A CASE STUDY

ON

HYPEREMESIS
GRAVIDARUM
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

1. Health Perception-
Health Management
Pattern
2. Nutrition-Metabolic
Pattern
3. Sleep-Rest Pattern
4. Elimination Pattern
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.
Her usual sleeping pattern
was 6-7 hours; if there could
be any chance, then she is
having her naps in the
afternoon.
The patient usually voids 4
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.
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

5. Activity-Exercise Pattern
6. Cognitive-Perceptual
Pattern
7. Role-Relationship
Pattern
8. Self-Perception-Self-
Concept Pattern
9. Sexuality-Reproductive
Pattern
10. Coping Stress Tolerance
Management
11. Value-Belief System
III. Physical Examination
General Appearance: Conscious and Coherent; weak in appearance
Vital Signs:
Temperature: 37 °C
Cardiac Rate: 80 bpm
Respiratory Rate: 22 cpm
times a day with yellow urine times a day and defecate once
output and defecates for 1-2 a day.
times a day.
The patient can perform her Her activities was been altered
normal daily living activities due to her hospitalization.
such as 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 about She wants to recover easily
the possibility that she will because she wanted to go
regain strength in just a home as soon as possible as
matter of days. well as her belief that she can
rest more at home aside from
the fact that she’s 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
that’s why they didn’t perceived it negatively on their part.
According to her, she doesn’t want to face a problem alone
that’s 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.
She seldom attends Sunday She prays to God to bless her
masses. and her family as well with
good health. And for fast
recovery for her.
Time and Date: 4:00pm; 8-19-09

ASSESSED AREAS TECHNIQUES FINDINGS ANALYSE

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

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 ANALYSE

VALUES S
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:
Predisposing Unknown 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 E.R to

treatment of the patient’s ROC.
condition.
-Secured consent to S.O.
-Secure consent.
-For lawful purposes.
-Monitored and recorded.
-Serves as a baseline data
-TPR every shift and record. checking the present health
status of the patient. -Instructed S.O. for strict NPO.
-NPO temporarily.
-To prevent aspiration/because

-Labs: CBC with APC,
urinalysis, with PT.
of temporary malfunction of
digestive system.
-To whether there were
-Follow-up laboratory for the
abnormal findings found.
result.

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

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

VII. Nursing Care Plan

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Deficient fluid After the shift of -Established rapport to -To gather Goal met:
volume related to nursing the patient and to the information. After the shift
The patient
hyperemesis interventions, the S.O. of nursing
verbalizes that
gravidarum as patient will interventions
“Dura ako ng
manifested by decreased the -For Baseline the patient
dura, nagsusuka
hypersalivation, possibility in -Monitored vital signs data. was able to
pa ko.”
vomiting and dry vomiting, and recorded. perform

Objective: skin. hypersalivation changes in her

decreased and skin status.
-To prevent
-Irritated becomes
-Monitored IVF drip and overload of
moisturized. And
-(+) nausea and its patency. the fluid. And
irritability will
vomiting IVF can help
diminish.
for the
-(+)
hydration of
hypersalivation
the patient.

-(+) dry skin

-Maintained quiet
-Vital signs
environment. -For
taken as
relaxation of
follows:
the patient.
BP: 90/70

CR: 80bpm -Provided comfort -To prevent

measures. irritation/
RR: 22cpm
discomfort of

T: 37°C the patient.

-Administered and
-To provide
documented medications
wellness to
(METOCLOPRAMIDE)
the patient.
given as ordered by the
And to
physician.
prevent
patient from
vomiting.

-Encouraged patient to
increase oral fluid -For

intake. hydration of
the patient.

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

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Acute pain related After 4 hours of -Established -To gather Goal met: After 4
to hyperemesis nursing rapport to the information. hours of nursing
The patient
gravidarum as intervention, the patient and to intervention the
verbalizes that
manifested by patient will the S.O. patient was relieved
“Masakit ang
verbal report and relieve from pain. -For Baseline from pain, can do
tiyan ko.” -Monitored vital
guarding data. things comfortably
The patient can signs and
Objective: behavior. and report pain scale
perform activities recorded. -To prevent to 5/10.
-9/10 pain scale (sitting, standing, overload of
-Monitored IVF
walking and etc.) the fluid.
-Irritable drip and its
comfortably.
patency.
-Grimacing Pain scale will
decelerate to 5/10. -For
-Guarding
relaxation of
behavior -Maintained
the patient.
quiet
-Vital signs environment.
taken as
-To lessen the
follows:
pain felt by
-Provided
BP: 90/70 the patient.
comfort
CR: 80bpm measures.

RR: 22cpm -Positioned the -To decreased

patient to her pain.
T: 37°C
comfortable
state.

- To alleviate
-Massage
suffering from
patient.
perceived
pain.

-Instructed S.O. -To prevent

not to leave the from fall.
patient.

Assessment Diagnosis Planning Intervention Rationale Evaluation

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

-For proper
-Provided air to
 patient. ventilation.

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

Assessment Diagnosis Planning Intervention Rationale Evaluation

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

-Facial tension

-Trembling -For relaxation

-Maintained
of the patient.
-Restlessness quiet
environment.
-Vital signs
taken as -Provided -To prevent
follows: comfort irritation/
measures. discomfort of
BP: 100/80
the client.

CR: 89bpm
-Promotes
-Provided calm
RR: 22cpm relaxation and
and peaceful
ability to deal
setting.
T: 37°C with
situations.

-Encouraged -For the patient

patient to pray to be filled with
God. faith and hope.

-Taught patient -For them to be

and S.O. about clarified about
the condition of the situation of
the patient. the patient.

VIII. Drug study

Metoclopramide
Drug Availability Classification Action Indication and Contraindi Adverse Nursing
Dosages cation Effect Intervention
GENERIC Injection: Emesis Contraind CNS: -Monitor
NAME: 5mg/ml Metoclopra Stimulates during icated to restlessness bowel
Metoclopra mide motility of pregnancy patients , anxiety, sounds.
Syrup: belongs to a upper G.I hypersens drowsiness, -Safety and
mide
5mg/5ml, class of tract, Adults: 5 to itive to fatigue, effectiveness
Hydrochlori
10mg/ml antiemetics increases 10mg P.O. or drug and lassitude, of drug
de
lower 5 to 20 mg in those fever, haven’t been
Tablets: 5mg, esophageal I.V. or I.M. with depression, established
BRAND 10mg sphincter TID. phechrom akathisia, for therapy
NAMES: tone, and ocytoma insomnia, lasting longer
Reglan blocks or seizure confusion, than 12
dopamine disorders. suicide weeks.
receptors at ideation, -When oral
the Contraind seizures, solution is
chemorecept icated in neuroletic used
or trigger patients malignant (10mg/ml)
zone. for whom syndrome, dilute in
stimulatio hallucinatio pudding,
n of G.I ns, applesauce,
motility headache, juice, or
might be dizziness. water just
dangerous before using.
(those CV: -Alert: Use
with transient diphenhydra
hemorrha hypertensio mine 25mg
ge, n, I.V. to
obstructio hypotensio counteract
n, or n, extrapyramid
perforatio supraventri al adverse
n). cular effects from
tachycardia high
Use , metoclopram
cautiously bradycardia ide doses.
in patients
with GI: nausea,
history of bowel
depressio disorders,
n, diarrhea
Parkinson’
s disease, GU: urinary
or frequency,
hypertensi incontinenc
on. e

Hematologi
c:
neutropenia

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.