sis Gravid Arum Paper

8/8/2019 sis Gravid Arum Paper

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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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sis Gravid Arum Paper