REPRODUCTIVE NURSING SYSTEM

Nirsing Care Plan for Hiperemesis

LECTURER:

Vetty Priscilla,S.Kp.,M.Kep.,Sp.Mat.,MPH
MEMBERS OF GROUP II
Cici novelia Manurung (1511314005)
Aysha Amelia (1511314014)
Rozi Ardi Tamala (1511314002)
Rahimah Febrialisa (1511314020)
Bobby Dwi Putra (1511314009)
Dinda Jeanita (1511314023)

NURSING FACULTY
ANDALAS UNIVERSITY
PADANG
2017/2018
 CHAPTER I
INTRODUCTION
A. BACKGROUND
Hyperemesis gravidarum is defined as excessive or uncontrolled vomiting during
pregnancy, leading to dehydration, electrolyte imbalance, or nutritional deficiencies,
and weight loss. The incidence of this condition is about 3.5 per 1000 births. Although
most cases disappear and disappear over time, one out of every 1000 pregnant women
will undergo hospitalization. Hyperemesis gravidarum generally disappears by itself
(self-limiting), but healing is slow and relapses are common. Conditions often occur
among primigravida women and tend to occur again in subsequent pregnancies.
(Lowdermilk, 2004).
Nausea and vomiting are the most common disorders we encounter in young
pregnancies and raised by 50 -70% of pregnant women in the first 16 weeks.
Approximately 66% of first trimester pregnant women experience nausea and 44% have
vomiting. Pregnant women vomit all what is eaten and drunk until their weight is greatly
reduced, reduced skin turgor, reduced diuresis and acetone arise, this condition is called
hyperemesis gravidarum and requires hospitalization.
Comparison of incidence of hyperemesis gravidarum 4: 1000 pregnancy.
(Sastrawinata, 2004) It is estimated that 50% to 80% of pregnant women experience
nausea and vomiting and approximately 5% of pregnant women require treatment for
fluid replacement and electrolyte imbalance correction. The typical pregnancy nausea
and vomiting occurs during the first trimester and is most easily caused by an increase in
the amount of HCG. Nausea is also associated with changes in the sense of smell and
feeling in early pregnancy. (Walsh, 2007).
B. PURPOSE
1. Knowing etiology and pathophysiology of hyperemesis.
2. Knowing the nursing diagnosis for patients with hyperemesis.
3. Knowing the nursing intervention for patient with hyperemesis.
 CHAPTER II
LITERATURE REVIEW
2.1. Etiology
The occurrence of hyperemesis gravidarum is not known with certainty. But some
predisposing factors can be spelled out as follows:
1. Adaptation factors and hormonal
In pregnant women who lack blood more often occurs hyperemesis gravidarum. Can
be included in the scope of adaptation factors are pregnant women with anemia,
primigravida women and over uterine distention in multiple pregnancies and
pregnant hydatidiform mole. A small number of primigravids have not been able to
adapt to estrogen and chorionic gonadrotropin, while in multiple pregnancies and
hydatidiform moles, the amount of hormone secreted is too high and causes
hyperemesis gravidarum.
2. Psychological factors
The association of psychological factors with the incidence of hyperemesis
gravidarum is unclear. It is likely that women who refuse to get pregnant, fear of
losing their jobs, breaking relationships with husbands and so on, are thought to be
factors of hyperemesis gravidarum.
2.2. Pathophysiology
The feeling of nausea due to estrogen levels increases. Nausea of continuous vomiting can
lead to dehydration, hyponatremia, hypokeoremia, urinary chloride decrease and
hemoconcentration, which reduces blood perfusion to the tissues and causes toxic substances.
Use of carbohydrate and fat reserves causes fat oxidation is not perfect resulting in ketosis,
hypokalemia due to vomiting and excessive excretion further increase the frequency of
vomiting and damage the liver. The esophageal and stomach mucous membranes can tear
(Mallory-Weiss Syndrome) resulting in gastrointestinal bleeding.
2.3. Nursing care
Assessment
1. Subjective Data
 Nausea and vomitus are the main symptoms. Patients can not hold food and lose weight.
Some patients complain of excessive salivation / hypersalivation. History of menstruation:
most patients are aware of menstruation that does not come and know that they are pregnant.
But sometimes patients can not provide this important information, thus obscuring the
diagnosis.
A. Nursing Diagnosis in Hyperemesis Gravdarum

1. Lack of nutrients not in accordance with the needs associated with nausea and
vomiting, ketidaiumaturan or lack of food intake
NOC :
a) Nutritional status
 Nutrient intake (1-5)
 Food intake (1-5)
 Fluid intake (1-5)
 Weight/height ratio (1-5)
b) Nutritional status : food & fluid intake
 Oral fluid intake (1-5)
 Oral fluid intake (1-5)
c) Nutritional status : nutrient intake
 Vitamin intake (1-5)
 Carbohydrate intake (1-5)
 Protein intake (1-5)
 Calcium intake (1-5)
NIC :
1) Determine patient’s ability to meet nutritional needs
2) Monitor recorded intake for nutritional content and calories
3) Provide appropriate information about nutritional need and how to meet them
4) Encourage calorie intake appropriate for body type and lifestyle
5) Provide patient with hight-protein, hoght calorie, nutrition finger food and drinks that can be
readily consumed, as appropriate
2. Discomfort associated with the onslaught of vomiting
NOC :
a) Discomfort level
 Nausea (1-5)
 Vomiting (1-5)
b) Nausea & vomiting control
 Recognize onset of nausea (1-5)
 Describes causal factors (1-5)
 Uses antiemetic medication (1-5)

NIC :

1) Teach the use of nonpharmacological techniques to manage nausea

2) Encourages the use nonpharmacological techniques before,during,and after chemotherapy,
before nausea occurs or incrase, and along with other nausea control measures
3) Control environmental factors that may evoke nausea
4) Encourage to learn strategies for managing own nausea

3. Impaired fluid and electrolyte balance associated with fluid loss

NOC :
a) Fluid balance
 Blood pressure (1-5)
 Serum electrolytes (1-5)
 24 hours intake & output balance (1-5)
b) Hydration
 Fluid intake (1-5)
 Skin tugor (1-5)
 Moist mucous membranes (1-5)
 NIC :

1) Monitor for abnormal serum electrolyte levels, as available

2) Monitor laboratory results relevant to fluid balance
3) Monitor for manifestations of electrolyte imbalance
4) Monitor hydration status (e.g.,moist mucousmembranes,orthostatic blood pressure)
 CHAPTER III
CONCLUSION
Hyperemesis Gravidarum is excessive nausea and vomiting so that the daily work is
disturbed and the general condition of pregnant women will be bad. Hyperemesis gravidarum
is a vomiting that occurs early pregnancy at the age of one trimester until entering the second
trimester, where all what which is eaten and drinked vomit so as to affect the general state of
pregnant mothers and daily work, decreased weight, dehydration, there is acetone in urine,
not because of diseases such as Appendisitis, Pielitis and so on but because of abnormalities of
mothers in this pregnancy. Therefore, in pregnant women who are experiencing nausea munta
in pregnancy should not be considered unusual, because excessive nausea vomiting at the time
of pregnant women will result in the mother's condition becomes weak and fetal development
disrupted.
REFERENCES