Case study presentation

The BSNII and PNII would like to express their gratitude to all the people
behind this case study especially the group who made this case study easy
through their joint effort, collaboration, steadfast support and good
camaraderie.
To our patient Ms. E.D, diagnosed with Hyperemesis Gravidarum (HG) to the
Administration and staff of Eming Lying-In Clinic and Medical Center who
showed courtesy and respect towards the practice of their profession, thank
you.
To our Clinical Instructor Prof. Juliet B. Batac, RN, MAN, who guided us
through this knowledge with patience, concern and care, we are truly grateful
ACKNOWLEDGEMENT and felt a sense of Pride of the profession. Indeed, Nursing is a noble
profession.
To our Dean Florante Z. Artienda, RN, MAN, thanks for the useful bits and
pieces of advises and unflinching support guiding us all the way.
To all the students who exerted their efffort gathering and compiling whose
names are as follows: Evangeline Zarate, Rhoaisa S. Matolo-Osagie, Jen Polido,
Daisy Diza, Jean Casiquin and Joannah Maribbay, thanks for being amazingly
beautiful.
Finally, we offer our Great to the God Almighty for making all things possible.
We thank Him for the beautiful people He sent and used for us to learn
nursing skills and knowledge with greater impact but in the most easiest and
fun way. Truly, one of the perks and blessings of life.
 lll. Review of System
 Title Page IV. Physical Assessment
i
A. Head to Toe Assessment
 Approval Sheet B. Gordon’s Functional Pattern
ii
V. Clinical Discussions
 Acknowledgement
iii A. Anatomy and Physiology
I. Introduction B. Pathophysiology
I. Background of the Study VI. Nursing Care Plan
II. Objectives VII. Drug Study
a) General Objectives VIII. Discharge Plan
b) Specific Objectives
III. Scope and Limitations
IV. Conceptual Framework
II. Clinical Summary
A. General Data
B. Chief Complaint
C. Source of Information
D. Past and Medical History
E. History of Present Illness
F. Personal and Social History
G. Familial History
 Hyperemesis Gravidarum (HG) is a condition where the pregnant woman suffers from grave,
persistent and severe nausea, extreme headache, decreased appetite, constant and abnormal regorge of food
intake (vomiting) which can dangerously cause dehydration, weight loss of more than 5% of body weight and
imbalances in electrolytes.

INTRODUCTION In layman, it is called morning sickness, however, Hyperemesis Gravidarum is a life threatening and an
extreme condition of nausea and/or vomiting which departs from the normal and common state of a pregnant
A. Background of the Study woman. The signs and symptoms of hyperemesis are salivating a lot more than normal, weight loss, dehydration
such as dark urine, dry skin, weakness, light headedness or fainting, constipation and Inability to take in adequate
amounts of fluid or nutrition.

Normally, pregnant women experienced only nausea and/or vomiting for the first three (3) months.
In the case of Hyperemesis Gravidarum, the abovementioned conditions are longer and can last up to the third
(3rd) trimester of pregnancy. According to “Medline Plus”, out of 100% of pregnant women, this ailment is
uncommon and less likely to appear, thus, only less than 3% of women suffer from Hyperemesis Gravidarum.
Based on research, this can happen to any pregnancy but is improbable on twin pregnancy.

Hyperemesis Gravidarum appears on the first trimester, particularly on the 4th and 6th week of pregnancy, and
aggravates and worsens on the 9th to 13th weeks.

Concurrently, doctors agree that Hyperemesis Gravidarum cause is unknown. It is however considered to be
linked or related to hormonal changes in pregnancy, specifically the Human Chorionic Gonadotropin (HCG).
HCG takes place when there is brisk rise of blood level. This HCG hormone is released by placenta. Unfortunately,
there is also no treatment to this illness, only ways and means to manage the said symptoms and conditions.
Women are at higher risk for hyperemesis if they have had the problem in previous pregnancies or
are prone to motion sickness.
It is suggested that Exams and laboratory test should be undertaken by the health care provider
such as Complete blood count, Electrolytes, Urine ketones and Weight loss to ensure that pregnant women has
no liver and gastrointestinal problems.
 a) General Objectives
At the end of this study, the group presenters hope
to provide nursing measures and client care plans for the
INTRODUCTION patients undergoing this condition. Moreover, it is our
B. Objectives purpose to educate patients of hyperemesis gravidarum,
more so, ourselves as the front line health providers in the
field.
b) Specific Objectives
This study aims to identify and understand the
clients pertaining to this condition and equip the patient as
well as the nurses with the knowledge, skills and right
attitude on handling and management when confronted by
this illness.
c) Scope Limitation
This case was based on a real patient, aged 24 years
old, handled by the Eming Lying-In Clinic and Medical
Center at Antipolo City, where the presenters were on duty as
assigned by the school. The case will be limited only to one
patient, her personal health condition and manifestations of
hyperemesis gravidarum, nursing intervention, nursing
interventions, medical management and some other
beneficial facts pertaining to illness.
d) Theoretical Framework
Faye Glenn Abdullah (March 13, 1919-February 24, 2017)
Abdellah developed the 21 Nursing Problems. Metaparadigm:
i. Nursing
• A helping Profession
• Nursing care is doing something to or for the person or providing information to the person
with the goal of meeting needs, increasing or restoring their self-help ability, or alleviating
impairment.
ii. Person
• People with physical, emotional and sociological needs
o Overt: Physical Needs
o Covert: Emotional and Sociological Needs
• The only justification for the existence of nursing.
iii. Health
• State when the individual has no unmet needs and no anticipated or actual impairments.
iv. Environment
• “To create and/or maintain in Therapeutic environment”.
• Patient interacts with and responds to their environment and the nurse is part of the
environment.
According to Abdella’s theory “ nursing is
based on an art and science that moulds
the attitudes, intellectual competencies,
Faye Glenn
and technical skills of the individual
nurse into the desire and the ability to
Abdellah
help people, sick or well, cope with their
health needs.”
(1960)
Abdellah’s 21 Nursing Problems are the
following:
1. To maintain good hygiene and physical 7. To facilitate the maintenance of
comfort. elimination.
2. To promote optimal activity: exercise, rest, 8. To facilitate the maintenance of fluid and
sleep. electrolyte balance.
3. To promote safety through prevention of 9. To recognize the physiologic responses of
accident, injury, or other trauma and the body to disease conditions—
through prevention of the spread of pathologic, physiologic, and compensatory.
infection. 10. To facilitate the maintenance of regulatory
4. To maintain good body mechanics and mechanisms and functions.
prevent and correct deformity. 11. To facilitate the maintenance of sensory
5. To facilitate the maintenance of a supply of function.
oxygen to all body cells. 12. To identify and accept positive and
6. To facilitate the maintenance of nutrition negative expressions, feelings, and
for all body cells. reactions.
13. To identify and accept
interrelatedness of emotions and
organic illness.
14. To facilitate the maintenance of
effective verbal and nonverbal
communication.
15. To promote the development of
productive interpersonal
relationships.
16. To facilitate progress toward
achievement and personal
spiritual goals.
17. To create or maintain a
therapeutic environment.
18. To facilitate awareness of self
as an individual with varying physical,
emotional, and developmental needs.
19. To accept the optimum possible
goals in the light of limitations,
physical and emotional.
20. To use community resources as
an aid in resolving problems that
arise from illness.
21. To understand the role of social
problems as influencing factors in
the cause of illness.
 As a nurse we should assist the patient to provide for the satisfaction of her
own needs. The entire care plan is directed at having the patient help herself
during the entire process of her pregnancy. Likewise client’s family members
should also be involved in the entire care plan throughout the hospitalization
and after discharge.
  Name : Ms. E.B
 Age/Gender : 24 years
old
 Address : Inarawan,
Clinical summary Antipolo City
Patient’s Profile  Religion : Baptist
 Birth Place : Antipolo

 Eduational Attainment : Accounting graduate

 Occupation : Certified
Public Accountant
 Civil Status : Single with Live-in
partner

 Date of Admission : July 31 2019

 Time of Admission : 7:00 PM
 Attending Physician : Dr. Arlyn V. Eming
 Admitting Diagnosis : G1, P0, (0000);
Hyperemesis Gravidarum (HG); Pregnancy uterine 10 weeks and 1 day
AOG by LMP not in labor; EDC March 1, 2020.
 Chief Complaint : Severe Headache,
dizziness, weight loss, nausea, dehydration, loss of appetite and vomiting.
 Source of Information:
The data was gathered from the patient’s record and personal
interview during Nurse-Patient interaction.

 General Data:
This is a case of a single unwed woman, aged 24 years old, first
time pregnant and employed as a Certified Public Accountant
(CPA), Filipino, Baptist, residing at Inarawan Antipolo City,
admitted on 31 July 2019, 7:00 PM at Eming Lying-In Clinic
and Medical Center.
Herein Patient, Ms. EB, has experienced severe nausea,
vomiting, dehydration, headache, dizziness and loss of weight
and appetite.
 History of Past Illness
Prior to her confinement at Eming Lying-In Clinic and Medical Cente, Ms. EB, is in
normal state of condition showing no sign or symptoms of any ailment.

 History of Present Illness

Ms. EB was admitted at Eming’s Lying-In Clinic and Medical Center on July 31, 2019
@7:00pm. On the 1st Week of July, she experienced onset of morning sickness. On the 2nd
to 3rd week of the same month, her nausea worsened and suffered 1x to 3x vomiting a day,
so she decided to go to Eming Lyin-In for Consultation and Check-up. She was
prescribed with Plasil as an anti-emetic once a day but theres no effect on her so on the
last week of july she went back to Eming Lying-In Clinic and Medical Center because she
feel’s like she almost lost her consciousness so Dra. Arlyn Eming decided to admit her.

LMP : 22
May 2019
OB-Gyne History : G1, P0, (0000)
AOG : 10weeks and 1day
 Family History
According to Ms. E.B, her maternal side has
Hypertension while on her paternal side
they have Diabetes.

 Personal-Social History
Ms. E.B works as a Public Accountant.
Review of system
 HEAD  GASTROINTESTINAL
 HEADACHE  CHANGE OF APPETITE
 EYES  NAUSEA
 GLASSES OR CONTACTS  VOMITING
 CHANGE IN VISION  MUSCULOSKELETAL
 SUNKEN EYEBALLS  BODY MALLAE
 EARS  BODY WEAKNESS
 DIZZINESS  NEUROLOGICAL
 MOUTH/ THROAT  HEADACHE
 DRY LIPS  ALMOST LOSS OF CONSCIOUSNESS
 PALE COLOR  WEAKNESS
 Body Parts Normal Actual Analysis
Physical Assessment Findings Findings

HEAD
Cephalocaudal ( IPPA Sequence ) Inspection,
Palpation, Percussion, Auscultation Skull Smooth, skull Head is NORMAL
contour, symmetrical,
symmetrical fontanels
intact,
smooth, skull
contour

Hair Scalp is moist; NORMAL

Hair is not oily Moist scalp
and and hair
absence of scar
in the
scalp

Face Symmetrical, NORMAL

palpebral Symmetrical
fissures facial
equal, oval, features equal
round, or in size
slightly square. palpebral
 Body Parts Normal Findings Actual Findings Analysis

EYES

Eyeballs Round and Eyeballs were sunken NOT NORMAL

Symmetrical and Dark

Lid margins Lies within the upper Lies within the upper NORMAL
portion of the iris portion of the iris

Conjunctiva Pink and moist Pink and moist NORMAL

Pupils Deep, black, round Black in color, round NORMAL

and equal of
diameter (2-6mm)

Eyebrow, eyelashes Hair evenly Equal movement and NORMAL

distributed, alignment, hair
symmetrical, equal evenly distributed,
movements curved slightly outward
slightly outward.
 Body Parts Normal Findings Actual Findings Analysis

Eye movement Both eyes should Both eyes move smoothly NORMAL
move smoothly and and symmetrically.
symmetrically.

VISION TESTING

Visual Field Able to move peripherally, 150 grade vision of With Astigmatism
clear vision of 20/20 both eyes, wearing ( near sighted )
Eyeglasses
EARS

Pinna Color same as facial, Color same as facial NORMAL

symmetrical, free skin, ears are
from lesions and symmetrical with
tenderness over the each other, no
area Lesions

External Canal Grayish-tan in color Grayish-tan in color NORMAL

 Body Parts Normal Findings Actual Findings Analysis

Hearing Acuity Can hear clear sounds Able to hear sound NORMAL
at the distance of clearly at the
3feet distance of 3feet.

NOSE Located Located symmetrically, NORMAL

symmetrically, mid midline of the face and
line of the face and is is without swelling,
without swelling, bleeding, lesions, and
bleeding, lesions, and masses
Masses

MOUTH/LIPS

Gums Pink gums (bluish or NORMAL

brown patches in dark- Pinks gums and moist
skinned clients) moist,
firm texture to gums

Teeth 32 adult teeth, smooth NORMAL

white, shiny tooth Complete teeth
 Body Parts Normal Findings Actual Findings Analysis

Tongue Midline of the mouth, Central position, pink NORMAL

pink, moist, rough, in color, has a smooth
symmetrical, moves lateral margin; no
freely lesions raised papillae,
thin whitish coating,
moves freely
Palate NORMAL
Pink and smooth Lighter pink in color,
posterior rough in texture, hard
a) Hard palate NORMAL

b) Soft Lighter pink, smooth Lighter pink, smooth NORMAL

LIPS soft palate Smooth texture NOT NORMAL

CHEEKS Pinkish color, moist Dry lips. Pale in color NORMAL

Same color as the skin Same color as the skin

and symmetrical and symmetrical
 Body Parts Normal Findings Actual Findings Analysis

NECK Symmetrical with the No neck engorgement, NORMAL

head in the central no palpable mass, no
position, able to move lymph nodes palpable,
in full ROM short neck turns head
easily side to side,
raises head when
prone.
LUNGS NORMAL
No chest pain, absence No abnormal sounds
of cough, no crackles, heard when auscultated
wheezes, rhonchi and
stridor heard during
auscultation
MUSCLES/JOINTS NOT NORMAL
Muscle/joints are in No swelling on both
good motion. Absence upper and lower
of stiffness. extremities. Low
Nonappearance of joint muscle tone. Body
redness or swelling mallae, feeling weak.
Low muscle tone.
 Body Parts Normal Findings Actual Findings Analysis

CHEST Chest wall intact, no Chest wall intact, no NORMAL

tenderness and no tenderness and no
masses masses.
BREAST NORMAL
Rounded shape, Recent change in breast
slightly unequal size, size and swelling due
generally symmetric to pregnancy, marked
asymmetry.
ABDOMEN NORMAL
Linea nigra due to Increased
pregnancy pigmentation of the
UPPER EXTREMITIES nipple and areola NOT NORMAL
No deformities, no
swelling or tenderness, No deformities, no
joints move smoothly. swelling or tenderness,
Normal movements joints move smoothly.
Weak movements due
to body mallae and
body weakness
Body Parts Normal Findings Actual Findings Analysis

LOWER EXTREMETIES No deformities, no Linea nigra is present NOT NORMAL

swelling or tenderness,
joints move smoothly. No deformities, no
Normal movements. swelling or tenderness,
joints move smoothly.
Weak movements due
to body mallae and
body weakness.

Rest and Activity:

Having a hard time sleeping due to headache, dizziness and pregnancy .
Works as a public accountant. No proper exercise. No restricted diet.
 ANATOMY AND
PHYSIOLOGY
 Predisposing
PATHOPHYSIOLOGY Precipitating Factors:

° Dec. secretion of free HCL

High levels of hormone
hCG or Estrogen factors:
° First time pregnancy
The exact cause of Hyperemesis Gravidarum in the stomach (G1P0)
remains unclear. However, there are several ° Slow emptying of the ° Sex: Female
theories for what may contribute to the stomach Excessive
° Environmental nor lifestyle vomiting
development of this disease process. Factor
° Vitamin deficiency (B6)
° Psychological Factors
Loss of Appetite

Weight loss Starvation

Abnormally Dehydration
thin/weak

Water electrolyte Lessen urine

imbalance output Dry Skin
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTIO RATIONALE EVALUATION
N
SUBJECTIVE: Imbalanced After INDEPENDENT: To avoid After 30
“Matindi ang nutritionless 30minutes of Let the patient pressure at the minutes of
pagsusuka ko than body nursing eat smaller but stomach. nursing
tuwing requirements intervention more frequent intervention
pagkatapos kong related to the patient will meals. the patient was
kumain.” As inability to identify relief able to feel
verbalized by the ingest, digest, from vomiting Suggest adding Because ginger relief.
patient. or absorb and ginger may be
nutrients discomfort. tea/supplements beneficial for The feeling of
OBJECTIVE: (prolonged lessening vomiting was
Pale, sunken vomiting) and vomiting reported
eyeballs, dry lips, weight loss. Advice patient to attacks. lessened.
low weak voice have smaller but
often fluid
To prevent
V/S TAKEN: intake.
T: 36.2°C dehydration.
P: 81 bpm Bland Diet
R: 20 cpm
BP: 100/70 mmHg DEPENDENT:
Administer
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTIO RATIONALE EVALAUTAION
N
SUBJECTIVE: Within Independent: To facilitate Within
“pakiramdam 30minutes the Advice the the 30minutes the
ko ako ay Alteration in patient will patient to take maintenance patient was
nanghihina.” body feel alive and a bed rest. of a supply of able to relax
As verbalized strong and be oxygen to all and move
movement.
by the patient. able to move body cells. comfortably
comfortably without feeling
OBJECTIVE: To provide a weak.
Weak-low voice Avoid loud healthy
when sounds. environment
speaking, free from
stress.
 DRUG NAME MECHANISM INDICATION CONTRAINDICA ADVERSE NURSING
OF ACTION TION EFFECT RESPONSIBILIT
Generic Name: Antagonizes the CNS: Drowsiness, Y
History: Any
Treatment of nausea Contraindicated
Metoclopramide central and and vomiting in dizziness, allergy to
patients with or
in patients with:
tiredness/fatigue,
peripheral caused by: metoclopramide;
Brand Name: sleep problems,
Plasil
dopamine 2 • Gastroesophageal • Gastrointesti agitation, depression,
history of GI
receptors in the reflux disease or nal Bleeding hemorrhage; any
headache
diabetic
Drug Class: medullary
gastroparesis • Obstruction mechanical
Antiemetic, GI chemoreceptor • Undergoing • Perforation CV: Transient obstruction or
Stimulant, trigger zone in the chemotherapy • Pheochromoc hypertension, perforation;
Dopaminergic area postrema that • Hyperemesis hypotension, pheochromocytom
Gravidarum
ytoma
Blocker bradycardia,
are normally • Diamond • Seizures a epilepsy;
tachycardia
Dosage:
stimulated by Blackfan • Depression lactation;
levodopa or Syndrome • Parkinson previously
10mg • Advanced liver GI: Diarrhea, bowel
apomorphine. It disease Disease disorders detected breast
Frequency: also blocks the • Postoperative • History of cancer
TID given for 3 days antiperistaltic prophylaxis when Tardive May also rarely cause
nasogastric a potentially fatal
effects of suction is
Dyskinesia Physical: Assess for
Route: condition called
apomorphine undesirable orientation,
Oral Neuroleptic
which slows its reflexes, BP, bowel
Malignant Syndrome
inhibition of sounds, normal
DRUG NAME MECHANISM INDICATION CONTRAINDIC ADVERSE NURSING
OF ACTION ATION EFFECT RESPONSIBILIT
Y
Generic Name: Dextrose: Provides a Treatment of Dextrose: Serious allergic • Suspend
Dextrose, Thiamine source of calories; nutritional or container
HCl promotes glycogen electrolyte loss due
Solution reactions are from eyelet
(Vit. B1), Pyridoxine deposition and to dehydration may be usually support.
HCl prevents ketosis; Dextrose: Indicated contraindicated rare but seek • Clinical
(Vit. B6), Riboflavin- readily metabolized as a source of water, in immediate evaluation
5- Thiamine: A electrolytes and and periodic
phosphate Na (Vit. hydrochloride salt calories patients allergic medical laboratory
B2), vitamin that is Thiamine: to help if any testing
Nicotinamide, D- essential for aerobic Maintains corn/corn noticeable should be
panthenol, Ascorbic metabolism, cell the nerves and heart done to
acid growth, healthy and ease
products symptoms arise monitor
Brand Name: transmission from vomiting Parenteral Large doses changes in
Suplenex of nerve impulses Pyridoxine: For the nutritional taken fluid or
Drug Class: and acetylcholine treatment of vitamin products are for a long time electrolyte
Parenteral synthesis B6 deficiency and balance.
Nutritional Pyridoxine: also used in contraindicated may • Obtain
Product Converted to combination for in also cause baseline
Dosage: pyridoxal 5- controlling nausea patients with headache, electrolyte,
25g/125mg/25mg/25m phosphate which is and vomiting during glucose ,
g/ an important pregnancy
anuria drowsiness and BUN, calcium
625mg/250mg/500mg coenzyme for the and in those numbness and
Frequency: synthesis of amino with phosphorus
1000mL to run acids and inborn errors of levels before
10gtts/min neurotransmitters starting
amino acid
DRUG NAME MECHANISM INDICATION CONTRAINDIC ADVERSE NURSING
IF ACTION ATION EFFECT RESPONSIBILI
TY
Generic Name: Dextrose It is used as a Any solution Common Suspend
Lactated Ringer’s container from
provides a source containing allergic eyelet support
and source of of water, dextrose reactions such • Remove plastic
5% Dextrose
calories. It electrolytes may be as: protector from
Injection outlet port at
Brand Name: is readily and calories. It contraindicate • Itching
bottom of
Lactated Ringer’s metabolized is also d in • Hives container
in and reduces known to be an patients with Swelling of • Refer to
5% Dextrose the loss alkalinizing known the face complete
directions on
Drug Class: of body protein agent. It allergic • Puffy eyes attaching the
Non-pyrogenic, and elevates total reactions to • Coughing administration
Parenteral Fluid, nitrogen. It fluid corn or corn • Sneezing set
Electrolyte, • Conduct clinical
also volume and is products. • Sore throat
Nutrient evaluation and
Replenisher promotes helpful • Difficulty in periodic
Dosage: glycogen in rehydrating breathing laboratory
Dextrose deposition and and • Fever determinations
to monitor
Hydrous minimizes or excretory • Injection changes in fluid
50g/L completely purposes. site balance,
Frequency: prevents swelling or electrolyte
1000mL to run ketosis if Redness concentrations
10gtts/min and acid base
sufficient balance.
Route:
DISCHARGE PLAN
A. MEDICATION
• Assure that the patient follows the prescribed
medications at home.
• Remind to take the medications at the right time, right
route and right dosage.
• Tell patient to avoid any self-medications and always
consult a doctor first before taking any medication
because it may cause
harm to the baby.
• Thoroughly educate the patient and family members
about the action of prescribed drugs and also their
potential side effects
and remind them to see physician immediately if any side effects may arise.
o Metoclopramide (Plasil) 10mg 2x a day
 B. EXERCISE
• Encourage sufficient rest and sleep to patient to replenish the energy lost caused by
severe vomiting.
• Suggest to patient to avoid places or things that emanate stress to enable fast
recovery.

C. TREATMENT
• Remind patient to seek immediate treatment when necessary as advised by the

DISCHARGE •
physician.
Inform patient to continue necessary diagnostic examinations to ensure that both
her and the baby are healthy without any
• complications.

PLAN D. HEALTH TEACHING

• Advise patient to avoid taking hot food if it triggers nausea and vomiting.
• Promote taking ample resting periods to avoid stress and to regain energy and weight
lost.
• Educate the importance of taking nutritional supplements to alleviate signs of
dehydration.
• Recommend to patient to report any constant or serious adverse reactions
immediately.
Thank you 