Hyperemesis Gravidarum: A Case Study Answered PDF

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A case study answered by the students. Hope this help....

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CASE #1: VOMITING IN PREGNANCY (HEG) Setting: Hospital Chief Complaint: Persistent vomiting History Present Illness: A 28-year-old woman was referred by her General Practitioner with persistent vomiting at 7 weeks gestation. She is in her second pregnancy and had a normal vaginal delivery 3 years ago. She is now vomiting up to 10 times in 24 hours, and has not managed to tolerate any food for 3 days. She can only tolerate small amounts of water. She saw her General Practitioner a week ago that prescribe Prochlorperazine suppositories but these only helped for few days. She feels very weak and is unable to take care of her son now. On direct questioning she has upper abdominal pain that is constant, sharp and burning. She has not opened her bowels for 5 days. She passing small amounts of dark urine infrequently but there is no dysuria or hematuria. There is no vaginal bleeding There is no medical or gynecological history of note except that she suffered from persistent vomiting in her first pregnancy requiring 2 overnight admissions. Physical Examination: She is apyrexial. Lying BP is 115/68mmHg and standing BP = 98/55mmHg, Pulse Rate (PR) = 96bpm. The mucus membranes appear dry. Abdominal examination reveals tenderness in the epigastrium but no lower abdominal tenderness. The uterus is not palpable abdominally. LABORATORY Blood Hemoglobin Mean cell volume White cell count Platelets Sodium Potassium Urea Creatinine Alanine Transaminase Alkaline Phosphatase Gamma Glutamyl Transaminase Bilirubin Albumin Pregnancy test Urinalysis Protein Blood Nitrites Leucocytes Ketones Glucose

Result 11.1g/dL 90fL 8.9 x 109/L 298 x 109/L 131 mmo/L 3.0 mmo/L 8.2 mmo/L 65 μmo/L 30IU/L 276IU/L 17IU/L

Normal value for pregnancy 11-14 g/dL 74.4 -95 fL 6-16 x 109/L 150-400 x 109/L 130-140 mmo/L 3.3- 4.1 mmo/L 2.4-4.3 mmo/L 34-82 μmo/L 6-32IU/L 30-300IU/L 5-43IU/L

12μ/L 34g/L Positive

3-14μ/L 28-37g/L

Negative Negative Negative Negative +++ Negative

Questions: 1. What is likely the diagnosis of this case and differential diagnosis? With the observed signs and stated symptoms, the prolonged nausea and vomiting, dehydration and postural hypotension, the most likely diagnosis of this case is Hyperemesis Gravidarum. Differential diagnoses include Gastroenteritis ad Urinary Tract Infection. Gastroenteritis is ruled out since diarrhea is one of its main symptoms aside from abdominal pain and vomiting. The patient in this case is having constipation for 5 days already. Moreover, UTI is only a differential diagnosis since the urinalysis is negative apart from ketones. WBC level for infection is also in its normal range. 2. What are the potential complications of this disorder?       

Dehydration Chronic Ketosis Muscle weakness and extreme fatigue Hypokalemia Wernicke’s Encephalopathy Korsakoff’s Syndrome Psychological

3. Make a pathophysiology about this case utilizing the presentation of the case.

4. How would you further investigate and manage this patient? a. Make 3 NCP using the ADPIRE format.(Assessment, Nursing Diagnosis, Planning, Intervention, Rationale, Evaluation)

b. Make your PDAR for each NCP.

c. Make your discharge teaching/health teaching using the acronym METHODS (medication, environment, treatment, health teaching, outpatient follow up, diet, spiritual, sexual, social)

5. What are the medical interventions relevant to the case? Include also the drugs that can be used in the case. (if there are)

NCP 1

Ass

Sub dat Persistent vomiting (up to 1 times in 2 hours) Not managed to tolerat any foo for 3 days Objective data: Tendernes s i

n ent ify l n ea ort in of nd

epigastriu m Ketones in urine

of nursing intervention s, patient will be able to gain balanced 3.Encourag nutrition. e eating (e.g., crackers, biscuit) in small frequent feedings. 4. Ensure appetizing presentatio n of the foods.

4. Instruct client not to eat fatty foods. 5. Monitor I&O.

6. Give supplement s as prescribed.

hypertension Long term: due to After 2 days pregnancy. of nursing intervention s, patient Snacks can gained reduce and balanced avoid nutrition. excessive excitatory nausea/vomitin g Presentation stimulates the client’s appetite and may help to initiate eating. Fatty/oily foods can stimulate nausea and vomiting To determine the hydration fluids needed and the loss of fluids when vomiting. Vitamin B1 can prevent complications due to excessive vomiting.

PDAR 1

Problem

Data

Action

Imbalanced nutrition Vomiting up 1. Limited PO intake until related to frequency of to 10 times in vomiting stops. excessive nausea and 24 hours 2. Encouraged eating (e.g., vomiting crackers, biscuit) in small frequent feeding. 3.Instructed the patient not to eat fatty foods to avoid the

Response

Client does not feel nauseated anymore. Tolerance of food intake is increased.

stimulation nausea/vomiting.

of

4. Monitored I&O. NCP 2 Assessment

Nursing Diagnosis

Planning

Intervention

Subjective Data: Can only tolerate small amounts of water. Feels very weak as verbalized by the patient.

Fluid and electrolyte imbalance related to excessive vomiting or lack of fluid intake

After 8 hours of nursing intervention the patient will have reduced vomiting, and improved nutritional intake.

1.Monitor vital signs

Verbalized upper abdominal pain. Has not opened her bowels for 5 days. Infrequent passing of small amounts of dark urine. Objective Data: BP is 115/68mmHg and standing 98/55mmHg Pulse Rate = 96bpm The mucus membranes are dry. Tenderness in the epigastrium but no lower abdominal tenderness.

PDAR 2

Rationale

Evaluation

After 8 hours of nursing intervention, the patient verbalized having reduced vomiting, and 2. Weigh To monitor improved nutritional patient and any intake document changes in evidence by daily good skin weight turgor and 3. balanced To help the Administer patient intake and output. antiemetic

To have a baseline data and to note significant changes

drugs

lessen vomiting

4. Monitor FHR and fetal activity

Monitoring the FHR to know if the baby(fetus) is doing well

5. Promote small amounts of food and fluid intake

Helps balance fluids and electrolytes and indicate that the patient’s treatment is working

Problem

Data

Action

Response

Fluid and electrolyte imbalance related to excessive vomiting or lack of fluid intake

Persistent vomiting. Has not managed to tolerate any food for 3 days.

1. Administered prescribed medication. 2. Encouraged adequate fluid and nutritional intake. 3. Monitored intake and output. 4. Monitored serum electrolytes.

The patient has stopped from vomiting and maintained normal body fluid levels.

NCP 3 Assessment

Subjective Data: Client feels very weak and stated that she is unable to take care of her son now. Objective Data: BP is 115/68mmH g and standing 98/55mmHg

Nursing Diagnosis

Planning

Nursing Intervention

Rationale

Evaluation

Activity intoleranc e related to persistent vomiting.

After 8 hours of nursing intervention , the client will identify factors that reduce activity tolerance.

1.Assess physical activity level and mobility of the patient

It provides a baseline information for formulating nursing goals and goal setting

2. Assess client’s nutritional status

Having adequate energy reserves are needed during activity.

After 8 hours of nursing intervention , the client has identified the factors that can reduce activity tolerance.

3. Encourage client to avoid heavy lifting

The mucus membranes are dry. Tenderness in the epigastrium but no lower abdominal tenderness.

Save energy and avoid using power continuously to minimize fatigue/sensitivit y of the uterus.

4. Encourage the patient to take a rest.

Enough sleep can help the patient regain her energy, This helps the patient to cope.

5.Encourag e verbalizatio n of feelings regarding limitations.

Positive affirmation comforts and motivates the patient to get better....