90 Hyperemesis gravidarum
Assessment
The first priority of care is to determine severity of the nausea and vomiting problem in patients who can no longer retain solids or liquids as well as the degree of dehydration and weight loss. Laboratory studies are prescribed to identify electrolyte imbalances. Patients may exhibit a low-grade fever, increased pulse rate, decreased blood pressure, weakness, dry skin, cracked lips, and poor skin turgor. Patients may appear extremely fatigued and listless with a possible loss of 5%-10% of total body weight, be constipated as a result of dehydration, and have a markedly decreased urinary output with ketonemia (presence of ketones in the blood). Women with diabetes who have hyperemesis need to be monitored closely to maintain glycemic control and avoid ketoacidosis. See “Diabetes in Pregnancy,” p. 619.
Diagnostic tests
Results for CBC, electrolyte panel, laboratory tests for liver enzymes and bilirubin levels, and kidney function:
Help to rule out the presence of underlying diseases previously listed.
Nursing diagnoses:
Risk for electrolyte imbalance
| ASSESSMENT/INTERVENTIONS | RATIONALES |
|---|---|
| Assess characteristics of the patient’s nausea/vomiting: frequency, duration, and severity; amount and color of vomitus; accompanying symptoms (abdominal pain, diarrhea, dyspepsia [a vague feeling of discomfort or bloating after eating]); and precipitating factors. Reassess q8h or as indicated. | This comprehensive initial assessment provides a basis for nursing interventions/teaching and a subsequent comparison for changes. |
| Assess for signs of dehydration: dry mucous membranes, poor skin turgor, decreased blood pressure (BP), increased pulse, possible low-grade fever, and increases in urine specific gravity, BUN, and hematocrit. | With fluid losses, blood and urine become concentrated, circulating blood volume decreases, BP may decrease, and the heart rate increases to compensate. |
| Assess for signs of electrolyte imbalance q8h (muscle weakness, cramps, irritability, irregular heartbeats), and monitor results of prescribed laboratory studies. | Potassium and magnesium are lost with prolonged vomiting. Muscles, including the myocardium, are weakened by loss of these electrolytes. Severe potassium loss impacts the kidneys’ ability to concentrate urine. |
| Initiate and monitor IV hydration while keeping the patient NPO (nothing by mouth) for 48 hr, as prescribed by the health care provider. | This approach aids in resting GI motility, resolving dehydration, and improving electrolyte balance caused by intractable vomiting. |
| Administer parenteral nutrition as prescribed by the health care provider. Secure assistance of the hyperalimentation team to manage patient’s nutrition. | Total nutritional needs can be met with parenteral nutrition, thereby helping ensure adequate fetal growth and preventing maternal malnutrition. |
| Encourage patient to take approximately 100 mL (e.g., in 1 oz portions qh) of liquid between each meal and avoid fluids with meals. | This measure prevents dehydration between meals, overdistension of the stomach during meals, allowing more space for caloric foods, and may prevent nausea. |
Nursing diagnosis:
Imbalanced nutrition: less than body requirements
| ASSESSMENT/INTERVENTIONS | RATIONALES |
|---|---|
| Assess for signs of starvation q8h (e.g., jaundice, bleeding from mucous membranes, and ketonuria). | Insufficient nutrition may cause hypothrombinemia, depleted vitamin C and B complexes, and ketosis. |
| Initiate and titrate enteral (nasogastric feeding) or hyperalimentation (parenteral nutrition by Intravascular therapy) as prescribed by the health care provider and agency protocols. | These are effective methods with which to administer nutrients and hydration when oral ingestion of food and fluids is not possible. |
| Start patient on oral intake when acute nausea resolves, beginning as prescribed with clear liquids (broth and bland juices) and advancing to solid foods as tolerated. | Because an individual tolerates liquids and foods differently it is important to gradually test which food(s) and pattern of eating is better tolerated. |
| Suggest alternative dietary patterns (e.g., frequent small and dry meals, six or more per day, followed by clear liquids). | Small, frequent, dry meals may reduce nausea and vomiting from a distended stomach. |
| Suggest eating meals with the highest protein/calorie intake when the nausea is the least problematic, possibly within 30 min to 1 hr after taking medication for nausea and vomiting. | When the meal providing the most nutrition is consumed at the time the patient is most likely to retain it, the patient may be able to absorb higher protein and nutrient levels necessary for pregnancy. |
| Suggest that patient drink high-protein supplemental beverages. | Liquids may be easier to tolerate than solid foods. |
| As indicated, suggest that the patient avoid food odors and foods that are greasy, highly spiced, rich, or overly sweet. | These measures prevent stimulating the gag reflex or increasing acid reflux. However, because some patients prefer salty and spicy foods, patient should try anything that is appealing and that she believes she will be able to keep down. |
| Encourage patient to stay upright for 2 hr after eating. | This prevents esophageal spasms that can be caused by reflux of acid and food into the esophagus. Gravity aids in facilitating movement of food through the esophagus to the stomach and into the small intestine. |
| Administer prescribed therapies for nausea, e.g., ginger or ginger syrup; antiemetic medications such as pyridoxine (vitamin B6) (Cochrane Review), metoclopramide (Reglan), or promethazine (Phenergan). | These therapies are known to decrease nausea and may enable the patient to ingest and retain fluid and food nutrients, vitamins, proteins, carbohydrates, and fats from oral intake. |
| Refer for acupuncture as prescribed by the health care provider to stimulate the median nerve at the P6 point, or encourage patient to wear an acupressure wristband. | Acupuncture at this site acts on the GI system. Many women report less nausea and vomiting with the wristband. |
| Assess weight at admission (or initial encounter), and document daily morning weight on the same scale. Compare with prepregnant weight, and monitor continued weight loss or gain. | Weight changes indicate progress with treatment and resolution of the condition or severity of losses and risk of maternal and fetal malnutrition. |
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