 11.0 L fL 6.7 L fL Low
Pct 0.190 0.360 % 0.297 % normal
DW 15.5 17.1 17.0 normal
ClinicalMicroscopy [UA]
Reference Values Actual Result Interpretation
COLOR yellow - amberamber
normal
TRANSPARENCY Clear SL turbidSL turbid
normal
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PH/ REACTION 5-6 [1.8 7.8]6.0
normal
SP. GRAVITY 1.010 1.0301.030
normal
ALBUMIN [-][++]
[+] kidney filtration
problem
SUGAR [-][-]
[+] DM
PREG. TEST[+]
[+] pregnant,
WBC 0 2 / hPF2 4 / hPF
High UTI
RBC 0 1 /hPF3 6 / hPF
High UTI
BACTERIA none - fewmoderate
normal
MUCUS THREAD plenty
A URATES/PHOSPHATES
moderatenormal
CASTS:
Fine granular
0 5 / lPF0 2 / lPF
normal
Blood Chemistry Reference Values Actual Result Interpretation
SODIUM 135 146 mmol/ L 145.6 mmol/ L normal
POTASSIUM 3.5 5.5 mmol/ L 3.25 mmol/ L normal
VII. Medical Management
Medical Regimen RationaleD5 LR 1 L, to run at 30 gtts/ min Lactated Ringers in 5% Dextrose hascomponents that are quickly absorbed by thebody, thus promoting quick electrolyte andfluid replenishing
D5 Nm 1 L x 20 gtts/ min Normosol-M in 5% Dextrose has componentsthat are quickly absorbed by the body, thuspromoting quick electrolyte and fluidreplenishing
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Metoclopramide 1 amp IV Q 8
Ampicillin 1 gm/ IV Q 6 ANST (-)
Cefalexin 500 mg 1 cap QID
VIII. Surgical Management
Surgical Preparation (Pre and Post) Rationale- no surgical procedure was done to thepatient -
IX. Drug Study
Generic name/Trade name/
Dosage/Frequency
Classification Indication Side/ AdverseEffect
NursingResponsibility
Cefalexin 500mg 1 cap QID
Anti-bacterialAgents
Cephalosporins
For thetreatment ofrespiratorytract infectionscaused byStreptococcuspneumoniaeandStreptococcus
pyogenes
hypersensitivity;GI disturbances;eosinophilia,neutropenia,leucopenia,thrombocytopenia.
PotentiallyFatal:Anaphylacticreactions;nephrotoxicity.
The drugshould betaken withor withoutfood. (Maybe takenwith mealsto reduceGI
discomfort)
Beforeadministration, askpatient ifhe isallergic topenicillinsorcephalosporins.
Mechanism of Action Contraindications
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Tell patientto takeentireamount ofdrug
exactly asprescribed,even afterhe feelsbetter.
Advisepatient tonotifyprescriberif rashdevelops orsigns andsymptomsofsuperinfection appear.
Inform patientnot to crush,cut, or chewextended-leasetablets.
Cephalexin, like thepenicillins, is a beta-lactam antibiotic. Bybinding to specificpenicillin-bindingproteins (PBPs)
located inside thebacterial cell wall, itinhibits the third andlast stage ofbacterial cell wallsynthesis. Cell lysisis then mediated bybacterial cell wallautolytic enzymessuch as autolysins; itis possible thatcephalexininterferes with anautolysin inhibitor.
Hypersensitivity tocephalosporins.
Classification Indication
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Metoclopramide 1 amp IVQ 8
AntiemeticGI stimulant
Used forpatients thatexperiencenausea andvomitting
Allergy toMetoclopramide
drowsiness,fatigue,insomnia
Assessment:1. History:allergy tometoclopramide, GIhemorrhage,
mechanicalobstruction orperforation,depression,epilepsy,lactation,previouslydetectedbreast cancer2. Physical:orientation,reflexes,affect, bowelsounds, normaloutput, EEG
Interventions:1. Monitor BPcarefullyduring IVadministration.2. Monitordiabeticpatients,arrange foralterations ininsulin dose ortiming ifdiabeticcontrol iscompromisedby Prophylaxisofpostoperativenausea andvomiting whennasogastricsuction isundesirableand intestinal
transit; littleeffect ongallbladder orcolon motility;increasesloweresophagealsphincterpressure; has
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sedativeproperties;inducesrelease ofprolactinalterations in
timing of foodabsorption.
X. Nursing Care Plan
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Cues NursingDiagnosi
s
Background of theDisease
Plan NursingInterven
tion
Rationale
Evaluation
Subjective
Madalsakongsumusuk
a asverbalized by thepatient
Objective
SunkeneyesThin withdry skin
ListlessLack ofsleep
Hyperactivebowelsounds. Paleconjunctivaand
mucusmembrane. V/Staken asfollows:
T: 36.6P: 98R: 18Bp:110/70
Nutritionimbalancedless thanbodyrequirements
related tonauseaandvomiting.
Originatingfrom thevomitingcenter,which islocated in
the lateralreticularformation ofthe medulla,controls andcoordinatesthe complexprocess ofvomiting(see figure).
This areareceivesinput from
other areaswithin thecentralnervoussystem(CNS),includingthechemoreceptor trig- gerzone (CTZ),cerebellum,vestibular
apparatus,corti- caland brainstemcenters, andsolitarytractnucleus.
These areasare rich inserotoninergic,muscarinic,histamine,oploid, anddopaminergic receptors,theblockade ofwhich hasbeenpostulatedto be themechanismof action ofantiemeticdrugs. The
efferentoutput from
After2 days.Ofnursinginterventions,
theclientwillbe abletomaintainusualweight.
Independent:Auscultate bowelsounds,noting
absenceorhyperactivesounds.Eliminatesmellsfrom theenvironment. Avoidfoods
thatmightcause orexacerbateabdominalcrampinglikecaffeinatedbeverages,
chocolate, orangejuice. Measureabdominal girth. Observeskin ormucousmembranedryness,andturgor.Noteperipheral edemaandsacraledema. Assessabdomenfrequently forreturn tosoftness,appearan
ce ofnormal
Inflammation orirritationof theintestine
maybeaccompaniedbyintestinalhyperactivity,diminishedwaterabsorption and
diarrhea. Reducesgastricstimulation andvomitingresponse. Mightincreaseabdominalcramping.
Providesquantitativeevidenceofchangesingastric orintestinaldistention.Hypovolemia,fluidshifts andnutritionaldeficitscontribute topoor skinturgor,edematoustissue.Indicates
returnof normal
METAfter 2 daysof nursingintervention,the patientwas able tomaintain her
usual weightmanifestedby bettersleep atnight,increase inappetite, andimprovedattitude andbehaviorPARTIALLYMET
After 2 daysof nursingintervention,the patientwas able togain a littleweightmanifestedby betterappetite, andimprovedattitude andbehavior
NOT METAfter 2 daysof nursingintervention,the patientwas not ableto maintainher usualweight due toan increase inthe frequencyof vomitingand nausea
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XI. Summary of Discharge Teaching
Once the patient received a going-home note, take home medications will bediscussed briefly and clearly. The action, when and when not to take the drug aswell as the side effects it may give. An environment with less or no strong smellshould be provided in order to not trigger vomiting. If any treatments wereadvice, the patient will be reminded to continue it diligently. Foods that maytrigger vomiting should be avoided and an increase intake of fruits andvegetables will be better. If any follow-up schedule was order, patient will bereminded of the set date. Lastly, patient will be advised to spend time prayingtogether with the family as it will strengthen family and spiritual bond.
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