A CASE STUDY

ON

HYPEREMESI
S
GRAVIDARU
M
Presented to:

MS. FLERIDA ZOBELLE TADENA, RN,

Clinical Instructor
Roxas District Hospital
I. INTRODUCTION
Hyperemesis Gravidarum (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:
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

Patient’s 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 didn’t 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.
Gordon’s 11 Functional Pattern

HEALTH PATTERN BEFORE DURING

HOSPITALIZATION HOSPITALIZATION
1. Health Perception- Believed that “she is Her reaction to
Health Management healthy” as long as she admission is bounded
Pattern can able to perform her by fear and anxiety
activities of daily living especially for the
and also with the possible complications
absence of disease. If that might suffer from
she is not feeling well, her illness and burdens
she will just have a rest of financial constraints
and take some OTC from the hospital
(over the counter) drugs expenses. Despite her
if her condition is no condition she is still
longer tolerable by her. filled with hope for early
recovery and to be
cured significantly.
2. Nutrition- The patient usually eats The patient cannot eat
Metabolic Pattern three times a day with properly due to anxiety
no snacks in between. in vomiting.
She usually eats
vegetables, the primary
food that is
conveniently available
to them and fishes as
the secondary food
available.
3. Sleep-Rest Pattern Her usual sleeping The patient was able to
pattern was 6-7 hours; sleep for about 4-5
if there could be any hours only, but those
chance, then she is hours of sleeping was
having her naps in the being interrupted
afternoon. brought by severe pain
in her abdominal part
that attacks both night
and day.
4. Elimination The patient usually The patient voids for at
Pattern voids 4 times a day with least 2 times a day and
yellow urine output and defecate once a day.
defecates for 1-2 times
a day.
5. Activity-Exercise The patient can perform Her activities was been
Pattern 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.
6. Cognitive- GENERAL: The patient can able to read and write
Perceptual Pattern 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.
7. Role-Relationship GENERAL: The patient can able to comprehend
Pattern 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.
8. Self-Perception- The patient is confident She wants to recover
Self-Concept Pattern 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
she’s also worried about
her hospital dues.
9. Sexuality- The patient is two months pregnant and she
Reproductive Pattern suffers abdominal pain, nausea and vomiting and
her sexual desire was being altered, but then her
husband do understand her situation that’s why
they didn’t perceived it negatively on their part.
10. Coping Stress According to her, she doesn’t want to face a
Tolerance problem alone that’s why in terms of her stress
Management 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.
 11. Value-Belief She seldom attends She prays to God to
System Sunday masses. 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 TECHNIQUES FINDINGS ANALYS

ES
1.Head
-Hair and Scalp -Inspection -Hair equally -Normal
-Palpation distributed
-Black in color -Normal
-Symmetry -Normal
-No nodules -Normal
-Presence of -Due to
dandruff poor
hygiene
2. Eyes
-Conjunctiva -Inspection -Pale -Due to
-Sclera -Inspection -Yellowish stress
-Due to
-Pupil -Inspection -PERRLA (Pupils her
are equally condition
rounded and -Normal
reactive to light
and
accommodation)
3. Nose
-Inspection -No lesion -Normal
-Palpation -No nasal -Normal
discharge -Normal
-No mass
4. Mouth
-Lips -Inspection -Dry and dark -Due to
dehydrati
-Teeth -Inspection -Presence of on
some dental -Due to
caries poor oral
-Gums -Inspection -Yellowish hygiene
-Dark in color
-Lack of
nutrients
in the
body
5. Ears
-Inspection -Symmetry -Normal
-Palpation -(+) cerumen -Due to
poor
-No nodules, hygiene
 mass -Normal
6. Neck
-Inspection -Symmetry, no -Normal
-Palpation lesions
-No palpable -Normal
lymph nodes
7. Skin
-Inspection -No lesion -Normal
-Palpation -No -Normal
mass/nodules -Due to
-dry and rough poor
hygiene
8. Nails
-Inspection -Long and dirty -Due to
-Palpation (both fingers poor
and toes) hygiene
-Blanch test -Less than 3
seconds -Normal
capillary refill
9. Chest -Inspection -Large chest -due to
expansion dyspnea
-Palpation -No lesion, no -Normal
mass
10. Respiratory
-Respiratory rate -Inspection -22cpm -Due to
-Breathing -Auscultation -ABS difficulty
(Adventitious in
Breath Sounds) breathing
11. Abdomen -Inspection -Flat -Normal
-Auscultation -Hypoactive -1-2
bowel sound bowel
sounds
-Percussion -Tympanic auscultat
-Palpation -No masses, soft ed
-Normal
-Normal
12.Extremities
-Upper -Inspection -No masses, no -Normal
extremities lesions
-Lower
extremities

IV. Laboratory Examination and other Diagnostic

Procedures

A. URINALYSIS
Name: Rowena Estellore
Color: Yellow Characteristics: Turbid
Albumin: (+) Sugar: (-) Reaction: 6.0
Spec.Grav.: 1.020
WBC: 10-15 RBC: 15-20 Epithelial Cell: Occasional

B. Hematology

PARAMETERS NORMAL RESULT ANALYS

VALUES ES
Hemoglobin 12-16g/dL 12.9 Normal
Hematocrit 0.38-52vol % 0.31 Low Hct
 WBC 5-10x10/L 7.1 Normal
Platelet Count 140-400x10/L 290 Normal
DIFFERENTIAL COUNT
Lymphocytes 25-35 25 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 life-
threatening 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 Precipitating
Factor: Factor:
-woman -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

DOCTOR’S ORDER RATIONALE NURSING

CONSIDERATIONS

8-19-09

-Please admit. -For management and -Facilitate transfer from

treatment of the E.R to ROC.
patient’s condition.
 -For lawful purposes. -Secured consent to S.O.

-Secure consent. -Serves as a baseline -Monitored and

data checking the recorded.
present health status of
-TPR every shift and the patient.
record. -Instructed S.O. for strict
-To prevent
NPO.
-NPO temporarily. aspiration/because of
temporary malfunction
of digestive system.
-Labs: CBC with APC, -To whether there were
urinalysis, with PT. abnormal findings found. -Follow-up laboratory for
the result.

-IVF: D5LR 1L x -To provide salts needed

30gtts/min. to maintain electrolyte -Observed sterile
balance; To provide technique in IVF
glucose (dextrose), the insertion. Regulate well
main fuel for and check its patency.
metabolism; To provide
water-soluble vitamins
and medications; and to
establish a lifeline for
rapidly needed
medications. -Gave meds as needed.
-Metoclopramide amp, 1
amp TIV prn. -For nausea and
vomiting of the patient
-Refer
as needed.

-For immediate report.

VII. Nursing Care Plan

Assessme Diagnosis Planning Intervention Rational Evaluatio

nt e n
Subjective: Deficient fluid After the shift -Established -To gather Goal met:
volume of nursing rapport to the informatio After the
The patient related to interventions, patient and to the n. shift of
verbalizes hyperemesis the patient S.O. nursing
that “Dura gravidarum will decreased interventio
ako ng dura, as manifested the possibility ns the
nagsusuka -For
by in vomiting, patient was
pa ko.” -Monitored vital Baseline
hypersalivatio hypersalivatio able to
signs and data.
n, vomiting n decreased perform
Objective: recorded.
and dry skin. and skin changes in
-Irritated becomes her status.
moisturized. -To
-(+) nausea And irritability -Monitored IVF drip prevent
and vomiting will diminish. and its patency. overload
of the
-(+) fluid. And
hypersalivati IVF can
on help for
the
-(+) dry skin hydration
-Maintained quiet of the
-Vital signs
environment. patient.
taken as
follows:

BP: 90/70 -For

relaxation
CR: 80bpm
-Provided comfort of the
RR: 22cpm measures. patient.

T: 37°C

-To
prevent
-Administered and irritation/
documented discomfort
medications of the
(METOCLOPRAMIDE patient.
) given as ordered
by the physician.

-To
provide
wellness to
the
-Encouraged
patient.
patient to increase
And to
oral fluid intake.
prevent
patient
from
-Encouraged vomiting.
patient to eat dry
toast foods.

-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 Diagnosis Planning Interventio Rationale Evaluation
nt n
Subjective: Acute pain After 4 hours -Established -To gather Goal met: After 4
related to of nursing rapport to informatio hours of nursing
The patient hyperemesis intervention, the patient n. intervention the
verbalizes gravidarum the patient and to the patient was
that as manifested will relieve S.O. relieved from
“Masakit by verbal from pain. pain, can do
ang tiyan -Monitored -For
report and things
ko.” The patient vital signs Baseline
guarding comfortably and
can perform and data.
behavior. report pain scale
Objective: activities recorded.
-To prevent to 5/10.
(sitting,
-9/10 pain -Monitored overload of
standing,
scale IVF drip and the fluid.
walking and
etc.) its patency.
-Irritable
comfortably.
-Grimacing -For
Pain scale will relaxation
-Maintained
-Guarding decelerate to of the
quiet
behavior 5/10. patient.
environment.
-Vital signs
taken as
follows: -Provided -To lessen
comfort the pain
BP: 90/70 felt by the
measures.
patient.
CR: 80bpm
-Positioned
RR: 22cpm the patient
to her
-To
T: 37°C comfortable
decreased
state.
pain.
-Massage
patient.
- To
alleviate
-Instructed suffering
S.O. not to from
leave the perceived
patient. pain.

-To prevent
from fall.

Assessme Diagnosis Planning Interventio Rationale Evaluation

nt n
Subjective: Ineffective After 3 -Established -To gather Goal met: After
breathing hours of rapport to information. 3 hours of
The patient pattern nursing the patient nursing
verbalizes related to pain intervention and to the intervention the
that “Hindi as evidenced the patient S.O. patient can
ako -For Baseline
by orthopnea, will be able perform proper
makahinga.” -Monitored data.
alterations in to breathe breathing
depth of properly. vital signs pattern and can
Objective: and
breathing and breathe
nasal flaring. recorded. -To prevent properly.
-Irritated
overload of
-Orthopnea -Monitored the fluid.
IVF drip and
-Alterations its patency.
in depth of
breathing -For
relaxation of
-Nasal -Maintained the patient.
flaring quiet
environment. -To prevent
-Vital signs irritation/
taken as -Provided discomfort of
follows: comfort the patient.
measures.
BP: 90/70 -Helps in the
-Positioned breathing
CR: 80bpm patient to pattern of
orthopneic the patient.
RR: 22cpm
position. It helps the
T: °C patient to
breathe
properly.

-For proper
-Provided air
ventilation.
to patient.

-Instructed
S.O. to -It helps the
massage patient’s
chest and breathing
back of the pattern.
patient.

Assessme Diagnosis Planning Interventio Rationale Evaluation

nt n
Subjective: Anxiety related After 3 hours -Established -To gather Goal met:
to perceived of nursing rapport to the information. After 3 hours
“Parang proximity of intervention mother. of nursing
mamatay na death as the will no intervention,
ko.” as manifested by longer feel -Monitored the patient
verbalized vital signs -For
the verbal the proximity was filled
by the and recorded. Baseline
report, of death. with hope.
patient. data.
irritability, facial
-Monitored
tension, -To prevent
Objective: IVF drip and
trembling, and overload of
its patency.
-Irritability restlessness. the fluid.

-Facial
tension -Maintained
quiet -For
-Trembling environment. relaxation
of the
- -Provided patient.
Restlessness comfort
measures.
-Vital signs
taken as -To prevent
follows: irritation/
-Provided discomfort
BP: 100/80 calm and of the
peaceful client.
CR: 89bpm setting. -Promotes
relaxation
RR: 22cpm and ability
to deal with
T: 37°C -Encouraged
situations.
patient to
pray to God. -For the
patient be
filled with
-Taught faith and
patient and hope.
S.O. about
the condition
of the -For them to
patient. be clarified
about the
situation of
the patient.

VIII. Drug study

Metoclopramide
Drug Availability Classificati Action Indication Contrain Adverse Nursing
on and dication Effect Interventio
Dosages n
GENERIC Injection: Metoclopra Stimulates Emesis Contrain CNS: -Monitor
NAME: 5mg/ml mide motility of during dicated restlessne bowel
Metoclop belongs to upper G.I pregnancy to ss, sounds.
ramide Syrup: a class of tract, patients anxiety, -Safety and
5mg/5ml, antiemetic increases Adults: 5 to hypersen drowsines effectivene
Hydrochl
10mg/ml s lower 10mg P.O. sitive to s, fatigue, ss of drug
oride esophageal drug and lassitude, haven’t
or 5 to 20
Tablets: sphincter mg I.V. or in those fever, been
BRAND tone, and I.M. TID. with depressio established
5mg, 10mg
NAMES: blocks phechro n, for therapy
Reglan dopamine mocytom akathisia, lasting
receptors at a or insomnia, longer than
the seizure confusion, 12 weeks.
chemorece disorders suicide -When oral
ptor trigger . ideation, solution is
zone. seizures, used
Contrain neuroletic (10mg/ml)
dicated malignant dilute in
in syndrome, pudding,
patients hallucinati applesauce,
for whom ons, juice, or
stimulati headache, water just
on of G.I dizziness. before
motility using.
might be CV: -Alert: Use
dangero transient diphenhydr
us (those hypertensi amine
with on, 25mg I.V.
hemorrh hypotensi to
age, on, counteract
obstructi supravent extrapyram
on, or ricular idal
perforati tachycardi adverse
on). a, effects from
bradycardi high
Use a metoclopra
cautiousl mide doses.
y in GI:
patients nausea,
with bowel
 history of
depressi disorders,
on, diarrhea
Parkinso
n’s GU:
disease, urinary
or frequency,
hyperten incontinen
sion. 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 doctor’s 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.
Hygiene 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.

OPD follow-up Keep all of follow-up appointments. Even though the patient feels
better, it’s important to have the doctor monitor her progress.
Diet -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.

Sexual/Spiritual Advised the patient to attend Sunday masses and encourage to pray
everyday for his condition and faster recovery.