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A Case Study Approach to

H O M E C A R E I M P L I C AT I O N S
Clients with Hyperemesis Gravidarum (HG) have nausea and/or vomiting that prevents adequate intake of food and fluids. A client could have weight loss, dehydration, nutritional deficiencies, metabolic deficiencies, difficulty with daily activities, psychosocial stress and depression. Managing a client at home with HG is very complex and requires a multidisciplinary approach.

Andrea Jennings-Sanders, DR. PH, RN

ccording to the Hyperemesis Education and Research Foundation (HER), Hyperemesis Gravidarum (HG) is defined as a severe form of nausea and vomiting in pregnancy (HER, 2006). This condition causes excessive pregnancy related nausea and/or vomiting that prevents adequate intake of food and fluids. In untreated cases and/or severe cases of HG, a client could have weight loss, dehydration with the production of ketones, nutritional deficiencies, metabolic imbalances, difficulty with daily activities, psychosocial stress, and depression (HER). For many women, HG commences

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between the fourth and sixth week of pregnancy with symptoms improving by the 15th to 20th week of gestation (HER). However, there are some women who have HG throughout their entire pregnancy. HG negatively impacts both the mother and the developing fetus. Studies have shown that those infants exposed to HG in utero are significantly more likely to have a low birth weight (Bailit, 2005; Doddset al., 2006). Another study indicated that those infants exposed to HG are more likely to be born earlier, be small for gestational age, and may die between 24 and 30 weeks of gestation compared with infants not exposed to HG (Bailit).

Epidemiology of HG
Approximately 60,000 cases of HG are reported annually in the United States; however, this statistic only reflects those women treated in hospitals (HER, 2006). Women who are treated for HG in emergency rooms, outpatient settings, or in home care are not accounted for in these statistics. Therefore, the overall number of cases is likely higher than reported in the literature. Some studies have shown some ethnic variation in the incidence of HG among women. Grjibovski et al. (2007) reported that HG was found in 2.2% of 3,927 Pakistani women and 0.9% of 1,997 Turkish women, both more than twice the incidence of Norwegian women. Another study in the United States found that women with HG were less likely to be white or Hispanic compared with nonwhites or nonHispanics (Bailit, 2005).

The cause of HG is unknown but several theories exist. It is suggested that HG occurs because of the increase in Human Chrionic Gonadotropin and other estrogen hormones. It is suspected that a gastric neuromuscular dysfunction occurs, which results in regurgitation of duodenal content back into the stomach resulting in nausea and vomiting. It was previously thought that HG was a psychological disorder, which attached great stigma to this condition and to women suffering from it (HER, 2006). However, there is no scientific evidence to support this theory. It is important to note that as a result of experiencing HG, women are going to naturally experience feelings of helplessness, isolation, and depression. Simpson et al. (2001) in their study could not support the theory that HG is a psychosomatic condition. The authors concluded that HG is a complex interaction of biological, psychological, and sociocultural factors. Lastly, there is some evidence that maternal genetic susceptibility contributes to the development of hyperemesis. Fejzo et al. (2008) determined the prevalence of hyperemesis gravidarum among relatives of affected individuals. Results from the study indicated that there is evidence for a genetic component to extreme nausea and vomiting of pregnancy. According to the HER Foundation (2006), there are common risk factors for hyperemesis such as women being less than 20 years of age, nonsmokers, food aversions before pregnancy, high saturated fat diet, posttraumatic stress disorder,

multiple gestation, history of motion sickness, sensitivity to oral contraceptives, migraine headaches, allergies, ulcers, mother or sister with HG, high blood pressure, liver disease, kidney disease, and poor diet.

Management of a Hyperemesis Client in a Home Healthcare Setting


Managing a client with HG can be very complex for a home healthcare nurse. It is a condition that needs to be treated and managed immediately before it progresses into a crisis situation with life threatening complications. Appropriate assessment and interventions by the home healthcare nurse can lead to positive short- and longterm outcomes for both the mother with HG and the infant. The following case study illustrate the complexities of HG and how home care nurses can manage HG clients effectively.

Case Study
Mrs. K. is a 32-year-old Asian woman who is married and is 4 weeks pregnant. This is her first pregnancy and just had her first visit with her physician. During her visit, Mrs. K. stated that she was nauseated and vomited frequently throughout the day. The obstetrics/gynecology (OB/GYN) assumed it was morning sickness and orders Phenergan to help control the nausea and vomiting. He tells Mrs. K. to make a follow-up appointment if the condition worsens. Two weeks later Mrs. K. sees the OB/GYN physician and states that her nausea and vomiting is now severe. She states that she is unable to go to work or do

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Using the Rhodes Index as an assessment tool for monitoring the number of vomiting episodes per day, the size of vomiting, the degree and length of nausea, and distress associated with the condition is key (Rhodes& Daniel, 2001). This tool can be accessed at: http://www.hyperemesis.org/ health-profesionals/diagnosis-assessment/rhodes-index.php.

any normal daily activities. The OB/GYN upon examination of Mrs. K. finds the following: Mrs. K. has lost 5 pounds in the last 2 weeks and shows signs of significant dehydration. Signs and symptoms include pallor, increased ketones in the urine, increased urine specific gravity, abnormal sodium and potassium levels, dry tongue, low blood pressure of 88/60 mm Hg, dizziness requiring a wheel chair from the car to the office, and extreme weakness resulting in inability to ambulate without assistance. She has a limited social support system since she just moved from another city. Mrs. K. tells the physician that her husband works 50 to 60 hours a week and is unable to care for her on a regular basis. The physician asked Mrs. K. if her mother suffered from severe vomiting and nausea during her pregnancy and Mrs. K. stated yes. After his examination, the physician recommended continuous intravenous therapy with vitamins and thiamine. In addition, he prescribed ondansetron (Zofran) as the medication of choice to decrease nausea and vomiting. Home healthcare visits by nurses were approved and are to begin immediately.

Assessment by the Home Care Nurse and Possible Interventions


Nutritional Assessment and Interventions

Since Mrs. K. is on continuous intravenous (IV) therapy, the first thing that the nurse should teach Mrs. K. is how to prime the IV tubing, inject the vitamins/thiamine, and inspect the IV insertion site for signs and symptoms of infection. It is important to highlight that the thiamine is important because a thiamine deficiency can lead to Wernickes Encephathopathy, which is an inflammatory, hemorrhagic form of encephalopathy. The multivitamins are also important to add to the IV solution since Mrs. K. is unable to take multivitamins by mouth. The nurse should monitor Mrs. K.s weight on an ongoing basis to determine her weight loss. Using the Rhodes Index as an assessment tool for monitoring the number of vomiting episodes per day, the size of vomiting, the degree and length of nausea, and distress associated with the condition is key (Rhodes& Daniel, 2001). This tool can be accessed at: http://www.hyperemesis.org/ health-profesionals/diagnosisassessment/rhodes-index.php

If Mrs. K.s hyperemesis subsides latter in the pregnancy, the nurse should educate her about the following dietary changes that may be of help: eat small frequent meals, eat dry crackers, eat toast before getting out of bed, drink lots of water between meals, eat foods that are easy to digest such as toast, crackers, bagels, rice, pasta, potatoes. Low fat protein such as lean meat, broiled fish, eggs, and boiled beans are also recommended.

Physical Therapy/Home Health Aide/Home Maker Services


Mrs. K. may benefit from physical therapy services to minimize muscle atrophy if her hyperemesis persists. She should be encouraged to do range of motion exercises while in bed. Mrs. K. should be encouraged to remain on the first level of her home to avoid any unnecessary falls. Home health aide services are appropriate for her since she is unable to bathe herself and her husband is away from home a large majority of the time. Homemaker services may also be of help to Mrs. K. since she is unable to do any of the instrumental activities of daily living. It is essential that the nurse serve

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as Mrs. K.s advocate to justify these services so that they can get approved by the home care agency and insurance company.

Monitor Labs/Vital Signs/Knowledge of Medication


The nurse must continuously monitor vital signs. The following labs should be monitored: ketones, urine specific gravity, sodium, potassium, liver en-

Mrs. K. describes her issues with hyperemesis. Secondary depression in this case may be related to malnutrition, inactivity, fatigue, lack of social support, feelings of helplessness, and loss of control of doing daily activities. As many women lack knowledge about HG, it is important to provide the client with available resources. The nurse should inform Mrs. K. that there are support groups and informa-

poorly managed and untreated HG can be an astronomical burden on the healthcare system. Some insurance plans will not cover hyperemesis so finding or establishing volunteer groups to assist the mother at home with care and with other issues such as child care should be considered. It is essential for physicians, nurses, and family members to raise awareness about this condition to local, state, and federal legislators.

Secondary depression is common for women with hyperemesis. The nurse has to be very supportive and compassionate while listening to Mrs. K. describes her issues with hyperemesis. Secondary depression in this case may be related to malnutrition, inactivity, fatigue, lack of social support, feelings of helplessness, and loss of control of doing daily activities.
zymes, abnormal thyroid and parathyroid levels, increased hemocrit. Mrs. K. has been prescribed Zofran and she should be aware of the side effects such as blurred vision or temporary blindness, slow heart rate, trouble breathing, anxiety, shivering, fainting, and urinating less than usual or not at all. The nurse should assess if Mrs. K. is considering alternative/complementar y therapies such as acupressure, message therapy, hypnosis, and the use of ginger or other herbal products. tion on the HER site http:// www.hyperemesis.org. There is also a father forum on the HER site. Other resources include: Hyperemesis Support Group http://health.groups.yahoo.com/ group/Hyperemesis and Hyperemesis Gravidarum Survivors http://www.angelfire.com/nt/ hugs. The nurse may suggest comfort measures such as music therapy and guided imagery to help Mrs. K. deal with her depression. Legislators need to know about the serious and horrific potential consequences of HG. So much is still unknown about HG and the long-term negative impact it has both on the mother and child. Future research and funding for HG is essential in finding a cure for this debilitating condition. Wagner et al. (2000) suggests that research analyzing serial fetal ultrasound studies to define optimal amounts of calories and proteins to support fetal growth and development may shed additional light on the nutritional management piece of HG. Fejzo et al. (2008) call for research that could identify genetic variants that may contribute to HG susceptibility. Furthermore, funds are desperately needed at the local

Nursing and Health Policy Implications


Hyperemesis is such a debilitating condition for women and if left untreated can negatively impact morbidity and mortality rates for the woman and unborn child. In addition, hospitalization costs associated with

Secondary Depression
Secondary depression is common for women with hyperemesis. The nurse has to be very supportive and compassionate while listening to

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level to establish community wide support groups and services for women with HG.

Conclusion
It is important for healthcare professionals to realize that identifying HG in a client early on allows for a prompt treatment regimen. A multidisciplinary team approach is needed to manage HG clients in a home care setting. Compassion and advocacy from the home care nurse is key as they are caring for HG clients. The home healthcare nurse must disseminate up to date knowledge about HG to their HG clients. This will allow women with HG to plan accordingly to help them manage their current and future pregnancies. Andrea Jennings-Sanders, Dr. PH, RN, is an Associate Professor, School of Nursing, Cleveland State University, Cleveland, Ohio.

Address for correspondence: Cleveland State University, 2121 Euclid Ave, RT 924, Cleveland, OH 44115-2214 (e-mail: a.jennings@csuohio.edu). The author of this article has disclosed that she has no financial relationships related to this article.
REFERENCES

Bailit, J.L.(2005). Hyperemesis gravidarum: Epidemiologic findings from a large cohort. American Journal of Obstetrics Gynecology, 193, 811-814. Dodds, L., Fell, D.B., Joseph, K.S., Allen,V.M., & Butler, B. (2006). Outcomes of Pregnancies. Obstetrics Gynecology, 107(2), 285-292. Fejzo, M., Ingles, S., Wilson, M., Wang, W., MacGibbon, K., Romero, R., et al. (2008). High prevalence of severe nausea and vomiting of pregnancy and hyperemesis gravidarum among relatives of affected individuals. European Journal of Obstetrics and Gynecology and Reproductive Biology, 141, 13-17.

Hyperemesis Education and Research Foundation. Hyperemesis Gravidarum. (2006). Retrieved December 15, 2008 from http://www.hperemesis.org/ Grjibovski, A.M., Vikanes, A., Stoltenberg, C., & Magnus, P. (2007). Consanguinity and the risk of hyperemesis gravidarum in Norway. Acta Obstetricia et Gynecologica Scandinavica, 12, 1-6. Rhodes, V.A., & McDaniel, R.W. (2001). Nausea, vomiting, and retching: Complex problems in palliative care. A Cancer Journal for Clinicians, 51, 232248. Simpson, S.W., Goodwin, T.M., Robins, S.B., Rizzo, A.A., Howes, R.A., Buckwalter, D.K., et al. (2001). Psychological factors and hyperemesis gravidarum. Journal of Womens Health and Gender Based Medicine, 10 (5), 471477. Wagner, B.A., Worthington, P., Russo-Stieglitz., K., Levine., A., & Armenti, V. (2000). Nutritional management of hyperemesis gravidarum. Nutrition in Clinical Practice, 15, 65-76.

For 120 additional continuing education articles related to maternal/child topics, go to nursingcenter.com/ce.

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